CHAPTER V
TRAINING IN HOSPITALS
OFFICERS
GENERAL PROFESSIONAL TRAINING
The original assignments of medical officers to general and base hospitals were determined by the Surgeon General; 1 that is to say, efforts were made to assign a competent medical officer of the Regular Army to command each hospital with three or four experienced noncommissioned officers of the Medical Department for the training of the enlisted force and as a nucleus for an organization. Furthermore, in the original assignments of Medical Reserve officers to hospitals, those assigned in the various specialties were carefully selected from among officers known to be especially qualified.
The details of the training of this personnel in the early period of the war were left largely to the initiative of each commanding officer to carry out as best he could, and varied in extent with the availability and qualifications of instructors.2 In all hospitals, even from the beginning, an effort at some military training was carried out, usually consisting of lectures on Army Regulations, Manual for the Medical Department, customs of the service, drill, guard duty, officer of the day duty, etc. Professional training and instruction was outlined and carried out in accordance with the instructions of the Surgeon General. It varied from the experience gained by the actual performance of duties, such as the assistance by junior officers to those already qualified, in the early period of the war, to very broad and complete courses of instruction which covered every phase of hospital work in the later period.
On account of the rapidly growing demand for Medical Department personnel for every variety of duty and the impracticability of training all so needed at the medical officers’ training camps, it was necessary to order many officers and men direct from civil life to hospitals.3 This resulted in temporary overcrowding in some instances but was beneficial in that the staff was doubled and even tripled at times, thus making it possible to secure sufficient personnel, over and above that required for the routine duty in the hospital, to carry out schedules of instruction. It soon became apparent to the Surgeon General that a certain proportion of these officers were not being qualified for their duties as rapidly as was desired; therefore, in the fall of 1917 the following outline of instruction was forwarded to the commanding officers of base and general hospitals to be used as a basis for the training of officers:4
PROFESSIONAL TRAINING OF MEDICAL OFFICERS
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.
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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 of 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 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:
1. 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 retraining after acute infections; in particular, influenza, trench fever, and diarrhea.
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.
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VI. The acute respiratory infections, sore throats and diphtheria--Continued
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 use 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:
1. 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.
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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.
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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 he removed there from.
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
1. 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. Drain.
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 wounds.
II. Pathology:
1. Shock.
2. Hemorrhage.
3. Dyspnea.
4. Hemoptysis.
5. Vomiting and hiccough.
6. Death, immediate causes of.
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II. Pathology - Continued.
7. Infection -
(a) Pyogenic.
(b) Tetanus.
(c) Bacillus--aerogenes.
8. Surgical emphysema.
III. Clinical aspects:
1. Pneumothiorax.
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. Sequele.
IV. Treatment:
1. 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. turbed. 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.
(e) Dressings. Immobilization of affected side -
1. Fresh eases.
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:
1. 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.
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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.
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 opthalmology 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.
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7. Inflammation of the lids and globe. In general, all eases of inflammation should suggest the following possibilities, arranged in the order of their importance:
Glaucoma.
Iritis.
Conjunctivitis.
Foreign body in the conjuntiva.
8. Trachonma 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 ease of injury of the globe.
13. The importance of X-ray examination in all eases 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.
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 or organic.
19. Ocular malingering.
20. Eye symptoms in eases 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.
Barany 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, eternoid, 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.
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NEUROLOGICAL SURGERY
Skull--Fractures:
1. Varieties -
(a) According to mechanism--bending, bursting, expansile.
(b) Simple or compound.
(c) According to form of fragments--fissurred, linear, comminuted, diastasis, depressed, perforating, gunshot.
(d) According to situation--vault, base.
(e) Infection and complications.
(f) Associated brain injuries.
(q) 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.
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.
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Spine - Continued
5. Variations in symptoms according to level.
6. The operative technique of laminectomy.
7. Extraction of foreign bodies.
Nerves:
1. Function -
(a) Motor.
(b) Sensory--epicritic, protopathic, (heel).
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.
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. Interpretatjon of dental and maxillary Roentgenograins.
FOOD AND NUTRITION
1. 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 soldiers 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. (6) 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 time various joints are most serviceable will he definitely defined and time reasons for choice of these positions given.)
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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 technique will he 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 technique 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.)
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. Rôle 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 23, Surgeon General’s Office, 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 f or 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; next 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 breathing; normal variations; auscultation from trachea; normal disparity between right and left apex; transmission of breath sounds from trachea; normal disparity between right and left apex; pulmonary rales; extra pulmonary sounds simulating roles; classification, crepitant, crackling, bubbling (so-called moist or subcrepitant rales), sibilant and sonorous rales; gurgling rales; consonating rales; cavity rales; pleural rales. Value of “expiration and cough” in eliciting rales. Check up one phase of the examination with the other. Value of the localization and locality of physical signs.
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As much as possible of the instruction outlined above was to be given in connection with the daily hospital routine; set classes and instruction were not to interfere with the efficiency of the hospital work.5
As stated above, the officers assigned to hospitals and in the various specialties, by War Department orders were carefully selected.2 With few exceptions they were competent in their accredited work, but they were required to perform many other duties in the hospitals in order that they might develop into well-trained and finished medical officers.2 The course of instruction quoted above was sufficient to render these medical officers capable of performing the multifarious and important duties of their positions; however, in December, 1917, it became apparent to the Surgeon General that a certain proportion of them were still not fully qualified.6 The disqualification was due, in most instances, to physical disability, mental incapacity, temperamental unfitness or slothfulness, or to lack of education or proper training. In some instances, it was only apparent or relative and due to the fact that the individual was for the time being assigned to duty for which he was not adapted.
In order to eliminate from the service officers who were incompetent because of actual physical or mental incapacity, and in order that those incompetent from other causes might be made competent or eliminated, the Surgeon General directed that commanding officers of base and general hospitals list all subordinates whose work was not reasonably good, inform them of the directions of the Surgeon General, make inquiry into each case as to why the work performed was not satisfactory, and to take such of the following steps as was considered necessary.7 All those suspected of mental incapacity were to be given a psychological examination on the lines and forms prescribed by the Surgeon General. The mentally capable men were to be tried in assignments other than those in which they had failed in their examinations. Arrangements were to be made with division surgeons and commanding officers of adjacent base hospitals for the temporary exchange of officers, in order that those failing in ward work might have a chance with a field or hospital unit. However, no man was to be exchanged as incompetent until his superior officer certified that he had personally given the man proper instruction in technique and was convinced that the man was not capable of becoming competent in that line of work within a reasonable time. The men exchanged were to be given proper instruction in the methods and details of this new work, and were to be assisted in its performance for a reasonable time so as to be saved to the service whenever possible. Those who, by reason of physical or mental incapacity, viciousness, or laziness, could not be made qualified were to be ordered before a board of officers convened for their discharge from the service under the terms of Bulletin No. 32, War Department, May 24, 1917, paragraph 9, and reported to the Surgeon General as unfit for the military service. Officers found unsuitable for hospital work, but who were qualified for field work were to be reported to the Surgeon General, with recommendations for their transfer to divisions.
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INSTRUCTION FOR SUBSTANDARD OFFICERS
The course of instruction prescribed by the Surgeon General on November 1, 1917, for medical officers in hospitals proved too advanced for the effective correction of incompetency, due to defective medical education and lack of knowledge of the basic technique of medical or medicomilitary practice. Therefore, another and simpler course was indicated and prescribed, as given below by the Surgeon General, for officers falling in this category, the idea being to secure for the service every man capable of developing into a useful officer.7
* * * * * *
(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.
(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 chief 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 which 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 instructions.
(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 while there be under constant instruction and will do a full days work each day under the supervision of an officer of known capacity.
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 FOR OVERSEAS HOSPITAL PERSONNEL
Previous to this time the personnel of base and evacuation hospitals organized for overseas service had been assigned to military and civilian hospitals adjacent to place of mobilization. Here the personnel in groups of practicable size were given professional instruction in the various departments of the hospitals. In May, 1918, however, it was realized in the Surgeon General’s Office that, if the hospital units being organized for our overseas service were to render efficient service when they arrived in France, it would be necessary for both officers and enlisted men to be assigned to hospital work in military hospitals in the United States and continued at this work until ordered overseas.8 The policy was therefore developed to send the personnel of these overseas hospital units to general and base hospitals in this country and to assign both
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officers and enlisted personnel, except such as were necessary for the administrative functioning of the unit, to temporary duty in base hospitals. In accordance with this policy, overseas hospital units were sent to practically all the large camps on May 3, 1918. On departure of these units others were ordered to the camps to take their places.
SPECIAL COURSES FOR OFFICERS
During the late summer and fall of 1917, schools were established in the important medical centers of the United States for the intensive training of medical officers in the specialties of medicine and surgery. The most important of these were schools of fractures and war surgery, including the Carrel-Dakin method of treating war wounds; oral and plastic surgery; orthopedic surgery; neurosurgery; psychiatry; cardiovascular disease; diagnosis and treatment of pneumonia and tuberculosis. Selected medical officers, recommended by the commanding officer of hospitals were ordered to these schools for courses of intensive instruction, at the completion of which they were ordered back to the hospitals, where they acted as instructors in these specialties to the permanent personnel and to those assigned for instruction.
On November 30, 1917, the Surgeon General sent to hospitals a syllabus containing abstracts of the latest literature of war surgery. Primarily, these abstracts were designed as a basis for the lectures provided for in the Surgeon General’s circular letter of November 1, 1917.4 The syllabus, supplemented by lantern slides and moving pictures, was forwarded to the principal hospitals in turn. The first pictures sent out were on the treatment of war wounds, the application of splints, and the treatment of burns; many others were prepared and sent out as they became available.9
Journal clubs were inaugurated in many of the hospitals and professional papers were prepared and read by members at the meetings of the club, and clinical demonstrations of interesting cases were made. These clubs in many instances served to stimulate and hold the interest of the medical officers and proved of value in disseminating information. 10
In the cantonment hospitals the professional instruction as prescribed by the Surgeon General was open to all medical personnel of the camp, including that of the divisions in training at the camps.
In the summer of 1918, in compliance with instructions from the Surgeon General, 11 selected enlisted men of long service and of proved character, and some of the new men who were suitably qualified, were assigned as assistants to the headquarters, registrars, and mess officers of base, general, and other hospitals and were given intensive instruction in these duties for the purpose of training them for commission in the Sanitary Corps, to fill vacancies for those positions in the base and evacuation hospitals for overseas service.
Weekly meetings were held between the commanding officers, the chiefs of services of base hospitals, and all the regimental surgeons, within the area from which the hospitals drew the sick, for the purpose of conferences upon all matters pertaining to admission discharge from the hospitals, and the further general improvement and cooperation of the two branches of the medical service.12
When the base hospitals and the general hospitals had become thoroughly organized, many of them became educational centers, where post-graduate medi-
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cal schools were conducted, not only for tile training of the local medical officers on duty in the hospitals thereof and the hospitals and other medical units in the cantonment, but also for medical officers ordered to these hospitals for courses of instruction from other stations. The courses of instruction given in these institutions usually included the special branches of medicine and surgery, and instruction in the duties of the chiefs of the various services of base and general hospitals. Courses of instruction were also conducted for nurses and enlisted men.13
The following courses were given in a base hospital in the late summer of 1918: 14
1. Six weeks’ post-graduate school for time officers (one clinic and one lecture daily)
2. A course of instruction to the regimental surgeons in traimming in the camp and base hospital work, the administration of the base hospital and coordination of the duties of a regimental surgeon with the base hospital. a
3. School for instruction in time diagnosis and treatment of pneumonia.
4. Two lectures weekly to nurses. a
5. A course in laboratory technique by the chief of the laboratory and his assistants. a
6. A course in operative and surgical technique for enlisted men. a
7. Instruction in social hygiene.
8. School of hygiene and sanitation.
9. Courses for the training of chief of surgical services, 30 days.
10. Courses for the training of chief of medical service, 30 days.
11. Instruction for chiefs of laboratories.
OUTLINE OF COURSE FOR CHIEFS OF SURGICAL SERVICE
(a) Relation to hospital administration (6 days):
1.The commanding officer.
2.The adjutant.
3.The ward officer.
4.The detachment.
5. Supplies and property.
6. Notification officer.
(b) Records and reports (2 days, and incidental instruction)
1. The registrar -
a. Reports, hospital.
b. Filing and indexing of records.
2. The supervisor of records -
a. Medical importance to patient.
b. Medico-legal value to Government and soldier.
c. Statistical importance.
3. Administrative officers -
a. Efficiency and rating of officers.
b. Efficiency and rating of men.
(c.) Special boards and committees (2 days, and incidental instruction):
1. Hospital efficiency hoard.
2. Disability board -
a. Line of duty.
b. Surgeon’s certificate of disability.
c. Limited military service.
3. Consultation board.
4. Aviation and other special boards.
5. Testimony before courts and boards.
a Training exemplified in previous pages of this chapter.
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(d) Sanitation (2 days):
1. General hospital sanitation.
2. The messes -
a. Food.
b. Conservation.
(e) Military instruction (daily)
1. Drill and setting-up exercises (30 minutes).
2. Military courtesies; Manual for Medical Department; Army Regulations; Manual for Courts-Martial; lectures and recitations (30 minutes).
(f) Organization of the surgical service:
1 Duties of chief of service.
2. Duties of assistants to chief.
3. Duties of ward surgeons.
4. Duties of operating teams.
5. Relations of surgical department -
a. Genitourinary.
b. Orthopedic.
c. Otolaryngological.
d. Oral and plastic.
6. Conferences, consultations, clinics, and lectures.
(g) Surgical objects:
1 Registrants and soldiers in training
a. Rejections of unfit.
b. Detection of malingerers.
c. Fitting of men -
(1) Operative.
(2) Nonoperative -
(a) Orthopedic.
(b) Training in convalescent camp.
d. Selection of operation procedures.
e. Time and training in convalescence.
f. Refusal of operation.
2. Wounded -
a. Steps in their care.
b. The base hospital.
c The general hospital.
3. Reconstruction -
a. Surgical.
b. Training.
(h) Technical Problems
1. Operative technique -
a. Preoperative care.
b. Postoperative care.
2. Operating teams -
a. Operator.
b. Assistants.
c. Anesthetist.
d. Nurses.
e. Corps men
3. Sepsis -
a. Clinical instruction.
b. Courses in antisepsis.
4. Special wounds -
a. Didactic instruction.
b. Clinical instruction if wounded are returned to hospital from France.
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(i) Management of the patients:
1 Admission -
a. Distinction and grouping.
b. Isolation of infections.
2. Discharge -
a. Command.
b. Convalescent camp.
c. Limited military duty.
OUTLINE OF COURSE FOR CHIEFS OF MEDICAL SERVICE
* * * * * *
(f) Organization of the medical service:
1. Duties of chief of service:
2. Duties of assistants to chief.
3. Duties of section supervisors.
4. Duties of ward surgeons.
(g) Methods:
1. The staff -
a. Staff conferences.
b. Individual conferences.
2. The service -
a. Classification and assignment of patients.
b. Discharge of patients.
c. General medical cases.
d. Cardiovascular cases.
e. Lung cases.
f. Neuropsychiatric cases.
g. Communicable diseases.
h. Convalescents.
i. Out-patients.
j. Reconstruction.
(h) Consultation:
1. System.
2. Recording.
(i) Medical instruction -
1. Individual.
2. Clinics, lectures, conferences, digests of medical lectures, etc. (to be conducted by student officers so far as possible).
* * * * * *
(f) Organization of the laboratory:
1. The central laboratory and ward laboratories.
2. Relation to chiefs of service and ward surgeons.
3. Administration of laboratory personnel.
4. Care of instruments and supplies.
5. Keeping of records.
6. Routine work, including -
a. Bacteriology and animal parasites.
b. Serology, Wassermann’s, etc.
c. Chemical analysis, urinalysis, and various chemical tests.
d. Test on blood, exudates, etc.
e. Pathological anatomy, gross and microscopical.
f. Post-mortems.
g. Preparing media.
(g) Work, in cooperation with the camp sanitary officers, in the control and prevention of disease, including:
1.Examinations of organizations for carriers of typhoid, meningococcus, malaria, etc.
2. Analysis of water, milk, and various foods.
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(h) 1. Relation of laboratory to department laboratory.
2. Relation of laboratory to Army Medical School.
3. Relation of laboratory to Army Medical Museum.
NURSES
The Army Nurse Corps personnel of general and base hospitals were assigned thereto by the Surgeon General. In so doing, an effort was made to select a certain number of nurses who were especially skilled in operating-room technique, the administration of anesthetics, in fracture work, orthopedics, etc., the idea being to use them as instructors for other nurses as well as instructors for enlisted men. This was not always possible, however, and many had to receive their special instruction from practical experience and from medical officers on duty in the hospitals after their assignment thereto.
In some of the hospitals a general course of lectures was outlined and given by the medical officer staff. The following is an example of such a course of general instruction.15 Two lectures per week were given on Tuesdays and Thursdays for 10 weeks. The lectures covered the period 6.45 to 7.15 p. m.
Tuesday, April 2. Lecture 1: Military point of view in regard to patients.
Thursday, April 4. Lecture 2: Camp sanitation.
Tuesday, April 9. Lecture 3: Typical infectious diseases in this war--enteric fever, dysentery, trench fever, infectious jaundice, malaria.
Thursday, April 11. Lecture 4: Meningitis.
Tuesday, April 16. Lecture 5: Pneumonia.
Thursday, April 18. Lecture 6: Carriers and contacts and their control; and
Tuesday, April 23. Lecture 6: Carriers and contacts and their control--Shiek tests, vaccines, isolation periods.
Thursday, April 25. Lecture 7: Character of war wounds; transport from field to base.
Tuesday, April 30. Lecture 8: Operating-room technique.
Thursday, May 2. Lecture 9: Dakin’s solution and antiseptics.
Tuesday, May 7. Lecture 10: Preparation and administration.
Thursday, May 9. Lecture 11: Fractures and splints.
Tuesday, May 14. Lecture 12: Infection of wounds.
Thursday, May 16. Lecture 13: Hemorrhage and shock; abdominal wounds.
Tuesday, May 21. Lecture 14: Chest wounds and gas poisoning.
Thursday, May 23. Lecture 15: Utilization of men unfit for active field service, graduated exercises, etc.
Tuesday, May 28. Lecture 16: Shell shock.
Thursday, May 30. Lecture 17: Orthopedics.
Tuesday, June 4. Lecture 18: Care of ear and nose cases.
Thursday. June 6. Lecture 19: Adaptation of field ration to special cases.
STUDENT NURSES
The establishment of the Army School of Nursing was authorized by the Secretary of War, May 25, 1918.b The plan of the school provided that it should be known as the Army School of Nursing and should be located in the Surgeon General’s Office. The course of training to be given in the various base hospitals, each hospital to be a composite unit having its own director, its staff of lecturers, instructors, and its teaching equipment--the course to lead to a diploma in nursing and extended over a period of three years. At the
b For further details. see p. 441.
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time of the signing of the armistice, 5,267 students had been accepted and were on duty in 25 military hospitals.
The course of study and the routine work in wards was in accordance with the requirements of the standard curriculum of schools of nursing, issued by the National League of Nurses in 1918. The time allowed the various subjects was divided between lectures by members of the Army medical staff and class quizzes, laboratory work, and demonstration by qualified nurse instructors.
These student nurses were also given instruction in drill, members of the student companies exercising the function of commissioned and noncommissioned officers.
NURSE ANESTHETISTS
In the fall of 1917, in order to supplement the number of skilled anesthetists in the Army, a number of women contract surgeons were appointed and assigned to duty in general and base hospitals for the purpose of instructing Army nurses in the administration of anesthetics. 16 In most of the hospitals courses were inaugurated, and instruction in this subject was given to certain officers, nurses, and enlisted men.
In August, 1918, a questionnaire was sent to the commanding officers of all base and general hospitals by the Surgeon General. The object of this questionnaire was to gather information concerning the number of skilled anesthetists on duty in each hospital; the types of anesthetics they were qualified to administer; the availability of adequate equipment; whether instruction had been given to officers, nurses, or enlisted men or contract surgeons; other pertinent information. 17
On September 23, 1918, the following letter was sent from the Surgeon General to all commanding officers of hospitals.18
The division of general surgery has completed plans directed toward strengthening the department of anesthesia in the various military hospitals.
These plans contemplate both improving the administration of anesthetics and assuring a constant supply of anesthetists developed by systematic courses of instruction to commissioned officers, nurses, and enlisted personnel.
It is imperative that every chief of surgical service through the commanding officer should cooperate intensively with the division of general surgery in building up a strong department of anesthesia, in order to guarantee adequate service to the surgical patients, both in the United States and overseas forces.
* * * * * *
The duties of the anesthetist shall consist in: (a) Supervision of administration of anesthesia and personal administration when desired or when requested by chief of surgical service. (b) Instruction of commissioned officers, nurses, and enlisted personnel in the fundamentals of anesthesia (pharmacology and physiological action of anesthetics), the art of administration, post anesthetic care and sequelae, and the indications for and technique of resuscitation.
Instruction will be confined to time use of the open drop-ether and the gas-oxygen methods in the order named. Gas-oxygen should not be taught until ether administration is mastered, and every means should be utilized to emphasize the gravity, difficulties, and dangers of gas-oxygen anesthesia.
This office has been specially requested by the chief consultant in surgery, A. E. F., to group nurse anesthetists into two separate classes: (1) Those who are skilled in drop-ether method and (2) those who are skilled in gas-oxygen.
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The length of the course of instruction should not cover more than six weeks. It need be no longer than the aptitude of the pupils demands. Classes should be limited to six pupils so that instruction may be intensive.
As soon as a pupil is found to be qualified, this office should be notified (the formn of monthly report to be used is inclosed), and his place as pupil filled by another officer, nurse, or enlisted man selected by the chief of the surgical service. In this way, it will be possible to furnish the overseas forces a constant supply of comnpetent anesthetists, while maintainimmg a higim degree of perfection in anesthetic administration in the United States hospitals.
The supply division of the Surgeon General’s Office has arranged to send you a sufficient number of tanks to guard against any interruption in the supply of nitrous oxide or oxygen. You should send tanks to be refilled before your reserve supply is compromised. You are to send your tanks to * * * for refilling.
If one of the gas machines requires repair that can not be made locally, immediate exchange should be arranged through the medical supply depot at New York and the division of general surgery notified.
On the 1st of every month a report made out by the anesthetist should be forwarded through military channels to this office, attention division of general surgery. The report should be made in accordance with the inclosed sample blank, copies of which will be furnished you. It is particularly urged that full, explanatory remarks be noted in the column marked “Remarks.” All data on this report pertaining to nurses should be submitted to the chief nurse for her guidance. This report does not substitute for the efficiency report rendered by the chief nurse.
ENLISTED MEN
The basis for the instruction and training in general of enlisted men of the Medical Department was laid down in the Manual for the Medical Department, Drill Regulations for Sanitary Troops, and Mason’s Handbook. Commanding officers of units and detachments were given great latitude in the choice of ways and means for training their personnel, and were held correspondingly responsible for the results obtained. These instructions were augmented from time to time by circular letters sent out by the Surgeon General and by department surgeons. The wide scope of the duties performed by the enlisted personnel of these hospitals necessitated a specialization which generally prevented a comprehensive course of instruction for the personnel as a whole.
Many of the base hospitals had their beginning in the small post hospitals, the personnel being increased as expansion of the hospital occurred, and it was generally the case in the early days of organization that the personnel was so small in proportion to the number of patients in the hospital to be cared for, that instruction was limited to vital requisites and consisted of hardly more than the practical experience gained in the general routine duties performed. As the personnel increased coincidentally with the growth and formation of new departments in their organization in the hospitals, it was found that many technically qualified men could be found in the classification of the personnel who could be assigned directly to services, where they functioned satisfactorily without further training throughout the existence of the hospital. 19
Instruction was largely carried out in separate departments of the hospitals and in the main was based on the practical performance of work under the guidance of those responsible for the given department. In this way, large numbers of men, both privates and noncommissioned officers, were trained in special work and made available for the formation of additional units for service at other near-by organized hospitals.
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Beginning in the spring of 1918, small detachments of enlisted men under the charge of an officer were assigned to several carefully selected hospitals in Philadelphia, New York, and other places for special training in hospital work.20 These detachments were largely used for assignment to hospital units for overseas service. As each detachment finished its training, or was called to rejoin its organization, another detachment was ordered to take its place.
In some hospitals, for the purpose of training the enlisted personnel, the detachment was divided into five groups, one group being designated for instruction for a certain number of hours each day of the week except Saturday, until each group had covered the entire course.21 In other hospitals similar methods were employed, the detachment being divided into eight or nine groups. The following is an example of such a schedule of instruction: 22
[table]
The following quotation was taken from the annual report of the commanding officer of the base hospital, Camp Custer, Mich., for the year of 1918: 23
Enlisted personnel. - Much attention has been paid to the development of an esprit de corps among enlisted personnel. The personnel was organized into six companies under detachment commander and his assistants, each company directly in charge of a sergeant. Competition between companies has been encouraged, both as to effectiveness in drill and in care of barracks. Barracks are all cubicled with sheets, floors oiled, and individual shelving is being installed as fast as time permits. Instruction has also been given in professional care of patients in wards, various courses having been outlined, based on Mason’s Handbook, with modifications after detailed study by medical officers. This teaching has been carried on in wards under the direction of ward surgeons, who have been encouraged to take a personal interest in the teaching of his individual ward personnel. The precise lesson for each day has been indicated and maintained uniformly over the hospital so that when a man was transferred from one ward to another his instruction might go on without interruption. Night men have been instructed together, gathering for the purpose one-half hour before going on duty. Classes in typewriting have been successfully maintained, and soldiers unable to speak or write English have been placed in classes and taught until able to do so. There have been 526 men trained in this detachment and transferred to other organizations and overseas. From time to time the hospital has received additional increments from draft and from the depot brigade. Many of these men were transferred to the hospital detachment because of their demonstrated unfitness for other organizations. A large number of these, however, have been salvaged and after training have proved to be valuable members of the detachment. Others, such as the insane and the crippled, had to be discharged.
In many base and general hospitals schools for noncommissioned officers were established for purposes of instruction of noncommissioned officers, selected privates, and privates first class, having the necessary qualifications
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to fit them for the various grades of noncommissioned officers. The following schedule is an example of the noncommissioned officers’ course.24
The following hours of instruction for each week, places of instruction, and subjects are designated, beginning Monday, January 21:
[table]
Men were selected from time to time from the detachment for the school. Those found unsuitable were promptly relieved.
Special courses of instruction were inaugurated in many of the hospitals for the training of selected enlisted men for various special lines of hospital work, such as operating room and surgical assistants, dental assistants, laboratory assistants, X-ray assistants, anesthetists, dispensary assistants, and ward masters. The following is an example of a schedule of instruction for ward masters and surgical and dispensary assistants. In many of the camps the enlisted men from the field units of the divisions were required to attend these courses of instruction.21
SCHEDULE OF INSTRUCTION
For specially selected men at the base hospital in duties of ward master, surgical and dispensary assistants.
In addition to the hours specified below, a minimum of five hours daily will be required to be spent in practical work in the wards, dispensary, and dressing rooms.
Thursday, Nov. 1:
10.30 to 11.30..........................First aid: Contusions and wounds.
1.15 to 2.15..............................Nursing: The ward; duties of ward master and nurses.
2.30 to 3.30..............................Minor surgery: Anesthesia, general and local.
Friday, Nov. 2:
10.30 to 11.30..........................First aid: Hemorrhages.
1.15 to 2.15..............................Nursing: Ward management and diets.
2.30 to 3.30..............................Minor surgery: Operating assistants, duties of.
Monday, Nov. 5:
10.30 to 11.30.........................First aid: Dislocations and sprains, diagnosis and treatment of.
1.15 to 2.15.............................Nursing: Beds and bed making; actual demonstration of.
2.30 to 3.30.............................Minor surgery: Operating assistants, duties of.
Tuesday, Nov. 6:
10.30 to 11.30.........................First aid: Fractures.
1.15 to 2.15.............................Nursing: Baths and bathing.
2.30 to 3.30.............................Minor surgery: Minor operations.
Wednesday, Nov. 7:
10.30 to 11.30..........................First aid: Fractures and treatment of.
1.15 to 2.15..............................Nursing: Enemata, irrigations, and catheterization.
2.30 to 3.30..............................Minor surgery: Review.
Thursday, Nov. 8:
10.30 to 11.30..........................First aid: Foreign bodies, ear, eyes, nose, and throat.
1.15 to 2.15..............................Nursing: External applications.
2.30 to 3.30..............................Minor surgery: Adhesive straps and strapping.
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Friday, Nov. 9
10.30 to 11.30..........................First aid: Heat and cold, effects of.
1.15 to 2.15..............................Nursing: Temperature, pulse and respiration.
2.30 to 3.30..............................Minor surgery: Splints and immobilization of fractures.
Monday, Nov. 12:
10.30 to 11.30..........................First aid: Insensibility, causes and diagnosis of.
1.15 to 2.15..............................Nursing: Symptons, subjective and objective.
2.30 to 3.30..............................Minor surgery: Surgical dressings.
Tuesday, Nov. 13:
10.30 to 11.30.........................First aid: Convulsions.
1.15 to 2.15.............................Nursing: clinical records.
2.30 to 3.30.............................Minor surgery: Preparation of patient and instruments.
Wednesday, Nov. 14:
10.30 to 11.30.........................First aid: Asphyxia, artificial respiration..
1.15 to 2.15.............................Nursing: Bandages and bandaging.
2.30 to 3.30.............................Minor surgery: Review.
Thursday, Nov. 15:
10.30 to 11.30..........................First aid: Heat and cold, effects of.
1.15 to 2.15..............................Nursing: Bandages, demonstrations of.
2.30 to 3.30..............................Materia medica and therapeutics: Drugs.
Friday, Nov. 16:
10.30 to 11.30.........................First aid: Poisoning, treatment of.
1.15 to 2.15.............................Nursing: Bandages and bandaging.
2.30 to 3.30.............................Materia medica and therapeutics: Drugs, Army supply table.
Monday, Nov. 19:
10.30 to 11.30.........................Pharmacy: Definitions.
1.15 to 2.15.............................Nursing: Infection and disinfection.
2.30 to 3.30.............................Materia medica and therapeutics: Drugs, Army supply table.
Tuesday, Nov. 20:
10.30 to 11.30.........................Pharmacy: Pharmaceutical operations.
1.15 to 2.15.............................Nursing: Infection and disafection
2.30 to 3.30.............................Materia medica and therapeutics: Drugs, active principles of.
Wednesday, Nov. 21:
10.30 to 11.30.........................Pharmacy: Official preparations.
1.15 to 2.15.............................Nursing: Infection and disinfection.
2.30 to 3.30.............................Materia medica and therapeutics: Active principles and classification of.
Thursday, Nov. 22:
10.30 to 11.30..........................Pharmacy: Making preparations.
1.15 to 2.15..............................Nursing: Instruments and appliances.
2.30 to 3.30..............................Materia medica and therapeutics: Administration of medicines.
Friday, Nov. 23:
10.30 to 11.30..........................Pharmacy: Making preparations.
1.15 to 2.15..............................Nursing: The operating room and surgical nursing
2.30 to 3.30..............................Materia medica and therapeutics: Dosage
Monday, Nov. 26:
10.30 to 11.30.........................Pharmacy: Weights and measures
1.15 to 2.15.............................Nursing: Infectious disease, nursing of.
2.30 to 3.30.............................Materia medica and therapeutics: Dosage.
Tuesday, Nov. 27:
10.30 to 11.30.........................Pharmacy: Prescription filling.
1.15 to 2.15.............................Nursing: Infectious diseases, nursing of.
2.30 to 3.30.............................Materia medica and therapeutics: Review.
Wednesday, Nov. 28:
10.30 to 11.30..........................Pharmacy: Incompatibilities.
1.15 to 2.15..............................Nursing: Infectious diseases, how spread.
2.30 to 3.30..............................Hygiene: Disposal of wastes.
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Friday, Nov. 30:
10.30 to 11.30........................Hygiene: Disease prevention.
1.15 to 4.15..............................Written examination in nursing, first aid, materia medica and therapeutics, pharmacy, minor surgery, and hygiene.
Those passing a satisfactory examination in the above subjects were reported eligible for special ratings.25
The plan adopted by the Red Cross for the organization of its first 50 base hospitals for the Army for overseas duty and of developing these institutions in and around large civilian hospitals and medical schools had for its training object the suitable grouping of qualified physicians and specialists. A less obvious but important result was the selection for these units of a relatively high percentage of enlisted men with college and other special training. Instead of simplifying the process of training, which at first would appear to be the result of the plan, the problem was really made quite complicated, for while the courses in nursing, first aid, etc., ordinarily prescribed for sanitary troops were quickly covered by men with these qualifications, such training was inadequate for the preparation of these men for the special work of a base hospital. Therefore, methods were adopted for meeting these conditions.
The first step taken before the mobilization of the unit was, by means of a questionnaire and a personal interview with each man, the making of a survey of the personnel. The result. of this was expressed on a large chart, exhibiting, in parallel columns, the names of the men; their education; their previous employment; their past experience in the Army, in hospitals, in commercial and professional pursuits, etc., and the personal impression of the examiner. This survey was used as a basis for the assigning of men for special training. It often showed in these early Red Cross units a high percentage with college training, including a number of premedical and first-year medical students, graduate students in protozoology, etc., and others with some previous military training, mostly in schools. As a rule, systematic training was not attempted until the men were mobilized and under definite military control. The men were generally divided into detachments, one to remain in camp, which included the necessary camp help, and the other attended hospital.
Each hospital detachment was placed in charge of a medical officer for general oversight and instruction. Special pains were taken in these assignments, first, to limit the number of men in any one place to those who could actually be used as pait of the hospital help; and, second, to fit into specially important places men capable of qualifying for them. For the latter purpose the tabulated survey of enlisted personnel was particularly useful.26
The training of the personnel of Base Hospital No. 38, at Philadelphia,27 exemplifies this method, but was probably more thoroughly and completely carried out (not only because of the large number of hospitals available in Philadelphia, but because of the excellent cooperation of those in charge of and the staffs of the hospitals in the city with the medical officers connected with the base hospitals) than was possible generally. Under the direction of the commanding officer and the director of the hospital a fully organized and thoroughly systematized course of instruction was prepared and placed in active and successful operation in October, 1917.27
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The various hospitals of the city were approached and each agreed to take a detachment of men for training. From 7.30 a. m. to 2.30 p. m. units of 5 to 10 men were on duty in these hospitals, where they were detailed to wards, dispensaries, operating rooms, and laboratories, and given instruction in caring for the sick and wounded. Some were required to carry stretchers, others ran ambulances, served food, assisted in dressing wounds, performed the function of ward orderlies, lifted and transferred patients, assisted in giving anesthetics, etc. Two to four drivers were assigned to spend their mornings in manufacturing and repair shops learning every detail of motor construction, tire and engine trouble, etc. Four men were sent to hotels and hospitals for kitchen work and to familiarize themselves with practical cooking. While details were sent out as indicated, other squads remained at the armory (the use of which was obtained for the hospital) as guards, performed police duty, cooking, etc., and received their military training.
The following is the schedule of instruction followed:27
SCHEDULE OF INSTRUCTION, OCTOBER 29 TO DECEMBER 17, 1917, BASE HOSPITAL NO. 38
7:30 a.m.......................................Small sections (5 to 10 men) sent for practical instruction in hospital work to the following hospitals: Jefferson, Pennsylvania, Polyclinic, St. Agnes, St. Joseph’s, Jewish, Samaritan, Frankford, Lankenau. Section of 6 men to Adelphia Hotel for instruction in cooking and kitchen. Above sections reassembled at armory, 2.30 p. m.
7:30 a.m.......................................Section sent to motor-repair shops for instruction in operating motors, in tire and engine troubles, and in motor-repair work. Reassembled in armory, 12 noon.
10 a.m..........................................Section; guard mount.
10.15 to 11.15 a.m. ....................Mason’s Handbook for Hospital Corps, Monday, Tuesday, Wednesday. Army Regulations, Thursday, Friday, Saturday.
12 noon......................................Lunch.
1 to 2 p.m....................................School of the soldier.
[table]
5.30 p.m.......................................Dinner.
6.15 to 7 15 p.m..........................French lessons on Tuesday and Thursday.
9 p.m............................................Lights out in squad room. (tattoo).
10 p.m..........................................Taps.
An important factor in the success of the training as a whole was the competition for promotion. The enlistments were made in the grade of private and it was early announced that promotions would be made on the basis of demonstrated fitness. Evening classes were held in Army Regulations, clerical work, etc., for those who desired to attend, to prepare candidates for the examinations for noncommissioned officers
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The same plan as that carried out by the base hospital units organized in connection with the medical schools and civil hospitals in the medical centers in the United States was followed by the base and evacuation hospital units organized in the medical officers’ training camps and cantonments, in so far as it was possible in the early months of the war, and in May, 1918, this policy was adopted by the Surgeon General, and the personnel of all these units was sent to the various cantonments for training in the cantonment base hospitals.8
The evacuation hospitals were organized principally at the medical officers’ training camps and at the training camp for medical enlisted reserve units at Camp Crane, Pa.28
The great problem to be solved by these units while undergoing training in the camps involved the development of an organization which would be able to function and carry out the work of an evacuation hospital in active service. This problem was particularly difficult in the early months of the war because neither the administration of an evacuation hospital at the front, its function, nor the scope of its activities was clearly understood in the United States until the summer of 1918. Therefore, data concerning the scope of the work and the requirements which they would be expected to meet were not available.29 It was necessary for those in charge of the training of evacuation hospital personnel to utilize as far as possible such opportunities as were available at near-by cantonment base hospitals for the training of personnel in their professional and administrative duties. Accordingly, arrangements were made with commanding officers of the hospitals to permit a limited number of men to assemble each day to receive instruction in the various departments of the hospitals. This included ward management, nursing, bed making, temperature taking, giving of enemas, anesthesia, sterilization of dressings and instruments, preparation of diets, management of the commissary storeroom, dispensary work, and care of the various classes of property. Instruction was also given to men who were to become clerks in the quartermaster department, medical property storeroom, the record office, the registrar’s office, and the receiving department of the hospital.
The instruction of these groups covered a period of three months, and at the end of that time a considerable degree of proficiency had been attained.
To develop the men physically and to instill habits of discipline, formations outdoors were held at different hours of the day. Setting-up drill usually immediately after reveille was required of both officers and men. Foot drill and practice march occupied the forenoon, while various classes were organized for afternoon instruction in first aid, venereal prophylaxis, litter drill, and bearer drill without litter.30
A policy of forming base and evacuation hospitals destined for overseas service, in the medical officers’ training camps, and after the preliminary military training (first period of this training) to send the personnel to the general and cantonment hospitals for the purpose of instructing them in hospital work proper, as stated above (second period of this training), was approved May 3, 1918. 8
No special provision was made at that time for the quartering of these troops at the various camps, and as a result they were, in most instances,
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quartered in buildings pertaining to the cantonment hospitals. The increased demand for these units for overseas service in the summer of 1918 made it necessary for the Surgeon General to call to the attention of the General Staff the fact that these units should be regarded as troops for overseas service, temporarily receiving instruction in the various hospitals, and that for the purpose of quarters, etc., came under the category of other mobile sanitary organizations being utilized for overseas service and should not be considered as organizations for the care of sick in hospitals in this country.31 It was recommended and approved that 18 evacuation hospitals and 36 base hospitals be kept constantly under training in the general and cantonment hospitals in this country at all times, and that as soon as an organization was ordered abroad another was to be sent to take its place in training. On August 10, 1918, 44 base hospitals and 12 evacuation hospitals were ordered from Medical Officers’ Training Camp, Fort Oglethorpe, Ga., to various camps for instruction of the personnel in base hospitals.31
The following description and schedule of the training of the personnel of an evacuation hospital was abstracted from the report of the training of one of these units from the time of its organization in the medical officers’ training camp until its departure for overseas.32
The commanding officer, adjutant, quartermaster, and one other medical officer were assigned to the hospital in February, 1918, but no enlisted men were assigned until the March draft. The hospital was organized on March 21, 1918, with a personnel of 4 officers and 170 recruits.
Training began at once. A classification of the men was made in order to try and select those qualified or partially qualified for certain kinds of work, and in this way a certain number of men were found more or less fitted for the duty to which they were assigned.
Seven were selected on account of some previous experience, or on account of an expressed preference for that service, and sent for instruction to the X-ray department of the base hospital at the training camp. This instruction consisted of lectures, quizzes, and practical demonstration, and included instruction in anatomy, physics, reading X-ray plates, dark-room technique, K. W. Waite and Bartlet transformer, and a United States portable unit, which included special practical training in the setting up and taking down of this portable outfit and the workings of the gasoline engine, the taking of Roentgenograms and their development in a portable dark room that was made by the students themselves.
Several enlisted men who had some knowledge of cooking were selected and sent to school for cooks and bakers for instruction. After completing their course of instruction they were appointed cooks in their own organizations and the organization opened its own mess.
As to the adequacy of the training which the personnel of these units received before departing for overseas, where they often were required to immediately proceed to the front and begin active operations, it was certainly, in the great majority of cases (although necessary on account of the existing state of war), entirely too short in time and limited in scope.29 Yet the majority of these units, as well as those of the base hospitals, rapidly became oriented and acquired sufficient additional training upon arrival overseas to creditably perform the
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work required of them, as shown by the war histories of these units. In this connection, one commanding officer stated that the 18 enlisted men assigned to a camp base hospital in the United States, in groups of 6 for practical and theoretical instruction in anesthesia, consisting of didactic lectures and quizzes, and watching and commenting on the administration of the anesthetic in operating room, gave the anesthetic to over 5,000 patients without a fatality due to the anesthetic. None of these men had ever been on any duty in a medical school or hospital.33
REFERENCES
(1) Annual Report of the Surgeon General, U. S. Army, 1918, 306.
(2) Letter from the Surgeon General of the Army to the commanding officers of hospitals, October 15, 1917. Subject: Personnel. On file, Record Room, S. G. 0. (Miscellaneous letters, memoranda, etc., 1917, 1918, 1919, 121-B-492).
(3) Annual Report of the Surgeon General, U. S. Army, 1918, 407.
(4) Letter from the Surgeon General to commanding officers of hospitals, November 1, 1917. Subject: Professional training of medical officers. On file, Historical Division, S. G. O.
(5) Memorandum from the Surgeon General to the commanding officers of hospitals, inclosing outline of instruction, November 15, 1917. On file, Historical Division, S. G. O.
(6) Letter from the Surgeon General of the Army to all department and division surgeons and commanding officers of hospitals, December 14, 1917. Subject: Instruction, training, and elimination of medical officers not rendering competent service. On file, Record Room, S. G. O. (Miscellaneous letters, memos., etc., 1917, 1918, 1919, 121-B-492).
(7) Circular letter from the Surgeon General to commanding officers of hospitals, December 14, 1917. Subject: Practical training substandard officers. On file, Historical Division, S. G. O.
(8) Letter from The Adjutant General of the Army to the commanding generals of all Regular Army and National Guard divisions and all base hospitals, May 3, 1918. Subject: Instruction of overseas base hospitals. On file, A. G. O. World War
Records Division, 322.2.
(9) Letter from the Surgeon General of the Army to the commanding officers of base hospitals (through division surgeons), Camp Dodge, Des Moines, Iowa, January 31, 1918. Subject: Material for instruction in surgery. On file. Historical Division, S. G.O.
(10) Correspondence on the subject of training in general and base hospitals. On file, Record Room, S. G. O., 353 (General and base hospitals).
(11) Letter from the Surgeon General of the Army to department, division, camp and post surgeons, surgeons of ports of embarkation, commanding officers, base hospitals, general hospitals, etc., undated. Subject: Sanitary officers. On file, Record Room, S. G. O. (Miscellaneous Letters, memos., etc., 1917, 1918, 1919, 121-b492 No. B-415).
(12) Letter from the Surgeon General, February 25, 1918, to division surgeons. Subject: Training of sanitary personnel. On file, Historical Division, S. G. O.
(13) Tenney, C. F.: A base hospital post-graduate course. The Military Surgeon, Washington, 1919, xlv, No. 3, 257.
(14) Correspondence on the subject of instruction in base hospital, Camp Jackson, S. C. On file, Record Room, S. G. O., 353 (Base Hospital, Camp Jackson) D.
(15) Special Order No. 125, base hospital, Camp Jackson, S. C., March 30, 1918. On file, Historical Division, S. G. O.
(16) Memorandum for the Surgeon General, November 1, 1917, signed by Col. Deane C. Howard, M. C. On file, Record Room, S. G. O., 231 (Anesthetics).
(17) Letter from the Surgeon General to commanding officers, August 20, 1918. Subject: Anesthesia. On file, Record Room, S. G. O. (Miscellaneous letters, memos., etc., 1917, 1918, 1919, B-501-C-596).
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(18) Letter from the Acting Surgeon General to commanding officers, base and general hospitals, September 23, 1918. Subject: Anesthesia. On file, Record Room, S. G. O. (Miscellaneous letters, memos, etc., 1917, 1918, 1919, B-501-C-596).
(19) Letter from the Surgeon General of the Army to all division surgeons, October, 3, 1917. Subject: Training of sanitary personnel of divisions. On file, Record Room, S. G. O. (Miscellaneous letters, memos., etc., 1917, 1918, 1919, 121-B-492).
(20) Letter from the Surgeon General to The Adjutant General’s Office, March 27, 1918. Subject: Special training for enlisted men of the Medical Department. On file, Record Room, S. G. O., 353 (Medical personnel).
(21) History of base hospital, Camp Grant, Ill., October 14, 1917, to July 23, 1918. On file, Historical Division, S. G. O.
(22) Memorandum from Headquarters, U. S. Army hospital, Fort Des Moines, Iowa, May 10, 1918, by Capt. W. S. Sharpe, M. R. C. Adjutant. On file, Historical Division, S. G. O.
(23) Annual report, base hospital, Camp Custer, Mich., December 31, 1918. On file, Historical Division, S. G. O.
(24) Memorandum of instruction, U. S. Army General Hospital, No. 4, Fort Porter, N. V., January 19, 1918, by First Lieut. Paul Compton, Sanitary Corps, adjutant. On file, Record Room, S. G. O., 352.31 (Instruction), Garrison Schools.
(25) Memorandum to all unit surgeons, 35th Division, October 30, 1917, by Lieut. Coi. W. T. Davidson, Pd. C., U. S. A., division surgeon, 35th Division. On file, Record Room, S. G. 0., 353 (General, Camp Doniphan) D.
(26) Kilgore, E. S.: Training the enlisted personnel of a base hospital, Army Base Hospital No. 30 (University of California). Journal of the American Medical Association, Chicago, 1918, lxx, No. 17, 1226.
(27) Letter from W. M. L. Coplin, major, M. C., director, Base Hospital No. 38, November 7, 1917, to the Surgeon General. Subject: Training of enlisted personnel for service in, base hospitals and in the branches of the medical service. On file, Record Room, S. G. O., 353 (B. H. Unit No. 38) J.
(28) Correspondence on the subject of evacuation hospitals. On file, Record Room, S. G. O. 353 (Evacuation Hospitals).
(29) Eliot, Ellsworth, jr., Pd. D.: The training of the personnel of an evacuation hospital for service at the front. New York Medical Journal, New York, May 24, 1919, cix, No. 21, 881.
(30) History of Evacuation Hospital No. 8. On file, Historical Division, S. G. O.
(31) Correspondence on the subject of organization of base and evacuation hospitals. On file, Record Room, S. G. O., 322.3 (Base Hospitals) J.
(32) History of Evacuation Hospital No. 15, signed by J. A. Wilson, Lieut. Col., M. C. On file, Historical Division, S. G. O.
(33) Eliot, Ellsworth, Jr., M. D.: Some experience in an evacuation hospital. Journal of the Medical Society of New Jersey, Newark, 1919, xvi, No. 9, 301.
