AMEDD Corps History > Medical Specialist > Publication
Professional Services and Activities of Dietitians
April 1947 to January 1961
Lieutenant Colonel Helen M. Davis, USA (Ret.)
Hospital food service has undergone revolutionary change since World War II with an attendant gradual and steady increase in the scope of responsibility of the Army dietitian. The food service program established in 19431 was revived in February 1947.2 Emphasis placed by this program upon the improvement of food service throughout the Army and the attainment of Regular Army status by dietitians gave impetus to the reorganization of hospital food service.
The Quartermaster General was made responsible for the Army food service program. Army commanders were delegated the responsibility for many activities of Class II installations and reported directly to the War Department concerning these.3 The food service program in the general hospitals was included among these activities. The restriction of The Surgeon General`s authority caused concern and he requested that food service in general hospitals be made the responsibility of his office.
The Surgeon General`s request was denied. By 1961, however, he had the responsibility for staff and technical supervision over the organization and operation of patient messes and the formulation of requirements for these messes. He was also responsible for the formulation of training doctrines and policies peculiar to patient feeding.4
Since food service played such a vital part in patient care, the Medical Department always had a prime interest in the proper control over it. To accomplish this, regulations were published which defined responsibilities and duties of food service personnel and established administrative procedures. The training of military food service personnel was the responsibility of The Quartermaster General and schools were operated for that purpose. Further training of enlisted food service personnel assigned to Army hospitals, as well as the training of civilian employees, was the responsibility of the head dietitian (later designated chief dietitian).5 A 1946 report of Army subsistence activities named Brooke General Hospital, Fort Sam Houston, Tex., and Fitzsimons Gen-
1Risch, Erna, and Kieffer, Chester L.: The Quartermaster Corps: Organization, Supply, and Services. Volume II. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1955, p. 69.
2War Department Circular No. 50, 21 Feb. 1947.
3War Department Circular No. 47, 21 Feb. 1947.
4Army Regulations No. 30-11, 22 Mar. 1960.
5Circular No. 3, Office of The Surgeon General, 3 June 1947.
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eral Hospital, Denver, Colo., as the exceptional messing installations of all the field and hospital messes visited.6 The investigating committee stated that these might well serve as models for food service activities in future planning.
Early in 1946, the Medical Department began studies of the food service operation of general hospitals with the intent to extend the investigation to station hospitals.7A survey team consisting of representatives of the Medical Department, Corps of Engineers, and the Quartermaster Corps visited hospitals and with the assistance of local personnel drew up plans for the renovation and re-equipping of mess facilities. Lack of funds and limitations placed upon construction hampered progress in this undertaking.
To implement the food service program at general hospitals, The Surgeon General directed a complete reorganization of the messes in these installations in June 1947.8 The chief dietitian (hospital food service supervisor) was made directly responsible to the commanding officer for the supervision and direction of the hospital food service program (chart 10). The titles of mess officer and director of dietetics were abolished, and for the first time, a hospital mess administrator was designated. This Medical Administrative Corps officer was directly responsible to the commanding officer for the proper administration of the hospital fund, the procurement of supplies, equipment, and personnel, central food storage, accountability for property, and the maintenance of pertinent records. Several general hospitals, following an earlier recommendation of The Surgeon General,9 had been functioning under this organizational concept. This achievement was due to the spearhead work and support of Col. Harry A. Bishop, MC, Hospital Division, Surgeon General`s Office, and to the progressive leadership of Maj. (later Lt. Col.) Helen C. Burns,10 Chief, Dietitian Consultants Division. Credit, too, was due to the work of Maj. George R. Allan, MSC, also of the Hospital Division, a staunch champion and constructive critic of the dietitian.
To expedite the implementation of the new organization, a 6-day training symposium for all chief dietitans at general hospitals was held in Philadelphia, Pa.11 Capt. (later Lt. Col.) Katharine E. Manchester, Surgeon General`s Office, conducted the meeting. Emphasis was placed upon the establishment and maintenance of adequate training programs and the standardization of forms which could be used in all Army hospitals.
6Extracts, letter, John L. Hennessy and eight committee members, to Secretary of War, May 1946, subject: A Report of Army Food Service Activities.
7Hospital Food Service Program, Bull. U.S. Army M. Dept. 8 (No. 9): 756-758, September 1948.
8Circular No. 70, Office of The Surgeon General, 3 June 1947.
9See footnote 5, p. 511.
10Later Maj. Helen B. Gearin, WMSC.
11Training Symposium for Army Dietitians, Philadelphia, Pa., 13-18 Oct. 1947.
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CHART 10-Hospital mess organization, 1947
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This period might well be considered a period of transition. It provided opportunity for managerial development of dietitians as Regular Army officers. Dietitians qualified by training and experience were ready to assume the new duties. The 136 dietitians who attended the Advanced Course in Mess Administration at the Medical Field Service School, Fort Sam Houston, Tex., in 1946 and 1947 had received valuable training in hospital food service management.
The changed organization was not entirely satisfactory. Conflict was inevitable with the dual control. Effectiveness was dependent upon full cooperation and understanding between the hospital mess administrator and the chief dietitian and, unfortunately, these did not always exist. Some hospital commanders were reluctant to accept the dietitian in her new role. In giving the dietitian added responsibility some authority was taken from the mess administrator. One recommendation is indicative of the apprehension regarding the future of the mess officer (mess administrator): `In the manner of assignment, it should be borne in mind that no male officer with the MOS 4110 (Mess Officer) should be assigned to a general hospital, since the duties of Hospital Mess Administrator do not utilize this mess experience. The result is that it may produce a dissatisfied, well qualified Mess Officer who feels stultified in his efforts to properly utilize his abilities. The Hospital Mess Administrator should be considered a routine administrative position to be occupied by an officer having an MOS 2121.`
The 1947 regulation prescribing the food service program had redesignated titles and established a military occupational specialty designation for mess personnel. The duty title Food Service Supervisor, MOS 4114 (later redesignated Food Adviser),12 was established. Since it appeared that the duties of the hospital food service supervisor were similar to those outlined in the regulation, authorization was given by The Surgeon General to adjust the personnel records of chief dietitians to include this classification.13
Later, it appeared that only graduates of food service courses prescribed by The Quartermaster General would be awarded the military occupational specialty designation 4114. When The Surgeon General suggested that the requirements for this specialty be modified to include the chief dietitian who functioned as the hospital food service supervisor, The Quartermaster General did not agree on the basis that it would lead to a variance in the training of food service supervisors and a lack of standardization in operating procedures and inspections. It was further pointed out that the dietitians lacked 142 hours in military food service training. When the Advanced Food Service Course became a requirement for the award of MOS 4114, the deficiencies in military food service training would be even greater.
In order to determine whether the 9-month Advanced Food Service Course, taught at Camp Lee, Va., would be of value to dietitians in the
12Special Regulations No. 30-11-1, 31 Jan. 1952.
13See footnote 8, p. 512.
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Medical Department, Capt. (later Col., USAF) Miriam E. Perry, Capt. Evelyn M. Girard, and Capt. (later Maj.) Nancy L. Huston were assigned to this course in September 1947. These three dietitians successfully completed the course and were awarded the MOS 4114. Their experience showed that many subjects were basic to the undergraduate education of the dietitian. As a result, it was not considered to be the best interest of the Army Medical Service to send other dietitians to this course. The Quartermaster General stood firm on the requirements for the award of MOS 4114. Except for the dietitians who had completed the Advanced Food Service Course, other Army dietitians were not, under existing regulations, eligible for MOS 4114.14 Records of dietitians were adjusted to delete this military occupational specialty requirement.
The Commanding General, Camp Lee, Va., found it difficult to obtain officers qualified by education, background, and experience to instruct in the Advanced Food Service Course. There was also a need for qualified instructors for the Quartermaster Corps Subsistence Course, taught in Chicago, Ill. The Quartermaster General requested that two of the dietitians attending the Advanced Food Service Course be assigned as instructors upon their graduation. Captain Girard was assigned to the Advanced Food Service Course. In addition, she acted as liaison officer for the Quartermaster School and the Surgeon General`s Office on all matters pertaining to hospital food service. She served in this capacity until October 1950. No assignment was made to the Quartermaster Corps Subsistence Course because of the shortage of dietitians.
Although reorganization in varying degrees was an accomplished fact, efforts continued for the improvement in standards of hospital food service. In May 1949, The Surgeon General established a hospital food service committee to develop standards, determine policies and procedures for hospital food service, and to prepare an appropriate and inclusive publication for their implementation.15 This committee met at Fitzsimons General Hospital in late June 1949.
Army dietitians on the hospital food service committee were: Capt. Lydia L. Romersa, Medical Plans and Operations Division, Surgeon General`s Office, Chairman; Maj. Myrtle Aldrich, Fitzsimons General
Hospital; Capt. Gladys T. Edwards,16 Percy Jones General Hospital, Battle Creek, Mich.; Capt. (later Maj.) Nannie R. Evans, U.S. Army Hospital, Fort Knox, Ky.; Captain Girard, Camp Lee, Va.; Major
Perry, Brooke Army Medical Center, Fort Sam Houston, Tex.; and Capt. (later Maj.) Velma L. Richardson, Letterman General Hospital, San Francisco, Calif. Other members of this committee were: Capt. Mary
14War Department Circular No. 152, 13 June 1947.
15Manchester, Katharine E.: History of the Management Research Program as Pertained to Hospital Food Service, March 1952. [Official record.]
16Later Maj. Gladys T. Hook, AMSC.
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C. Horak, Air Force dietitian stationed at Fairfield-Suisun Air Force Base, Calif.; and Major Allan, and Maj. Ersel E. Martin, MSC, representing the Medical Plans and Operations Division.
The committee`s recommendations to The Surgeon General were to establish a new organizational structure for hospital food service, to establish a permanent committee to periodically review all policies and procedures for Army hospital food service, and to set a deadline of 31 August 1949 for the final draft of the publication. It was also recommended that the new organization, procedures, and forms be field tested at Valley Forge General Hospital, Phoenixville, Pa. This hospital was set up and served as a pilot installation to test the new organizational pattern for Class II hospitals.17 Later, U.S. Army Hospital, Fort Meade, Md., was used as a test installation to determine if the organizational pattern, procedures, and forms developed for general hospitals would be applicable to station hospitals. The results were most favorable. A permanent committee was established to complete a draft of the required publication. This committee was terminated in September 1949 when the completed draft was given to Major Manchester, who was assigned to the Management Research Program of the Surgeon General`s Office.
Before implementing the new organizational structure, policies, and procedures in all general hospitals, Walter Reed General Hospital, Washington, D.C., was selected in February 1950 as the second testing site. Dietitians in general hospitals were kept informed as to developments so that they could analyze their food service operations and would thereby be prepared to contribute to the total program. Ideas were gleaned, sent to hospitals for comment and, if sound, were accepted. Cooperation was easy to obtain for all dietitians felt a keen need for standard operating procedures and for forms to facilitate efficiency of operation. Every effort was made to utilize both military and civilian personnel in the positions for which they were best qualified. Training of individuals to meet their increased responsibilities was essential.
The management research team, consisting of administrative officers (management engineers), an Army nurse, and a dietitian visited all general hospitals by September 1950. Implementation of the new program at all general hospitals was made easier by the fact that the services and divisions throughout the hospitals were undergoing reorganization at the same time. Participation by a member of the Army Nurse Corps made the changes in the ward food service organization and procedures much more acceptable to the nurses in the hospitals.
The work at Valley Forge General Hospital was the nucleus from which
the organizational pattern of all hospitals was developed. The first tangible result of the research effort was the publication in 1950 of a directive establishing the food service division (chart 11) in general hospitals.18 This division was to be headed by a dietitian who was re-
17See footnote 15, p. 515.
18Circular No. 119, Office of The Surgeon General, 15 Sept. 1950.
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CHART 11-Food service division organization in general hospitals, 1950
sponsible for all food service operations. This gave her all of the duties previously assigned to the hospital mess administrator with the exception of the custodianship of the hospital fund. This latter responsibility was assigned to the hospital treasurer. The position of hospital mess administrator was abolished. Dual control over hospital food service activities ceased to exist.
The functions of food service were classified under five branches: production and service, meat processing, pastry, ward food service, and food supply. Because of the dietetic internship, a training branch was added to the organizational structure of Walter Reed and Brooke General Hospitals. In 1955, the functions within the five branches were consolidated into three branches: food supply which included meat processing, production and service which included pastry preparation, and ward food service.19 Fixed general hospitals at oversea areas were authorized to make use of such parts of the directive as were applicable.
The adoption of the hospital food service organization and functions was well underway in January 1951 when one hospital in each Army area and U.S. Army Hospital, Fort Belvoir, Va., were set up as pilot station hospitals. As these hospitals became operational according to the new organization, personnel (including dietitians) from hospitals within an Army area participated in a workshop and, in many instances, visited a pilot hospital to obtain information. The organization and functions of each branch was defined by regulation for Class I hospitals in January 1952.20 Capt. (later Maj.) Elna Petersen, assigned to Valley Forge General Hospital in April 1951, supervised this program.21
Policies and procedures developed during the organizational research period were incorporated into a tentative procedural manual
19Army Regulations No. 40-22, 29 Apr. 1955.
20Special Regulations No. 40-610-5, 16 Jan. 1952.
21Major Petersen, as a member of The Surgeon General`s team, represented the food service division at the hospital management conferences conducted by the Surgeon General`s Office and Army Area headquarters.
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which was published on 18 February 1952.22 This manual served as a guide to general hospitals and authorized certain forms for use by the food service division. All information was made available to station hospitals. Individual hospitals proceeded with the reorganization as authorized locally. There was no official publication directing this action. Policies and procedures for all Army hospitals were established in September 1956.23 The first directives were specific as to how food service was to be administered. Later, the philosophy of allowing hospital commanders more freedom in the control of their operation came into existence and continued throughout the period covered by this chapter. The dietitian, however, had gained a sound background in accounting procedures and food supply control and was prepared for management responsibilities.
Hospital commanders generally were receptive to the new organization which authorized the dietitian to be chief of the food service division. The efficiency reports for a few officers reflected some lack of acceptance. They were commended for their work only to have this praise negated in the numerical rating and by the statement of the commander`s belief that only a male officer should be in charge of food service activities with supervision over enlisted personnel.24 To some, lack of male supervision meant disaster. One headquarters` document credited the mess steward with contributing to the success of the change in organization of that command.25 This document firmly stated that the director would have to be an outstanding person or else have a strong mess steward.
Reluctance to accept the dietitian in her new role usually changed to satisfaction. The firm background laid in bringing about the new organization was responsible for the high degree of acceptance by hospital commanders and for the readiness of the dietitian to accept full responsibility. Full support of The Surgeon General contributed greatly to the rapid and effective transition. The Army dietitian had now attained the same professional status as was being enjoyed by her civilian counterpart.
Throughout the years there has been no question as to the dietitian`s role in the dietary treatment of the patient. She, at all times, worked closely with the professional staff of the hospital. To facilitate co-
22Tentative Procedural Manual No. 3, Hospital Food Service, Office of The Surgeon General, 18 Feb. 1952.
23Army Regulations No. 40-333, 19 Sept. 1956.
24Annual Report, 10th Station Hospital (Korea), 1950. "It is the considered opinion of the undersigned that insofar as this Theater is concerned a male Officer should head the Mess Department and not a member of the WMSC, and it is doubtful as to whether the Mess Department of any numbered unit should be headed by a woman. The hours are long and strenuous, requiring travel to ration dumps in cold and inclement weather. Strict disciplinary control and supervision over some 40 enlisted men is another requirement more suited to a male Officer.`
25Annual Report, 98th General Hospital, 1952.
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ordination with the staff and to update hospital diets, the guide for prescribing Army hospital diets was revised in 1951.26
The Surgeon General, responsible for insuring the nutritional adequacy of the ration, requested the Food and Nutrition Board, National Research Council, to submit an expression of opinion and recommendations for the nutritional therapy of Army patients suffering or recovering from various types of injury or disease. The report entitled `Therapeutic Nutrition` was released in 1952 in response to this request.27
The report contained the following indictment concerning the quality of dietary care provided Army patients:
Dietary practices in hospitals have not kept up with the recent advances in the field of therapeutic nutrition. The majority of therapeutic diets outlined in the various hospital manuals, including the military, do not supply the nutrients necessary to maintain good nutrition during the acute phase of an illness, and insufficient attention is given the extra requirements for the convalescent and rehabilitation phase of medical care.
A recommendation was made that there should be an adequacy of calories, vitamins, and other constitutents of the diet and that most sick and injured patients should be given at least 150 grams of protein per day.
During 1954 and 1955, nutritional surveys were conducted in Army hospitals by the Medical Nutrition Laboratory.28 These studies revealed that the average patient on the regular diet consumed approximately 2,800 calories with a protein intake of 105 grams. This was below the standard recommended by the National Research Council.
Further studies indicated that the protein requirement for patients should be established at two levels: (1) 150 grams of protein daily for those experiencing sufficient metabolic insult to result in a protein `catabolic phase` with a concomitant nitrogen loss and (2) 110-115 grams for those requiring a lesser amount of protein daily. The basic dietary standards prescribed by The Surgeon General were usually considered adequate for previously well-nourished individuals who required only brief periods of hospitalization.29
Therapeutic diets were developed and tested at U.S. Army Hospital, Fort Belvoir, from 1 April 1955 through 30 June 1956, in order to establish a firm basis for the nutritional standards for Army hospital diets. Capt. Nannie R. Evans, assigned to this hospital, assisted with the feeding studies. Based upon recommendations of the National Research Council and upon the findings of this study, the manual for hospital diets was again revised to reflect increased allowances of protein and calories.30
26Technical Manual (TM) 8-500, 4 Jan. 1951.
27Pollack, H., Halpern, S. L.: Therapeutic Nutrition. Publication 234, National Academy of Sciences-National Research Council, 1952.
28The Medical Nutrition Laboratory is a Class II activity of the Surgeon General`s Office, located at Fitzsimons General Hospital, Denver, Colo.
29Department of the Army Circular No. 40-6, 14 Apr. 1955.
30Technical Manual (TM) 8-500, 4 Dec. 1957.
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From time to time, requests were received in the Surgeon General`s Office for dietitians to assist in research projects. They have been assigned to the various research units to participate in studies and to assist in writing reports and articles for publication. These assignments included nutritional surveys on various categories of personnel, irradiated food studies conducted by the Medical Nutrition Laboratory, Quartermaster Depot, Chicago, Ill., and by the Medical Nutrition Laboratory, Fitzsimons General Hospital; studies on hepatic and metabolic diseases conducted by the Department of Metabolism, Walter Reed Army Institute of Research, Washington, D.C.; metabolic studies on severe burn cases conducted by the Surgical Research Unit, Brooke Army Medical Center; and, more recently, nutritional studies of Puerto Rican diets conducted by the Department of Metabolism, U.S. Army Tropical Research Medical Laboratory, Fort Brooke, San Juan, Puerto Rico. The studies in Puerto Rico carried the research personnel to isolated areas where they lived among the Puerto Ricans in order to observe them closely and gather data on their food habits.
An officer from the Nutrition Branch, Preventive Medicine Division, served on the Quartermaster Menu Board as the official representative of The Surgeon General. The Chief, Dietitian Section, Women`s Medical Specialist Corps, usually attended the meetings of this board as well as the preliminary meeting where the menu was discussed and revised before presentation to the board. This officer was thus able to maintain close liaison with representatives of the Food Service Division, Quartermaster General`s Office. Dietitians served as the post surgeon`s representatives on the post menu boards to insure that changes made in the master menu prescribed by The Quartermaster General did not adversely affect the nutritional content of the menu.
In March 1949, The Surgeon General recommended that the Quartermaster General`s Office, with the cooperation of his office, conduct a study of rations for enlisted members of the Women`s Army Corps. The current ration was too concentrated a source of energy for women and therefore tended to cause obesity in these individuals. 1st Lt. (later Capt.) Helen R. Barefoot was assigned to The Quartermaster General`s Food Service Division for a period of 6 months to assist with this study.31 Although information from this study proved valuable in later modifications to the master menu, a further nutritional survey was recommended to ascertain the exact nutrient intake required for women performing various types of duty. Nutrition officers were not available for assignment to this proposed survey and it was never initiated.
31Disposition Form, Maj. Carl J. Koehn, MSC, Chief, Nutrition Branch, Preventive Medicine Division, Office of The Surgeon General, to Lt. Col. C. A. Rogers, QMC, Chief, Food Service Division, Office of The Quartermaster General, 16 Mar. 1949, subject: Assignment of Dietitian to OQMG to Study WAC Menus, with comments thereto.
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Although several dietitians rendered valuable service to the Quartermaster Corps, Maj. Helen T. Klemm was the only dietitian to be recognized by having her portrait placed in the Quartermaster Association Hall of Fame, Camp Lee, beside other outstanding individuals who have distinguished themselves with the Quartermaster Corps. This honor was awarded in January 1960.32
Patient`s Food Service
Before 1950, the nurse, as well as the dietitian, had definite responsibility for ward food service.33 It was not unusual for the ward nurse to prepare eggs and toast for patients` breakfasts and to serve all trays. When the dietitian was given full responsibility for all food service, the nurse was relieved of this nonprofessional responsibility. Some nurses were reluctant to relinquish this portion of the patients` care, but generally the release from nonprofessional duties was welcomed. In a few isolated instances, the transfer of ward kitchens to the food service division was extremely slow because of difficulty in obtaining necessary personnel spaces to staff the ward kitchens.
Infants` formulas
Although the preparation of infants` formulas had usually been the responsibility of the nursing service, at times the question arose as to whether this was the responsibility of the hospital food service. In 1947, The Surgeon General directed that this function be assigned to the nursing service.34 The need for rigid aseptic conditions was stressed and such conditions did not exist in the ward or main kitchen areas. Hospital construction planning today follows the concept that the formula room should be convenient to and under the supervision of the nursing service.
Centralized ward food service
A centralized ward food service project was initiated by The Surgeon General as part of the Management Improvement Program in November 1951 at Valley Forge General Hospital. The purpose of this project was to test airline-type equipment and service in order to effect improvements in hospital ward food service. Many civilian hospitals were visited to observe systems of centralized food service. Of particular interest was the adaptation of commercial airline equipment to hospital feeding at Barnes Hospital, St. Louis, Mo.
Various types of equipment were tested. Six food carts were constructed locally. Each had an 18-tray capacity and consisted of cold
32The Forge, 5 Feb. 1960. (Published at Valley Forge General Hospital, Phoenixville, Pa.)
33See footnote 5, p. 511.
34Circular No. 84, Office of The Surgeon General, 25 June 1947.
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and heated sections. Because of weight consideration, the airlines were using plastic tableware. For this reason, plastic tableware from several commercial firms was tested.
From 1951 to 1955, Captain Petersen was the project officer for the centralized ward food service study. In order to evaluate the advantage and economies effected by a centralized system, a section of the kitchen was devoted entirely to this type of food service system. A daily average of 125 bed patients were fed from the centralized system while the other bed patients were fed from the ward kitchens, a decentralized service. Captain Petersen planned the centralized service layout, investigated and procured proper equipment, and worked with equipment manufacturers to assist with the development of a satisfactory cart for the centralized ward food service.
On 25 March 1954, a feasibility study was made by the Chief, Hospital Methods Improvement Branch, Medical Plans and Operations Division, Surgeon General`s Office, to determine the advantages of using the new system in Army hospitals. It was found that centralized ward food service was an improved method of feeding patients on the wards. Because of central tray loading, better portion control, and the use of a selective menu, a 25-percent reduction in food losses resulted. It was recognized that a centralized system could be adapted, by the use of mobile equipment, to existing Army hospitals with little or no modification in buildings or facilities.
The project conducted at Valley Forge General Hospital pointed out many advantages of centralizing ward food service activities into the main kitchen instead of serving all trays from widely dispersed ward kitchens (fig. 142). Since this hospital, although two stories high, was constructed on a horizontal plan, the test did not provide data as to the efficiency of operation or the problems incident to this type of food service in a vertical-plan hospital. The latter type was approved for new hospital construction.
In December 1955, The Surgeon General authorized a centralized ward food service test to be conducted at Brooke General Hospital.35 All data, reports, and equipment lists from Valley Forge General Hospital were made available to Brooke General Hospital. Twelve new hot and cold food service carts were shipped to this hospital so that the test could be expanded to a multistory building. This was considered desirable in order to conclusively demonstrate the practicability and economy of the new system.
The main hospital building at Brooke General Hospital was completely converted to centralized ward food service (fig. 143), while the Annex IV mess, serving approximately the same number of trays, remained on a decentralized system. Therefore, it was possible to make some definite observations relative to the advantages and disadvantages of the two food service systems. No traffic problem arose in the
35Smith, S. G.: Report on Central Ward Food Service Test at Brooke Army Hospital. Mil. Med. 121 (No. 5): 291-296, November 1957.
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multistory building with two elevators. Since the food carts did not have to go up and down steep ramps, the weight of the cart and spillage of food was no problem at this hospital. In this test, standard Medical Department china, silver, and trays were used and were found to be satisfactory.
As a result of the test at Brooke General Hospital certain advantages were evident. With the centralized system, it was possible to supervise and check each tray. This degree of accuracy was most difficult with decentralized tray service. The institution of selective menus improved patient satisfaction. An approximate 80-percent decrease in food waste was noted, mainly due to reduction in the quantity of modified diet foods prepared for the wards, as well as a minimum of plate waste because patients on regular diets were permitted to make a selection of food items and portion sizes and patients on modified diets were given consideration as to their food preferences. A reduction of approximately $50 to $100 per week was effected in the maintenance and operation of the ward kitchens. Centralized tray service also reduced the cost of nourishments approximately 70 to 80 percent. Estimating the cost of hospital space at $25 per square foot, the hospital gained $77,500 in space with the closing of seven ward diet kitchens.
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In view of the excellent results of the centralized tray service tests, certain hospitals were encouraged to implement the system. Officers from the Hospital Methods Improvement Branch, Medical Plans and Operations Division, visited hospitals and made recommendations for the implementation of centralized service. The chiefs of the food service divisions visited one of the two test hospitals for 2 to 5 days to observe and study the new system. Procedural manuals were developed and revised as new procedures were established. Copies of these were given to the visiting dietitians to assist them in implementing the program at their hospital.
One of the principle difficulties encountered in the development of a centralized food service system was the design and construction of a satisfactory food carrier. As equipment companies became engaged in the manufacture of a combination hot and cold food service cart, new models were evaluated at Brooke General Hospital to determine which ones were most acceptable to Army hospitals. Field user evaluations were also made at the U.S. Army Hospital, Fort Meade. There being more interest by hospital commanders in converting to centralized service, a procurement document was developed to serve as a guide for local procurement of carts. After these carts were in use for a period of time, reports were submitted to The Surgeon General as to the advantages and disadvantages of the carts obtained under the procurement document. As a result of unsatisfactory equipment reports, The Surgeon General developed specifications for a one-time central procurement of food carts. The number of carts to be procured was based upon the hospital requirements at that time. Carts were not stocked at depots.
Financial Management
Financial management of Army hospitals has always been of primary concern to The Surgeon General. Subsistence funds, in particular, have been singled out for special scrutiny. Hospital commanders have been directed to supervise messes constantly and to exercise every precaution to prevent waste.
In January 1946, the central hospital fund in the Surgeon General`s Office and hospital funds in the field were authorized as nonappropriated funds. The central fund was administered under the direction of The Surgeon General and local funds were under the commanding officer of the hospital to which they pertained. The purpose of the hospital fund was to handle financial transactions for both subsistence and patient welfare.36 Hospital commanders could make expenditures for nonfood items from the hospital fund, but such purchases had to contribute directly to the welfare, comfort, and pleasure of the patient.
Subsistence income for patients was based upon the value of the
36Army Regulations No. 40-590, 21 Jan. 1946.
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garrison ration37 plus 25 percent for nontuberculous patients and 50 percent for tuberculous patients. Money received for subsisting patients and nonpatients at hospital messes was paid into the hospital fund. The maintenance of the hospital fund on a sound financial basis was primarily dependent upon the efficiency of the mess operation and patient welfare expenditures. In July 1950, the prescribed rates allowable as subsistence reimbursement for paid patients and military dependents were established by the Bureau of the Budget. This resulted in a considerable reduction in the subsistence income at each hospital. At this time, the central hospital fund had insufficient working capital to subsidize hospital funds. Strict economy and efficient management of food service activities was of utmost importance.
July 1952 was a critical point in the management of subsistence funds. Beginning with this date, money for subsisting patients and non-patients at hospital messes was no longer to be paid into the hospital fund.38 Welfare funds were similarly affected. Dietitians generally welcomed this change, for now funds were specifically designated for the purchase of subsistence. Under the hospital fund system, it was not unusual for the dietitian to save in order that items needed elsewhere in the hospital could be purchased. To what extent this was done depended upon the interests of the hospital commander and upon the total amount of money available. Under these circumstances, it was impossible to determine hospital food requirements. The inevitable result, at the insistence of the Bureau of the Budget, was the development of a system whereby food expenditures were isolated and would more nearly represent requirements.
The new system brought several changes.39 The allowance for subsistence was now the value of the garrison ration. Hospitals having 10 percent or more tuberculous patients were authorized an additional 15-percent allowance for these patients. The garrison ration value was computed monthly by the local commissary officer and was based upon prescribed quantities of specified food items.40 Ration cost was based upon the dollar value of food issued to the messes and the number of rations earned. The requirement continued for the requisitioning of all food items from the commissary serving the installation.
It was recognized that the loss of the hospital fund might result in a decrease in subsistence funds. To prepare hospitals, a directive was issued in January 1952 directing the practice of certain economy measures and the gradual reduction of expenditures so that by 1 June 1952 the cost of the hospital ration would be the same as the garrison
37A ration is `the allowance of food for the subsistence of one person for one day.` The garrison ration is that prescribed in time of peace for all persons entitled to a ration, except under specific conditions for which other rations are prescribed, and consist of specific allowances of certain food items. (Army Regulations No. 30-2210, 15 Mar. 1940; See also Risch, Erna: The Quartermaster Corps: Organization, Supply, and Services. Volume I, United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1953, pp. 174-207.)
38Army Regulations No. 40-630, 12 June 1952.
39Special Regulations No. 40-630-1, 12 June 1952.
40Army Regulations No. 30-2210, 15 Mar. 1940.
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ration.41 Admonition was given to continue to satisfy the dietary requirements of patients and nonpatients subsisting in hospital messes.
Although hospital commanders were forewarned as to the changes in subsistence procedures there was a period of confusion and adjustment. The regulations and circulars pertaining to the new accounting system were in some instances received after the effective date of 1 July 1952. General hospitals had to change their cost accounting procedures. For many station hospitals, with no established cost accounting system, it was a most difficult transition because of lack of personnel trained in cost accounting. One problem for the oversea hospital was the difficulty in establishing a new system of commissary accounting. Previously these hospitals had drawn the field ration and the supplement for patients. It was now necessary to establish commissary accounts and requisitioning procedures.
There was gradual acceptance and appreciation of this system of subsistence accounting which required strict control over the procurement and issue of food supplies. Educating duty personnel to the limitations placed upon food expenditures was a perplexing problem. Few people really understood the impact of the loss of the hospital fund on the food service operation and the welfare activities. The ingenuity and the managerial ability of the dietitian were heavily taxed to provide acceptable nutritious meals for patients and personnel while experiencing sudden changes and reductions in subsistence funds.
The Bureau of the Budget appeared satisfied that Army hospitals were taking a step in the right direction in the accounting of subsistence funds. This satisfaction did not last. Food service management in federal hospitals continued to be evaluated and compared and the comparison was not always favorable to the Army Medical Service. The ration pattern and the method by which rations were counted were of particular concern to the Bureau of the Budget.
The Veterans` Administration had established a ration pattern which favorably impressed the Bureau of the Budget. This pattern was the result of 5 years` intensive study and served in ascertaining the nutritional level of feeding. It consisted of a specified allowance of food items such as meat, milk, and vegetables per individual served. There was no standard ration pattern within the military service, although, in 1949, consideration had been given to proposing legislation for a common ration.42 In May 1958, a committee,43 reporting on a study of ration allowances for military hospitals, stated that there was need to establish a standard ration pattern for military hospitals in terms of the number of ounces of each major food category and standards for pricing out such a pattern. No positive action was taken on this matter.
The fact that the cost of the Army hospital ration was based upon
41Department of the Army Circular No. 9, 29 Jan. 1952.
42Memorandum for Record, Lt. Col. Frederick H. Gibbs, MSC, Executive Officer, Medical Plans and Operations Division, Surgeon General`s Office, 8 Jan. 1949.
43Report, Study of Ration Allowances for Military Hospitals, 26 May 1958.
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the number of rations earned rather than on those actually served was of concern to the Bureau of the Budget. By counting rations earned, credit was received for personnel who were authorized to subsist but were not actually present for all meals. The amount of credit for extra rations varied among hospitals; therefore, a comparison of food costs was unrealistic. Hospitals with a wide variation between the rations earned and the rations served could more easily stay within the monetary allowance. The fact that this was accomplished was not a true indication of operational efficiency nor of the service of high quality food. Generally, the larger installations had a distinct advantage while the small hospitals on isolated posts had a distinct disadvantage.
The disparity in rations continued to be a problem. In order to have information available to support the medical care budget, The Surgeon General required hospitals to report on the total number of rations served for the period 1 July 1954 through 28 February 1955.44 In 1956, the monthly statement of food service operations was changed to include a report on the number of rations served by category of personnel subsisting.45 No change was made in the method of arriving at hospital food costs. Finally, effective in July 1959, Army hospitals were required to use rations served rather than rations earned in determining food costs.46
Two events affected hospital food costs after the initiation of the hospital ration system in 1952: the supply of surplus dairy products and the change in pricing the local master menu. The supply of surplus dairy products resulting from legislation enacted in 195447 was a boon to the dietitian. Restricted quantities of butter at 4 cents per pound and cheese at 2 cents per pound, plus an authorization to exceed the hospital ration rate by the cost of milk used in excess of the normal allowance, made it possible to provide a more acceptable menu within established allowances. The normal allowance of milk was first established as that amount above the average authorized by the installation menu for July, August, and September, 1954. Later, the normal allowance was established at 8 ounces per ration.48 The boon turned into a boomerang for the surplus milk cost was reflected in the total food cost which was considered excessively high by the Bureau of the Budget.
Additional funds for hospital expenditures resulted from a change in the pricing of the local master menu. Beginning in January 1957, the master menu as planned, rather than food components of the garrison ration, was priced by the local commissary officer. By so doing the value of the garrison ration represented the actual cost within the geographic area of food required for the menu. There was no change at the Quartermaster General`s Office in pricing components of the
44Department of the Army Circular No. 40-5, 6 Apr. 1955.
45Special Regulations No. 40-630-1, Changes No. 1, 26 Apr. 1956.
46Army Regulations No. 40-333, 27 May 1959.
47Public Law 690, 83d Congress, 28 Aug. 1954.
48(1) Department of the Army Message No. 428879, 19 June 1956. (2) Circular No. 111, Office of The Surgeon General, 29 Oct. 1956.
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ration as a basis for overall cost control of the master menu. The following statement from a hospital report is indicative of the benefit derived from this change:49
With the changes effective 1 January 1957 in the pricing of the Master Menu and the subsequent raising of the hospital ration rate, our Food Service Division is now able to maintain a menu considered to meet the nutritional and acceptability needs of our patients.
In January 1958, because of the gradually rising costs of Army medical service, The Surgeon General sent an economy letter to hospital commanders. Raw food costs were pointed out as one of the serious problem areas. Almost immediately a more drastic measure was taken by ordering hospitals to achieve a flat reduction in food costs. Hospitals experiencing a cost for raw food, including excess milk, above $1.15 per ration served for January 1958 were ordered to take steps effective on 1 April 1958 to reduce this cost by 10 percent or to $1.15 per ration served, whichever was higher. Installations operating below the $1.15 figure were cautioned not to raise costs.
This strict reduction in ration allowance unfortunately came at a time when the value of the garrison ration was increasing. In some instances, hospitals had to operate at a level below that authorized for subsisting troops in the same area and on the same posts. Since surplus milk was now considered a part of the raw food cost, some hospitals immediately limited the quantities of milk served. To complicate the situation further, the diet manual prescribing increased levels of protein was being received by hospitals.
A newspaper article appearing on 16 April 1958 set off a reaction.50 According to this article, troops were having all the milk they desired but the hospital was restricting the consumption of milk. The Surgeon General had not directed the reduction of any component of the diet but had placed a limit on total food costs. To resolve the inequities brought about by the establishment of a flat rate for all hospitals and to provide an average cost per ration served which would fluctuate in direct relationship to the local value of the garrison ration, the original order was rescinded and new instructions were issued.51 Hospitals were authorized the local value of the garrison ration or field ration A, plus the increment for tuberculous patients and plus the local cost of 1½ pints of fresh whole or recombined milk.
Throughout this period of drastic change in the hospital ration rate, a detailed system on food cost accounting was in effect. Daily food issues were costed by the food groups and daily and accumulative comparisons were made.
In hospitals where the cost accounting system was working effectively, the cost of food issued to the mess was known to the dietitian on the day following the actual issue of food. With this accurate and current food cost data, the dietitian could
49Essential Technical Medical Data, Headquarters, United States Army, Europe, Medical Division, for April-June 1957, dated 29 Aug. 1957.
50The Denver Post, 16 Apr. 1958, `U.S. Buys Huge Milk Surplus But Army Hospital Rations It.`
51Army Regulations No. 40-330, 5 June 1958.
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more scientifically make changes in future menus to control food expenditures. Under this cost accounting system the dollar value of the food inventory was carried as part of the net working capital. Daily and weekly fluctuations in the monetary value of the inventory were relatively unimportant, but every effort was made to maintain a fairly constant monthly monetary value for the inventory. Food issues as well as increases or decreases in the dollar value of the food inventory were reflected in the ration cost at the end of the month.
Effective on 1 July 1959, food purchases and rations served rather than food issues and rations earned were established as the basis for determining the cost of the hospital ration.52 The change to food purchases was brought about by the fact that the food service division was the only segment of the hospital not operating on an item-purchased basis under the current hospital accounting system. Other changes concerning financial management were effected. Weighted values were given each meal thereby more nearly reflecting the cost of the meal. The food inventory, no longer a part of the net working capital, was not considered in determining ration cost. The food service report was required quarterly rather than monthly. Except for the last quarter of the fiscal year the reports from station and oversea hospitals were consolidated by the command of which they were a part. Hospitals were authorized to exceed the monthly hospital ration rate, but were cautioned to carefully watch costs so that the ration value for the fiscal year would not be exceeded.
The simplification of food cost accounting met with different receptions. Dietitians and individuals responsible for cost records were reluctant to relinquish any controls because they were accustomed to checking daily costs. Purchases did not reflect actual day-to-day costs. The elimination of daily posting of food issues on the stock record cards and of the food inventory gave concern to the dietitians. Previously established controls did not have to be discontinued for authority was given for the establishment of such controls as were believed necessary to afford adequate protection over subsistence supplies. There continued to be divided opinion as to whether the prescribed controls were adequate for efficient operation. Financial responsibilities have been accepted and administered by the dietitian in a highly commendable manner. The one person who gave the dietitian the greatest assistance during this period of financial turmoil was Nephtune Fogelberg, Comptroller, Surgeon General`s Office. He understood the dietitian`s problems and was always available to give counsel and encouragement concerning the financial management of the food service division.
Food Procurement
In 1947, at the beginning of the period covered by this chapter, the procurement of food supplies through the Quartermaster Market
52See footnote 46, p. 529.
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Center was not entirely satisfactory. Many complaints were received by the Dietetic Consultants Division about the quality of produce, meats, dairy products, and poultry. Surveys by representatives of The Surgeon General verified these complaints. After months of investigation and presentation of facts to the Quartermaster General`s Office, standards of service to Army hospitals were defined.53 Much improvement was noted. Procurement of special food items for patient feeding is probably the area which needs the greatest attention at this time. The ration or supplement for hospital patients, without doubt will be affected by developments in the troop ration, which now includes precooked and prepackaged foods.
Equipment and Facilities
Because of wartime emergency conditions and the shortage of supplies, hospital equipment and facilities in 1947 were not of the standard desired by The Surgeon General. Items such as steam tables, cold counters, coffee urns, toasters, and dish tables were substandard and needed replacement. Some hospitals were still using coal ranges which were time consuming to fire, dirty, and lacking in temperature control. The Drinkwater Cart, an insulated food conveyor, was still in service.
In January 1947, specific recommendations were made by The Surgeon General for the replacement of inferior-type equipment.54 Later in that year, the use of nonstandard items such as paper tray covers and souffle cups, napkin dispensers, diet identification tags, and tray card holders were recommended by The Surgeon General.55
Metal compartment trays were gradually replaced by plastic trays and china. This greatly improved the attractiveness of food service (fig. 144). With the use of china for bed patients came the development of a bed tray to take the place of the wooden bed tray. This tray was of metal and so designed as to be used as a bookrest, a desk, or as a stand for the patients` tray. It was to be left in the ward for the patient`s convenience. Nursing service was unreceptive to this procedure for storage of the tray was a problem. After hooks were made available on the ward to accommodate the tray, this problem was eliminated. In spite of the effort to upgrade equipment, some wooden trays are still in use.
A plastic tray 15¼ by 20½ inches came into use with the metal bed tray. This plastic tray was larger than the standard tray in order to accommodate the dishes required for bed patient food service. This tray was too large to go through the dishwashing machine. Hand washing was a laborious and unsatisfactory process. This situation was
53(1) Memorandum, Field Headquarters, Quartermaster Market Center System, Office of The Quartermaster General, for All Officers in Charge, Quartermaster Market Centers and All Marketing Specialists, 26 May 1947, subject: Standards of Service-Army General
Hospitals. (2)
See footnote 34, p. 521.
54See footnote 5, p. 511.
55See footnote 34, p. 521.
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FIGURE 144-Continued. C. Metal tray. (U.S. Army photograph.)
alleviated to some extent by the authorization of a dishrack to hold the tray. Because of excessive warping, the tray was never entirely satisfactory. Action was taken in 1959 to standardize a more durable tray which could be obtained from more than one commercial source. This action was not accomplished during the period covered by this chapter.
After the transfer of the responsibility for Medical Department china to the Quartermaster in 1959, hospitals encountered difficulty in obtaining standard items of china. Because of the depletion of stocks in the Quartermaster depots, purchases had to be made on the open market. This resulted in unmatched china on the patient`s tray and usually an increased cost to the purchaser. This problem was not resolved by January 1961.
Along with the action to replace obsolete equipment came the modernization of facilities. With the passing of time, cantonment-type hospitals in particular were deteriorating. As funds were made available, layouts were rearranged and new equipment replaced those pieces judged to be unservicable or obsolete. Replacement of the eight-place table with swinging stools by the four-place table with separate chairs contributed to make the dining room less institutional in appearance and atmosphere (fig. 145). Harold Hasle, Food Service Section, Quartermaster General`s Office, rendered invaluable service in the matter of facilities planning and equipment procurement.
Early in the period covered by this chapter, renovation of the ward
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serving kitchen was stressed. Wooden cabinets were replaced by stainless steel cabinets, dishwashing machines took the place of sterilizers, a combination stove and griddle was provided, and kitchen space was enlarged. With the adoption of centralized tray service, the equipment and space requirement for ward food service changed.
As hospitals are planned and constructed, changes are taking place to improve facilities. Requirements, of necessity, will have to be reevaluated in the light of experience and of information gained concerning developments in equipment. The food service section of the newly constructed hospitals received fewer complaints than many other areas. Among the difficulties encountered, however, was the amount of kitchen floor space and the quantity of installed equipment in hospitals built on a chassis for future expansion. This extra space and equipment meant additional cleaning for which personnel spaces were not authorized. Storage and office space were generally inadequate. Dietitians were unhappy with offices where there were no windows. It is recognized that there will be differences of opinion as to layout and equipment and that there will be problems concerning space allocation and placement. Planning for Army hospitals is done years in advance of construction, and sound forecasting of requirements is therefore imperative.
Personnel
Military personnel
Enlisted personnel presented a special problem throughout the period covered by this chapter. The using service often had little or no voice in the selection of enlisted men, as their assignment came through normal requisitioning channels of the Quartermaster. Enlisted men trained and experienced in hospital food service management were often transferred from the Medical Department after their tour of duty in a hospital was completed. It was felt that identification would aid in obtaining and retaining men experienced in hospital food service. Throughout World War II and later, requests were made for the establishment of military occupational specialty designation for hospital food service enlisted personnel. The Air Force has been authorized to identify their hospital food service enlisted personnel, but similar authorization has yet to be attained by the Army Medical Service.
Because of this situation, the training of enlisted men with no previous hospital experience in all phases of hospital food service was of utmost importance. Training of military cooks was conducted continuously in each hospital. It has been estimated that approximately 3 months were required to train an enlisted man to be effective in hospital food service management. His loss to the Medical Department was costly in time and effort expended in training. Probably one of the greatest disadvantages for the untrained men was their lack of
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experience in dealing with civilian personnel. The complicated and detailed civil service regulations and the need for more effective techniques in management of civilian employees made their orientation most difficult.
In 1946 and 1947, efforts were made to establish a separate 6-week course for hospital cooks and hospital ward diet cooks. Its purpose was to furnish practical experience to enlisted men in regard to patients` diets and to familiarize them with the general administration of the hospital mess. Diet food preparation and food service in the ward diet kitchen would thereby be more efficient. The course was to be 240 hours and was to include: organization of the dietetic department, 3 hours; personal hygiene, 1 hour; equipment use in hospital diet kitchens, 2 hours; nutrition and diet therapy, 8 hours; principles of diet cookery, 6 hours; menu plans for special diets, 4 hours; food service for special diets, 5 hours; on-the-job training, 210 hours; and examination, 1 hour. This course was to be conducted in a general hospital. These efforts recognized the requirement in the Medical Department for hospital food service trained enlisted personnel, however, no favorable action was taken. In 1950, and again in 1955, similar courses were submitted for approval to The Adjutant General. These, too, were disapproved.
With the emphasis on efficiency and economy of hospital food service during the period covered by this chapter and with the shortage of dietitians, it was obvious that a formal training program would have provided the Medical Department with trained personnel. These individuals could have been used not only in the cooking and serving of hospital diets, but also in the management, supervision, and training of other personnel. With a limited number of personnel and limited money for subsistence, it was increasingly evident that noncommissioned officers responsible for management and supervision of dining rooms and ward kitchens would require additional training to develop skills over and above their basic Quartermaster military occupational specialty requirement.
Hospital reports during later years have specifically mentioned the deterioration in the quality of enlisted food service personnel. One headquarters stated that over a period of 2 years there had been a trend downward in experience, interest, initiative, and overall capabilities in the food service personnel assigned to hospitals.56
Today the career field for food service personnel is not especially attractive to the ambitious enlisted man. The food service program of 1947 gave promise of a rewarding future for the food service man. This promise has not materialized and prospects grow even dimmer in view of the great emphasis placed upon skills in electronics and missiles. For the maintenance of high standards, it is imperative that physically able and mentally alert men be assigned to and be retained in the food service field.
56Essential Technical Medical Data, Headquarters, United States Army, Europe, Medical Division, for January-March 1957, dated 27 May 1957.
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FIGURE 146-On-the-job training session for civilian food service employees.
Civilian personnel
Problems relating to civilian personnel have also been perplexing. From time to time, reduction in force of civilians has created havoc in well-organized hospital operations. Each time this has occurred, qualified individuals have been lost and a period of adjustment and training followed. Hiring of civilian employees, when restricted to selection from a registry, has complicated the selection of qualified individuals. A few dietitians have been able to establish specific job standards which have assisted in the elimination of a large percentage of those believed undesirable and resulted in a reduction in labor turnover. The older worker with decreased capabilities for hard physical labor is often a dilemma to the dietitian. The service and loyalty of these workers is recognized, but there is little room for sentiment when personnel spaces are authorized on the basis of work measurement rather than on individual ability.
The need to establish job standards for food service workers has been evident for some time. The U.S. Army Hospital Management Research Unit conducted a study of the food service division at Brooke General Hospital. The purpose of the study was to develop performance standards for work units in work areas which were determined to be measurable and to develop a method by which performance standards could be applied to food service activities so as to
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measure the effectiveness of manpower usage and the personnel requirements for any sustained workload. A report of the study,57 which is believed to be one of the few made in the field of hospital food service, was made in 1958. Findings from this study were used in the development of a staffing guide for Army hospital food service.
Training of civilian food service employees was emphasized (fig. 146). For some time a program of ward and mess attendant training had been established.58 On-the-job training of these employees was conducted in all hospitals. To assist in the training of military and civilian food service personnel, a four-part film entitled `Training Hospital Food Service Personnel` was made and released in 1951.59 Revision had been made in accordance with changes in food service organization and procedures except that centralized tray service had not been included. The film was widely used and continues to serve as a useful training tool.
57Report, U.S. Army Hospital Management Research Unit, Brooke Army Medical Center, 1958, subject: Work Measurement in Army Hospitals, Food Service Division Study, Brooke Army Hospital.
58Special Regulations No. 40-590-75, 10 June 1949.
59Part I, "Introduction,` was filmed at Fitzsimons General Hospital, Denver, Colo., with Capt. Lydia L. Romersa acting as technical dviser. Part II, `Sanitation,` and Part III, `Equipment,` were filmed at Valley Forge General Hospital, Phoenixville, Pa. Part IV, `Serving Food` was filmed at the Signal Corps Photographic Center, New York, N.Y. Maj. Helen M. Davis served as technical adviser for the last three parts. Capt. Katharine E. Manchester and Capt. Dorothy Adams, ORC, were responsible for the original script and served as advisers prior to the filming at Fizsimons General Hospital.
