(Special District Manager Letter, Medical Division, No. 1. Obsolete) MEDICAL CONSULTANTS AVAILABLE FOR SERVICE AT HOSPITALS AUGUST 31, 1922. In connection with regular inspections of hospitals which are reported on Form 2566, United States Veterans' Bureau, it is desired that under paragraph 9, subparagraph c, a list of the consultants of all branches of medicine who are available for service at the hospital be attached to the report with statement as to how often each consultant was called to the hospital during the past three calendar months in reference to the care of United States Veterans' Bureau beneficiaries. The inspector will interrogate the commanding officer or superintendent of the hospital and determine if, in his opinion, the character of the work and the qualifications of the consultants are satisfactory. The above list will be furnished in addition to the list called for by subparagraph c, which pertains to all officers regularly assigned to full-time duty at the institution. ROGER BROOKE, Acting Assistant Director. (Special District Manager Letter, Medical Division, No. 2. Obsolete) HOSPITAL INSPECTION REPORTS SEPTEMBER 11, 1922. Attention is directed to the fact that in making reports of hospital inspections on Form 2566 there has been neglect on the part of many medical inspectors to give complete answers to all questions and make full statements under the various paragraphs and subparagraphs. The use of dashes and the absence of notations conveys no information, and such reports are not acceptable to the central office. In future these inspection reports will show more detail, in order that the most complete information possible may be available in the district and central offices. Form 2566, United States Veterans' Bureau, report of hospital inspection, having been in use for some months, suggestions relative to changes or other constructive criticisms are invited from officers concerned with a view to possible alterations in this form. All suggestions or criticisms will be addressed to the assistant director, medical division, attention medical inspection subdivision, and forwarded not later than October 1. ROBERT U. PATTERSON, Assistant Director. (Special District Manager Letter, Medical Division, No. 3) CONSULTANT SERVICE OCTOBER 30, 1922. In order to better coordinate the medical work of the district organizations with that of the United States veterans' hospitals, and to reduce the cost of consultant service in cities in which a district or subdistrict office and a United States veterans' hospital are both located, you are instructed to give immediate consideration to two methods by which this result may be accomplished. 1. The detail of medical officers on duty in hospitals to district or subdistrict offices for part-time service in such specialties of medicine and surgery as the hospital staff affords. This will tend to reduce medical personnel necessary to operate the district or subdistrict dispensaries and credit will be given to the hsopital in its cost accounting system for the services of its medical officers so detailed to the district. Unnecessary examinations will be eliminated and increased medical efficiency will be gained by this procedure. 2. Combining the district or subdistrict staff of attending specialists with that of the United States veterans' hospital and the formation of one group to be attached, to the United States veterans' hospital, to be known as the "United States veterans' attending specialists," whose services are available both in the hospital and in the dispensary. Their salaries will be paid by the hospital from the appropriation for medical and hospital service. A record will be kept by the district of the amount of work or time given to the district dispensary, which report will be furnished the hospital for credit in the cost accounting system. In order to accomplish these results careful analysis of the situation must be made conjointly by the district medical officer or his representative and the medical officer in charge of the hospital concerned and an agreement reached upon the details necessary. You are therefore instructed, and the medical officer in charge of the hospital will be so instructed, to submit a conjoint letter recommending and requesting bureau approval for the action agreed upon. In the event that definite action can not be mutually agreed upon, separate recommendations should be submitted by the district manager and the medical officer in charge of the hospital. The use of the staff of United States veterans' hospitals in district or subdistrict office dispensaries to the fullest extent is believed to be a most important procedure from the standpoint of efficiency and economy, both to the district organization and to the hospital. In this way the claimant will be afforded the advantages of continuity of observation by the same physician and specialist before, during, and after hospitalization without being subjected to an unnecessary repetition of interrogation and examination. ROBERT U. PATTERSON, Assistant Director. (Special District Manager Letter, Medical Division, No. 4. Canceled by General Order No. 345) NOVEMBER 4, 1922. In order that the annual report of the inspection service, United States Veterans' Bureau may be accurately compiled, it is requested: 1. That the district medical inspector include in his monthly report, Medical Form 1868, revised March, 1922, under the heading "Remarks," the entire personnel, both professional and clerical, on duty in the inspection service, and the salary of each person; this list to include individuals temporarily assigned for inspection duty as authorized by District Manager Letter, Medical Division, No. 10, April 29, 1922, giving pro rata salary for time while so detailed, as, for example: 2. That every individual traveling under temporary assignment to the inspection service, as authorized by District Manager Letter No. 10, April 29, 1922, submit a monthly report of inspection made on Form 1866, March 29, 1922. 3. That inspections or special investigations enumerated under column captioned "Nature of inspection," will contain the name and location of the institution or individual concerned. 4. It is further requested that reports for the months of July, August, September, and October, which have already been forwarded, be revised in accordance with the above requests. ROBERT U. PATTERSON, Assistant Director. (Special District Manager Letter, Medical Division, No. 5) SCHEMA FOR THE CLASSIFICATION OF PATIENTS ON EXAMINATION NOVEMBER 8, 1922. 1. Attached hereto is a schema for the classification of patients on first and subsequent examinations as adopted by the American Sanatorium Association. This classification should be carefully studied and followed by all medical men in your district who examine ex-service men for the Veterans' Bureau for pulmonary tuberculosis. 2. It is requested that you place a copy of this schema in the hands of every medical examiner and furnish at least one to each contract hospital or State sanatorium within your district hospitalizing tuberculous beneficiaries of this bureau. A copy should also be given to each follow-up nurse in your district. 3. United States Public Health Service Nomenclature of Diseases and Conditions, 1921, and Addenda are modified accordingly, and all reports of diagnosis upon examination should be consistent with the terminology included in the attached schema. 4. As it is evident that the use of the terms "quiescent" and "apparently arrested" imply a knowledge derived from sanatorium or hospital observation over a considerable period of time, these terms can not correctly be used by examiners in the field. They should confine their terminology to "active," "inactive," and "healed" lesions. ROBERT U. PATTERSON, Assistant Director. SCHEMA FOR THE CLASSIFICATION OF SUBSEQUENT OBSERVATIONS Apparently cured.-All consititutional symptoms and expectoration with bacilli absent for a period of two years under ordinary conditions of life. Arrested. All constitutional symptoms and expectoration with bacilli absent for a period of six months; the physical signs to be those of a healed lesion; Röntgen findings to be compatible with the physical signs. Apparently arrested.—All constitutional symptoms and expectoration with bacilli absent for a period of three months; the physical signs to be those of a healed lesion; Röntgen findings to be compatible with the physical signs. Quiescent.-Absence of all constitutional symptoms; expectoration and bacilli may or may not be present; physical signs and Röntgen findings to be those of a stationary or retrogressive lesion; the foregoing conditions to have existed for at least two months. Improved. Constitutional symptoms lessened or entirely absent; cough and expectoration with bacilli usually present; physical signs and Röntgen findings to be those of a stationary or retrogressive lesion. Unimproved. Essential symptoms unabated or increased; physical signs and Röntgen findings to be those of an active or progressive lesion. Died. SPECIAL PROVISIONS AND DEFINITION OF TERMS It is expected that all sanatoria or others using this classification will specify in their reports whether or not Röntgen ray pictures have been used. Physical signs and Röntgen findings are often at variance and a given lesion should be classified by the method revealing the greater extent or intensity. For the convenience of those who want to specify in each case the basis of classification the following optional scheme of symbols is provided: When Röntgen findings or physical signs are the basis of the classification the letter (R) or the letter (P) may be written, respectively, after the group title, as moderately advanced (R) or moderately advanced (P). When the two examinations agree the symbol (PR) may be used. If a case is classified far advanced solely because of the presence of a serious tuberculous complication, the symbol (Comp.) may be affixed. It should be made clear that Röntgen findings may be positive where physical signs are negative or doubtful, or less frequently, that definite tuberculosis may exist without demonstrable Röntgenographic change. Pneumothorax, spontaneous or induced, is to be regarded as a serious complication and its presence places the case in the far advanced group. If, at the time of discharge, pneumothorax exists the patient's condition is not to be considered as better than improved. This classification provides for the following groups and subgroups: Minimal A Moderately advanced A Far advanced A Far advanced B The following definitions of Röntgen findings are based on the study of stereoscopic negatives (plates or films). Fluoroscopy may be of help, but alone is of less value. UNDER MINIMAL 1. Slight lesion (a), physical signs. Possibly slight depression above or below the clavicle, lessened movement of the chest, narrowing of the isthmus of apical resonance or restricted diaphragmatic excursion; slight or no impairment of resonance; slight or no change in quality or intensity of breath sounds, with or without some change in the rhythm (i. e., prolonged expiration); vocal resonance possibly slightly increased; rales present, absent or transitory. If sputum contains tubercle bacilli, any of these. (b) Röntgen findings.-Röntgenograms to show lessened transmission of light in the form of poorly defined, light mottling, or diffuse haziness interpreted as infiltration or conglomeration of tubercle, or more intense shadows of a well defined, stellate, or fibrillar character interpreted as fibrosis, with or without opacities interpreted as calcification. 2. A small part of one or both lungs.-Total volume of involvement, regardless of distribution, shall not exceed the equivalent of the volume of lung tissue which lies above the second chondrosternal junction and the spine of the fourth or body of the fifth thoracic vertebra on one side. UNDER MODERATELY ADVANCED AND FAR ADVANCED 3. Lesion allowable under moderately advanced.-One or both lungs may be involved, but the total involvement shall not exceed the following limits: (a) Slight disseminated infiltration or fibrosis which may extend through not more than the equivalent of the volume of one lung. (b) Severe infiltration with or without fibrosis which may extend through not more than the equivalent of one-third the volume of one lung. (c) Any gradation within the above limits. (d) Total diameter of cavities, if present, should not exceed 2 cms. 4. Physical signs of moderately advanced lesions are more variable than those of minimal lesions, and do not usually determine the exact extent of the involvement. 5. Röntgen findings in moderately advanced lesions.-Röntgenograms to show shadows similar in character to those described under minimal (par. 1 b) but more extensive or more intense, with or without areas of rarefaction interpreted as cavity formation. 6. Definite evidence of cavity formation.-Tubercle bacilli usually present; elastic fibers may be present in sputum. Physical signs may not be definite, but a combination of any four of the following signs is to be taken |