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                         CONFERENCE OF OFFICERS
                              IN CHARGE OF
                          GOVERNMENT HOSPITALS
                                SERVING
                       VETERANS OF THE WORLD WAR


                                  ★★★


                                HELD IN
                 AUDITORIUM, DEPARTMENT OF THE INTERIOR

                            WASHINGTON, D.C.

                     JANUARY 17–21, 1922, INCLUSIVE




                                CONTENTS


              Opening Session   Tuesday, January 17, 1922.
              Second Session    Tuesday, January 17, 1922.
              Third Session   Wednesday, January 18, 1922.
              Fourth Session  Wednesday, January 18, 1922.
              Fifth Session    Thursday, January 19, 1922.
              Sixth Session    Thursday, January 19, 1922.
              Seventh Session    Friday, January 20, 1922.
              Eighth Session     Friday, January 20, 1922.




                  _CONFERENCE OF OFFICERS IN CHARGE OF
                      GOVERNMENT HOSPITALS SERVING
                       VETERANS OF THE WORLD WAR_


                           _WASHINGTON, D.C.
                    JANUARY 17–21, 1922, INCLUSIVE_

                _AUDITORIUM DEPARTMENT OF THE INTERIOR_


                       UNDER THE AUSPICES OF THE
                 U.S. FEDERAL BOARD OF HOSPITALIZATION

 Brig. Gen. Charles E. Sawyer, Chairman. Chief Coordinator.
 Col. Chas. R. Forbes, Vice-Chairman.    Director, Veterans’ Bureau.
 Dr. W. A. White, Secretary.             Supt., St. Elizabeths Hospital.
 Maj. Gen. Merritte W. Ireland.          Surgeon General, U.S.A.
 Rear Admiral E. E. Stitt.               Surgeon General, U.S.N.
 Brig. Gen. H. S. Cumming.               Surgeon General, U.S.P.H.S.
 General George H. Wood.                 President, N.H.D.V.S.
 Hon. Charles M. Burke.                  Commissioner of Indian Affairs.




 PROCEEDINGS OF CONFERENCE OF OFFICERS IN CHARGE OF GOVERNMENT HOSPITALS
                    SERVING VETERANS OF THE WORLD WAR




           _Opening Session_      Tuesday, January 17, 1922.


At 10:00 A.M. the meeting was called to order by Brigadier-General
Charles E. Sawyer.

The roll was called by Dr. W. A. White.

General Sawyer delivered the following address on the subject, “The
Present Status of Federal Hospitalization from the Standpoint of the
Federal Board.”

“Commanding Officers:

You are here, as your program indicates, by invitation of the Federal
Board of Hospitalization. That you may know your host, the following
facts are submitted:

The Federal Board of Hospitalization was created by an Executive Order
of President Harding. The purpose of the Board is expressed in the Order
creating it, which is as follows:

                           “Circular No. 44.

                          TREASURY DEPARTMENT,
                          Bureau of the Budget
                               WASHINGTON

                                                       November 1, 1921.

FEDERAL BOARD OF HOSPITALIZATION.

TO THE HEADS OF DEPARTMENTS AND ESTABLISHMENTS:

1. For the purpose of coordinating the separate hospitalization
activities of the Medical Department of the Army, the Bureau of Medicine
and Surgery of the Navy, the Public Health Service, St. Elizabeths’
Hospital, the National Home for Disabled Volunteer Soldiers, the Office
of the Commissioner of Indian Affairs, and the United States Veterans’
Bureau, there is hereby organized a Federal Board of Hospitalization.

2. The Board shall be composed of the following officials: An official
to be designated by the President, who shall be known as Chief
Coordinator and who shall be President of the Board; the Surgeon General
of the Army; the Surgeon General of the Navy; the Surgeon General of the
Public Health Service; the Superintendent of St. Elizabeths’ Hospital;
the President, Board of Managers, National Home for Disabled Volunteer
Soldiers; the Commissioner of Indian Affairs; and the Director of the
United States Veterans’ Bureau.

3. It shall be the duty of the Board:

    (a) To consider all questions relative to the coordination of
hospitalization of the departments represented.

    (b) To standardize requirements, to expedite the inter-department
use of existing Government facilities, to eliminate duplication in the
purchase of supplies and the erection of buildings.

    (c) To formulate plans designed to knit together in proper
coordination the activities of the several departments and
establishments, with a view to safeguarding the interests of the
Government and to increasing the usefulness and efficiency of the
several organizations, and to report to the President thereon.

4. The Chief Coordinator of the Board of Hospitalization shall preside
over the Board and be responsible for its efficiency and for developing
its activities along practical lines. After a full discussion of any
question by the Board, the decision of the Chief Coordinator will be
final as to any action to be taken or any policy to be pursued, but any
member may appeal from the decision to his own immediate superior.

                                        By direction of the President:

                                                    CHARLES G. DAWES,
                                                    Director of the
                                                  Bureau of the Budget.”

From this you will readily see that the extent of the work under the
administration of this Board is very far-reaching and is an innovation
in Federal Hospitalization activities, for beside being interested in
behalf of reasonable economies in administration, the Federal Board of
Hospitalization is particularly and especially interested in carrying
out the highest ideals of modern hospitalization for the far advanced
Veteran.

The President and his administrative family have in mind, as the basic
principle of all hospital service, the very best that can be supplied,
measured by real end-results.

The Board of Hospitalization represents all of the Departments of the
Government directing and controlling the Federal Hospitals of the United
States. Each of the Chiefs of these Departments will speak of his
particular relation to the subject of Hospitalization as it refers to
the World War Veteran, as the program proceeds.

In order that each of you may understand the magnitude of the entire
subject of Hospitalization of the World War Veteran, I wish to present
the following facts;

Today there are being hospitalized under Government control, in Federal
Hospitals, 22,440 World War Veterans, who are distributed among the
various Departments as follows:

                 U.S. Public Health Service      16,373
                 U.S. Army Hospitals              1,681
                 U.S. Navy Hospitals              1,059
                 Soldiers Home Hospitals          2,500
                 Dept. of the Interior Hospitals    827
                                                 ——————
                           A total of            22,440

This does not take into account patients in contract hospitals which now
number 9,066. This enumeration demonstrates something of the scope and
nature of the work for which the members of the Board of Hospitalization
are responsible.

It may interest you to know that there are now under construction 7,592
new beds, which will be ready for occupancy within the next few months
and that the Government is at present contemplating at least 2,500 more
beds under the new Langley Bill, so ultimately the Government will have
under its direct administration hospital capacity for a minimum of
32,000 patients, which is estimated to be the peak load.

Heretofore there has been no coordinate plan of operation of these
various institutions. Under the Board of Hospitalization all of this has
been changed and today, you, whether from the Army, Navy, Public Health
Service, National Home for Disabled Volunteer Soldiers or the Department
of the Interior are all members of one big professional family, each
engaged in the same service, under the same regulations, for the care
and treatment of the World War Veteran.

The Hospitals engaged in this service number at present 107, distributed
as follows:

   77 Hospitals controlled and operated by the Public Health Service,
    6 Hospitals controlled and operated by the War Department,
   14 Hospitals controlled and operated by the Navy Department,
    9 Hospitals controlled and operated by the Soldiers Homes,
    1 Hospitals controlled and operated by the Interior Department.

These institutions are located in all sections of the United States from
the Atlantic to the Pacific and constitute one of the greatest
hospitalization propositions within the history of any country.

The personnel engaged represents an Army of almost as many more persons.
In other words, Uncle Sam, within himself, is today keeping in operation
a hospitalization program incomparable with anything with which former
experiences are familiar.

With this representation of the subject and its magnitude, I wish to
remind you that each one of you personally and individually is a part of
this great machine; and upon you rests the responsibility of the
carrying out of such policies as are adopted by the Central
Administration.

In order that there might be perfect coordination and cooperation in all
of these hospitals and that all institutions serving the World War
Veteran might be operated upon a standardized basis, the Board of
Hospitalization recently adopted the following regulation as to
personnel:

 Doctors,                            1 to every 20 patients
 Nurses,                             1 to every 10 patients
 Occupational Therapists,            1 to every 50 patients
 Social Workers,                     1 to every 50 patients
 Vocational and Prevocational       14 to every hospital of 200 patients
   trainers and assistants
 Other hospital employees.         130

Making a total of 182 employees to every 200 patients, or almost one
attendant and assistant to each patient.

This arrangement provides that all patients will have equal care and
attention of such a similar type as to guarantee to all classes of
patients the best of professional, nurse and domiciliary attention that
can be given, no matter in what Department they are being treated.

All of the Departments constituting the Board of Hospitalization are now
meeting in joint sessions, wherein they take up in detail all of the
matters pertaining to the welfare of the Veteran Hospitalization
subject. Out of this consideration there is developing a much better
understanding, a more complete system of operation, better conduct and
much better end-results.

One of the objects of this conference is that you the better understand
by personal contact with each other and with the different phases of the
work, what the business of caring for these veterans in its entirety
means. We know of course that you each have your special problems, you
each have certain affairs within yourselves that keep your attention
very much engaged in the things with which you come personally in
contact, but we thought it would give you a better impression of the
magnitude and importance of the subject if we were to have you here
where those who are responsible for the direction of the affairs of
Hospitalization could meet you individually.

We want you to know that we are greatly interested in you and the
service you are rendering. We wish you to feel assured that your
interests are our interests. We wish to impress upon you that the
conduct of the affairs under your administration means the reputation
and the historical record of the Government’s treatment of the World War
veteran.

We are anxious indeed that you should get from this meeting inspiration
for better work and encouragement in the efforts that you are putting
forth, new ideas with which to meet the great and everchanging
propositions which are before you, closer touch with those who, like
yourselves, are interested in the World War defenders. This accomplished
and each of us will have benefited and the expense of time and money in
your coming here will be justified.

Your contact here should make you bigger and broader men. If you will
take out of the great opportunities that are presented in the privileges
of this meeting, the effects which may be obtained, we are sure that you
will go back to your respective fields of service better satisfied, more
capable and certainly more determined than ever to render the best
service there is within you under all circumstances and conditions.

It seems pertinent that I should impress upon you at this time that no
matter what kind of institutions the Government may possess, how well
equipped with apparatus, or how pleasing in location, without your
interest, without the scientific care and attention which you can
provide, without your determination and your loyal support and action in
all of the affairs pertaining to the conduct of these institutions, they
will fail.

On the other hand, if you will give them the best within you, if you
will keep yourselves professionally and administratively in the vanguard
of such affairs, if you will go whole-heartedly, persistently and
determinedly forward to the carrying out of the highest ideals your
constructive visions can invent, the world War Veteran will realize that
in his Government he has the care and appreciation of the best
Government under the sun.

Allow me to again admonish you that upon you individually and personally
rests much of whatever is to come to the present Administration, either
in the form of complaint or of eulogy. To the end that it may be eulogy,
let there ever abide with you the assurance that the President of the
United States and all of his administrative assistants will be with you
heart and soul in everything that promotes the interest of the
rehabilitation of the World War Veteran. Remember that you owe to your
country and to yourselves that you practice economy, that you deal
fairly, that you act squarely with all of the propositions which come to
you. Do not forget that you should be loyal to the Departments to which
you belong, ever obedient to the orders of your Chiefs; that you be
faithful, earnest and sincere, honest, conscientious and ever active in
behalf of the highest principles connected with the maintenance of the
institution with which you are connected and finally that you be ever
able to register and substantiate yourselves as American citizens, full
of an American spirit, loyal to country and to flag.

If you will do these things, you will have the everlasting gratitude of
the President of the United States, you will be entitled to and will
receive the econiums of our dear doughboys and above all you will have
the satisfying consciousness of a noble duty truly done.

In order that the business of the conference may be transacted
expeditiously and effectively, the following rules will be enforced by
the presiding officer of each session:

 1. Those having addresses upon specified subjects are expected to
      present a typewritten copy to the Secretary that it may be kept
      for reference in the Office of the Board of Hospitalization.

 2. All addresses will be limited to 15 minutes. All special subjects
      will be limited in presentation to ten minutes. General
      discussions will be limited to five minutes.

 3. Each session will begin promptly on time.

 4. Roll call of the attendants will be taken at the beginning of each
      meeting.

 5. Reports of all proceedings of sufficient importance will be recorded
      by the expert stenographers in attendance.

 6. This is a business affair and should be so considered by all
      present. We are here to develop plans. We are here to receive
      suggestions and get in line for the execution of orders which will
      lead to the development of the highest order of hospital care and
      treatment. With these suggestions we will proceed to the carrying
      out of the program.”

“I have pleasure at this time in introducing to you Colonel Charles R.
Forbes, who will speak to you on the ‘Relation of the Veterans’ Bureau
to all Hospitalization Activities’.”


COLONEL FORBES: Addressed the conference as follows:

“Upon the signing of the Armistice on November 11, 1918, there was
immediately commenced the demobilisation of the armed military and naval
forces of the United States, comprising approximately 4,000,000 men and
women. As an aftermath of war service from the result of battle wounds,
gassing, injuries and disease it was anticipated that there would be a
large number of men and women who would be physically disabled, either
temporarily or permanently, partially or totally. While it was known
with a reasonable degree of accuracy how many there were who has been
discharged from the several services on Surgeons’ Certificate of
Disability and the number discharged with disability noted at the time
of discharge, it was not possible to foretell the magnitude of that
considerable body of men and women who though discharged from the
service apparently in good health would subsequently develop a
disability traceable to military service. Even at the present time, more
than three years after the Armistice it is not possible to state the
exact magnitude of the medical problem confronting the United Veterans’
Bureau, since new claims for compensation because of disability are
being filed at the rate of approximately 541 per day. As an index
however to the magnitude of this problem, gentlemen, let me tell you
that to date have been filed more than 762,000 claims for compensation
for disability and death incurred in military or naval service. While
this total number of claims have not all been allowed, this number does
constitute the present potential load for the United States Veterans’
Bureau.

By the original War Risk Act and subsequent acts amendatory thereto,—the
United States Government recognized its very great obligation to the
ex-service men and women who had become disabled through service, and by
these Acts provided not only financial aid to the disabled veterans but
also all reasonable medical and surgical treatment and care, whether in
a hospital, out-patient office, or at home.

The problem of hospitalization itself soon became of paramount
importance. It was initially recognized that, in spite of the meagre
governmental hospital facilities then available for the care of
beneficiaries of the United States Veterans’ Bureau, it was essential
for the best administrative control of veteran patients and for the best
professional control over their treatment to place the beneficiaries of
the United States Veterans’ Bureau under government supervision in
government owned or operated institutions. The carrying out of this
policy has been proceeding steadily at a rate commensurate with the rate
at which additional government hospital beds have been made available.
At no time however has it been possible to discontinue the use to a
considerable degree of contract civil institutions. Even at the present
time the United States Veterans’ Bureau is utilizing approximately 757
civil institutions for the care of approximately 8,924 of its
beneficiaries, and has contracts with a total of 1,524 civil
institutions for such care. It is however significant to note while in
July 1920 more than fifty percent of Veterans’ Bureau patients were in
contract hospitals, on January 1, 1922, but 30 percent of patients were
in contract hospitals. Furthermore the number of hospitals being
utilized at any time had dropped from approximately 1200 to 757.

The curtailment in the use of private facilities was of course the
direct result of increased facilities in government operated hospitals.
The United States Government had originally stipulated that the
hospitalization of veterans of the World War should be provided for the
United States Public Health Service through its Marine hospitals and
such other hospitals as it had been authorized to acquire. When however
it was discovered that the immediate facilities offered by these
hospitals were insufficient to meet the demand for hospitalization, the
hospital services of the United states Army, the United States Navy and
the National Homes for Volunteer Disabled Soldiers were to a certain
extent made available to the United States Veterans’ Bureau.

In March, 1919, the United States Public Health Service was operating
but 21 small Marine Hospitals. In order to meet the demand made upon it
by the then Bureau of War Risk Insurance, additional hospital facilities
were rapidly acquired, so that by November, 1919 there were in operation
a total of 38 hospitals with a total bed capacity of approximately
7,625. A year later namely on November 1, 1920 there had been made
available a total of 52 hospitals representing 13374 hospital beds. At
the present time, January, 1922, there are available 65 United States
Public Health Service Hospitals representing approximately 18,200
hospital beds. It is true that due to the necessity of securing with the
least possible delay adequate hospital beds, it was necessary to make
use of certain Army cantonment hospitals of temporary structure.
Hospitals of this type are admittedly unsatisfactory, and it is my
earnest desire to close such hospitals just as soon as properly located
hospitals of permanent construction are available to take their place.

Although prior to July, 1920, there had been a limited use made of the
facilities of the Army, Navy and National Soldiers’ Homes in the case of
Veterans’ Bureau patients, it was not until that date and in accordance
with provisions of the Sundry Civil Act of the 66th Congress that a
systematic and more extensive use of these facilities was proposed. It
was perceived that with the general reduction in the Army and Navy
personnel a number of large and well equipped government hospitals were
not being utilized to their full capacity. The utilization of these
facilities would have a two fold result, first, the placing of a larger
number of patients under direct government medical supervision, and
second, a more pronounced curtailment in the use of contract civil
facilities.

In June, 1920, under plans agreed upon by the representatives of the
then Bureau of War Risk Insurance and of the several government services
there were immediately made available 4181 hospital beds, not including
those in operation by the United States Public Health Service divided
among the services as follows: Navy Department Hospitals, 1760; War
Department Hospitals, 1510; National Soldiers’ Homes, 911. Additional
plans contemplated increased facilities by all those services. At the
present time, January 1922, in accordance with these plans the following
number of beds have been made available by these three services: Navy
Department, 3396; War Department, 2917; National Soldiers’ Homes, 3317;
Total, 9630.

I have briefly outlined the growth to the present time in government
hospital facilities available to the United States Veterans’ Bureau.
Combining the figures I have enumerated it is seen that the total number
of available government hospital beds has increased during a period of a
little more than two years and a half from a few thousand beds in 21
Marine hospitals to a total of 28655 beds in 94 government hospitals.

Let me now outline briefly the growth in our hospital population over
this period. In September, 1919 there were recorded a total of 6003
patients of the Bureau of War Risk Insurance, which total had increased
by January 1920 to 10907, and by July 1920 to 19,489, averaging over
this period a monthly increase in hospital patients of approximately
1225. From July 1920 to January 1922 the hospital population increased
from 19,489 to 29,263.

These 29,263 patients are hospitalized to the following extent in the
several classes of facilities: United States Public Health Service,
13,874; United States Army, 1530; United States Navy 1473; National
Soldiers’ Homes, 2637; St. Elizabeth’s Hospital, Interior Department,
825; Contract Civil Hospitals, 8924. By general class of disease,
these patients are divided as follows: Tuberculosis, 11,822;
Neuro-psychiatric, 8,414; General medical and Surgical, 9027.

Of the total number of 28,655 government hospital beds available, 20,339
are occupied at the present time, leaving a balance of 8,316 unoccupied
hospital beds.

As previously stated, it is the policy of this Bureau wherever
practicable, to remove beneficiaries of the Bureau from contract
institutions and place them in hospitals operated by the governmental
medical services. If it were possible at the present time to fill every
vacant government bed by patients in contract hospitals we would still
be obliged to continue 608 cases in contract institutions.

An analysis of the vacant government beds shows that they fall under the
following category:

                  For tuberculosis               2,292
                  For neuro-psychiatric            748
                  For general medical & surgical 5,276
                                                 —————
                              Total              8,316

An analysis of the patients in contract hospitals shows they are
classified as follows:

                    Tuberculosis               2,930
                    Neuro-psychiatric          4,004
                    General medical & Surgical 1,990
                                               —————
                              Total            8,924

A review of these two sets of figures shows that although there are
apparently ample facilities for the care of general medical and surgical
cases, there is a real and serious shortage of government beds for the
care of tuberculosis and neuro-psychiatric cases.

In considering the use of government hospital beds at present reported
vacant, it is of course entirely impracticable to attempt to accomplish
the complete filling up of all government hospitals. As you all realize,
this is due to a number of reasons, chief of which are (1) the
administrative necessity at all hospitals of maintaining a surplus of
beds amounting to from ten to fifteen percent of capacity to allow
flexibility in case of epidemic or sudden emergency; and to permit
unhampered the routine admission and discharge of patients, (2) the
location of vacant beds away from the points of greatest demand, and (3)
the fact that the vacant beds available are not of the type required at
points where the Bureau needs them.

From an analysis of this whole situation it is believed that we have
sufficient beds available for the care of general cases with the
exception of two or three areas of the country, such as Memphis,
Tennessee, and in the metropolitan district of New York. Some provision
must be made to care for cases of a general nature because facilities at
these points are totally inadequate. In New York, the existing
facilities must be given up by June 1922.

However, the number of general medical and surgical cases requiring
treatment will steadily diminish and contract hospitals in many
instances would ultimately be able to care for their needs. On the other
hand, the Bureau must make provision for the care of tuberculosis and
neuro-psychiatric cases for many years to come.

The general medical and surgical cases are a type which justify the use
of contract institutions more than the other classes referred to, by
reason of the comparatively short length of time that treatment is
indicated: emergency conditions which require immediate hospitalization
where the patient may be; and the disinclination on the part of
claimants to be far from home, especially when a surgical procedure is
indicated.

The hospital program of the Veterans’ Bureau is meant to provide
approximately 20,500 permanent beds for the treatment of tuberculosis
and mental cases. It is estimated that between the present time and the
end of 1923 the Veterans’ Bureau will lose the use of approximately
5,400 beds because the hospitals will have to be abandoned by reason of
expiration of lease, temporary nature of the structure, or for other
cogent reason.

The hospitals being constructed out of the Langley Bill (Act of 4 March
1921) and appropriations for the Public Health Service made either by
the Secretary of the Treasury or the United States Veterans’ Bureau
which will become available during the two years ending with the
calendar year of 1923, will only provide 7,198 beds, while during the
same period of the time the Bureau will lose 5,397 beds for the reasons
already indicated. The ultimate loss of beds by reason of expiration of
lease, temporary nature of the structure, etc., will be approximately
4,875 greater than the beds which will be provided as result of
construction now going on under existing appropriations.

From careful studies that have been made, it is evident the Bureau will
require additional hospital facilities at the following points:

   500 beds for tuberculosis patients in the State of California;
   500 beds for insane in California;
   200 beds in Chicago to enable the Edward Hynes Jr. Hospital to be
         converted into a hospital for mental cases;
   150 beds for general medical and surgical cases in the vicinity of
         Memphis;
   600 beds for general medical and surgical cases in the metropolitan
         area of New York;
   250 beds for general medical and surgical cases at the Walter Reed
         Hospital
 _____
 2,200

It has recently become apparent that the neuro-psychiatric hospital at
Marion, Indiana, operated by the National Home for Volunteer Disabled
Soldiers, can only care for nervous and mild mental cases, and is not
prepared to handle definitely insane. Development in the future may make
it necessary, therefore, to ask for further provision for insane at that
or some other point in the country east of the Mississippi River.

Estimating that we will have approximately 2,000 or 2,500 cases in
contract institutions for many years, the Bureau is endeavoring to
provide for a maximum load of about 32,000 cases, the peak probably
being reached in 1922. It is estimated that the general medical and
surgical cases will diminish rapidly, but that permanent beds for the
treatment of approximately 13,000 tuberculosis, and 9,500
neuro-psychiatric cases must be available.

Gentlemen, I have attempted briefly to outline the growth and the
magnitude of our hospitalization program, and have told you roughly what
the expectation and needs of the United States Veterans’ Bureau in
regard to hospitalization facilities are. It is all summed up in our
earnest endeavor of the United States Government to provide every
ex-soldier, sailor, marine or nurse who becomes a beneficiary is the
United States Veterans’ Bureau with the best medical treatment available
under the best conditions possible. But in spite of our needs for
additional governmental hospital facilities, I want to assure you all
that to my best knowledge there is not a single veteran of the World
War, eligible for treatment and who has applied for hospital treatment,
for whom hospital facilities have not been found or who has not been
offered hospitalization.”


GENERAL SAWYER:

“Allow me to suggest just one thing. You will notice that on the program
there is a time for general discussion of all these subjects, and I wish
you would make pencil notes of the things that appeal to you as being of
importance enough to be called up during the discussion. We are here
really to get out of this all we can, and we want you to feel free to
call for any further consideration of these subjects when we get to that
hour of discussion.

I have pleasure in introducing Major Merritte W. Ireland, who will
address you upon the subject of ‘The Army’s Relation to the
hospitalization of the World War Veteran’.”


GENERAL IRELAND:

The treatment provided in our military hospitals for World War soldiers
may be summarized in instructions approved by the Secretary of War,
which were about as follows: That no member of the military service
disabled in line of duty even though not expected to return to duty,
would be discharged from the service until he had attained complete
recovery or as complete recovery as could be expected he would attain
when the nature of his disability was considered. It was laid down,
further, that physical reconstruction consisted in the completest form
of medical and surgical treatment carried to the point where maximum
functional restoration, mental and physical, had been secured. To secure
this result the use of work, mental and manual, was required during the
convalescent period. This therapeutic measure, in addition to aiding
greatly in shortening the convalescent period, retains or arouses mental
activities, prevents the state of mind acquired by chronic hospital
patients, and enables the patient to be returned to service or to civil
life with the fullest realization that he can work in his handicapped
state and with habits of industry much encouraged, if not newly formed.
Early in 1918, the Secretary of War also authorized the Medical
Department to proceed with the scheme for reconstruction of officers and
enlisted men of the Army alone without consideration of the other
bureaus of the government involved. This reconstruction it was clearly
understood would end at the point where the medical reconstruction
ceased and the future reconstruction of such cases was to be completed
by other agencies of the Government after the individuals had been
discharged from the Army.

Patients then were cared for in military hospitals up to the point of
maximum functional restoration, both mental and physical. In the case of
patients who were ultimately to be discharged from military service,
arrangements were made whereby the Federal Board for Vocational Training
might have access to these men as soon as it was known that they were to
be discharged and the educational officers of the Medical Department
were directed to cooperate with the representatives of the Federal Board
to the fullest possible extent, in order that the patients concerned
might have all the advantages assured them by the Federal Government.

It was recognized that in order to make this program successful for the
attainment of the maximum physical and mental condition through complete
medical and surgical treatment, it would require the establishment of a
policy of extended publicity. This embraced the necessity to educate the
public to the need of this physical reconstruction for the disabled men
before their return to civil life; to educate the family of the soldier
with regard to the need of continued treatment that they might be
satisfied to have them remain in hospital, and finally, to educate the
soldier himself by placing in his hands at the earliest possible moment
after his disability had been incurred the necessary literature which
would inform him of his status as a soldier and of the privileges, which
were to be his as a disabled man, from the Medical Department of the
Army, the Federal Board for Vocational Education, the Bureau of War Risk
Insurance, and also to place in his hands such literature as would
inform him of facts concerning various trades from which he might choose
a vocation, together with all the information in regard to the need for
men in the various industries of the country.

As above outlined this policy of treatment was carried out. At the
approved time for the discharge of the patients from the military
service, they at once became beneficiaries of the Bureau of War Risk
Insurance and subject to further physical reconstruction or education,
if such were necessary, under the direction of the Federal Board, Public
Health Service or the Bureau of War Risk Insurance.

Such facilities as were in our hospitals and were not required for the
care of the sick of the active list of our army were placed at the
disposal of the discharged veterans of the World War. This was done
mainly in two ways: first, by turning over to the Public Health Service
which was charged with the medical work of the Federal Board, many
complete hospitals and second, by caring for many of the veterans in our
own hospitals after their proper discharge from the service.


               _HOSPITALS RELEASED FOR CARE OF VETERANS_

By virtue of Act of Congress in March, 1919, every military hospital,
including its supplies, no longer required for the proper care of the
sick in the military service was to be turned over to the Public Health
Service if the latter service so desired. A detailed classified list of
hospitals approximating 2,460 beds turned over under this law follows:


 General Hospitals at permanent military stations which were transferred
                        to Public Health Service.

                       Name                         Bed        Date
                                                  capacity  transferred

 Fort Bayard, New Mexico                              1000 June 15, 1920
 Fort McHenry, Maryland                                200 June 15, 1920
 Whipple Barracks, Arizona                             600 Feb. 15, 1920
                                                      ————
                      Total                           3600


  Hospitals on Leased Properties transferred to Public Health Service.

                       Name                         Bed        Date
                                                  capacity  transferred

 [1]O’Reilly Gen. Hosp., Oteen, N.C.                  1300 Oct. 15, 1920
 [1]Hoff Gen. Hosp., Staten Island, N.Y.              1468 Oct. 15, 1920
 Gen. Hosp. #10, Boston, Mass.                         700 July 1, 1919
 Gen. Hosp. #12, Biltmore, N.C.                        450 Sept, 1, 1919
 Gen. Hosp. #13, Dansville, N.Y.                       288 April 2, 1919
 Gen. Hosp. #15, Corpus Christi, Texas                 262 May 31, 1919
 Gen. Hosp. #16, New Haven, Conn.                      500 Sept. 1, 1919
 [2]Gen. Hosp. #17, Markleton, Pa.                     187 Mar. 27, 1919
 Gen. Hosp. #24, Parkview, Pa.                         700 July 30, 1919
 Gen. Hosp. #32, Chicago, Ill.                         550 May 15, 1919
 Gen. Hosp. #34, East Norfolk, Mass.                   340 June 24, 1919
 Gen. Hosp. #40, St. Louis, Mo.                        530 June 12, 1919
 Emb. Hosp. #4, (polyclinic) N.Y.                      374 Aug. 15, 1919
 Norwegian Lutheran and Deaconess Home, Brooklyn,      250 May 15, 1919
   N.Y.
 Post Hosp., Q.M. Terminal, Sewell’s Point, Va.        250 May 27, 1919
 Nitrate Plant, Perryville, Md. (approx)               150 Oct. 1, 1919
                                                      ————
 Total                                                8299


       Camps and Cantonments taken over by Public Health Service.

                       Name                         Bed        Date
                                                  capacity  transferred

 Camp Beauregard, Louisiana                           2144 Mar. 18, 1919
 Camp Cody, New Mexico                                1289 Apr. 14, 1919
 Camp Hancock, Georgia                                1604 Mar. 27, 1919
 Camp Joseph E. Johnston, Florida                      816 July 17, 1919
 Camp Logan, Texas                                    1156 Mar. 12, 1919
 Camp Sevier, S. Carolina                             1396 Apr.  5, 1919
 Camp Fremont, California                             1156 Mar. 20, 1919
                                                      ————
 Total                                                9561
                                                           = Total
                                                             21,460

Footnote 1:

  Indicates buildings constructed by the Army on leased ground.

Footnote 2:

  General Hospital No. 17 was closed as an Army hospital on March 27,
  1919, the Public Health Service having stated that it did not desire
  this hospital. Later on, however, this hospital was taken over by the
  Public Health Service.

Hospitals abandoned by the Medical Department, U. S. Army, and available
to the Public Health Service, but not occupied by that Service because
they were not located where additional hospitalization was needed.

          General Hospitals          Capacity         Abandoned

 GH #1, New York City                    1258 Oct. 15, 1919
 GH #3, Colonia, New Jersey              1650 Oct. 15, 1919
 GH #8, Otisville, N.Y.                  1000 Nov. 15, 1919
   (tuberculosis)
 GH #9, Lakewood, New Jersey              986 May 31, 1919
 GH #11, Cape May, New Jersey             750 July 20, 1919
 GH #18, Waynesville, N. C.               600 June 30, 1919
   (tuberculosis)
 GH #22, Philadelphia, Pa.                450 June 10, 1919
 GH #23, Hot Springs, N. C.               600 Mar. 15, 1919
 GH #35, West Baden, Ind.                 800 June 30, 1919
 GH #36, Detroit, Michigan                900 Aug. 10, 1919
 GH #38, East View, New York              850 July 15, 1919
 GH #39, Long Beach, L. I.                550 May 21, 1919
                                        —————
                Total                   10394


        Base (Camp) Hospitals        Capacity         Abandoned

 BH Camp Wadsworth, S.C. (GH #42)        1000 October 10, 1919
 BH Camp Bowie, Texas                    1000 Subsequent to Mar. 3, 1919
 BH Camp Custer, Michigan                1500 Subsequent to Mar. 3, 1919
 BH Camp Gordon, Ga.                     1500 Subsequent to Mar. 3, 1919
 BH Camp Greene, North Carolina          1000 Subsequent to Mar. 3, 1919
 BH Camp McArthur, Texas                 1000 Subsequent to Mar. 3, 1919
 BH Camp McClellan, Alabama              1000 Subsequent to Mar. 3, 1919
 BH Camp Shelby, Mississippi             1000 Subsequent to Mar. 3, 1919
 BH Camp Sheridan, Alabama               1000 Subsequent to Mar. 3, 1919
 BH Camp Taylor, Kentucky                1500 Subsequent to Mar. 3, 1919
 BH Camp Upton, L.I., N.Y.               1500 Subsequent to Mar. 3, 1919
 BH Camp Wheeler, Georgia                1000 Subsequent to Mar. 3, 1919
                                        —————
                Total                   14000


           Port Hospitals            Capacity         Abandoned

 EH #1, (St. Marys) Hoboken, N.J.         500 Oct. 31, 1919
 DH #3, (Greenhut Bldg.) New York        3100 July 15, 1919
   City
 DH #5, (Grand Central Palace)           2700 June 30, 1919
   N.Y.C.
 BH Camp Merritt, New Jersey             2000 Dec. 15, 1919
 BH Camp Mills, L.I.  N.Y.               2000 Sept. 18, 1919
 BH Camp Stuart, Newport News, Va.       2000 Sept. 10, 1919
                                       ——————
                Total                   12300

                               Total    36694

In addition to the foregoing the following permanent military posts have
been recently acquired by the Public Health Service from the Army:

               Post                       Size of Post

   Boise Barracks, Idaho         4 troops cavalry
   Ft. W.H. Harrison, Montana    4 companies infantry and hdqrs. 1892
   Ft. Walla Walla, Washington   4 troops cavalry and hdqrs.     1859
   Ft. McKenzie, Sheridan, Wyom. 8 companies infantry & hdqrs.   1898
   Ft. Logan H. Roots, Arkansas  4 companies infantry            1892


         _VETERANS’ BUREAU CASES TREATED IN MILITARY HOSPITALS_

“Now, with reference to assistance rendered within our own hospitals, in
an interview with the Director of the War Risk Insurance in 1919, I
heard the former Secretary of War say that he considered it an
obligation on the Army to assist in caring for the discharged World War
veterans and that any vacant bed in Army hospitals was always available
for the treatment of these men. To carry out this policy, the Bureau of
War Risk and later the Veterans’ Bureau was from time to time advised by
the Medical Department of the number of available beds in our hospitals
in which we could accept for treatment veterans of the World War. The
number of beds thus offered has varied slightly from time to time, but
has always been on the increase, particularly since last July. Last May
1450 beds were available to the Veterans’ Bureau; in October 1752 beds
were available, and by November 24th 2200 beds were available. The
following brief table gives the exact status on January 5, 1922:

    Hospital    │Beds as │   Patients in Hospital   │  Total   │ Vacant
                │ signed │                          │  Cases   │  Beds
                │   to   │                          │  Under   │ B.V.B.
                │ B.V.B. │                          │treatment.│
                │  (1)   │                          │          │
 ───────────────┼────────┼────────┬────────┬────────┼──────────┼────────
                │        │ T. B.  │ Neu-P. │ G.M. & │          │
                │        │  (2)   │   (3   │   S.   │          │
                │        │        │        │  (4)   │          │
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
 Army & Navy    │     150│       0│       2│      85│        87│      72
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
 Beaumont       │     200│      43│       5│      18│        66│     134
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
 Fitzsimmons    │     600│     787│       0│      74│       861│     338
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
 Letterman      │     250│       7│       7│      58│        72│     237
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
 Ft. Sam Houston│     300│     139│      11│      63│       213│      87
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
 Walter Reed    │     750│      26│      24│     334│       384│     366
 ───────────────┼────────┼────────┼────────┼────────┼──────────┼────────
      TOTAL     │    2250│    1002│      49│     632│      1683│    1234
 ───────────────┴────────┴────────┴────────┴────────┴──────────┴────────

Within a few days we expect to open up several hundred beds at
Fitzsimmons General Hospital for veterans suffering from tuberculosis.
This last large increase has been made possible by funds transferred by
the Veterans’ Bureau to the War Department for the specific purpose of
enlarging this hospital. When the construction and alteration made
possible by these funds has been completed (and the completion is
expected almost daily) 700 additional beds for the tuberculosis will
have been provided in permanent structures for a little over $1000 per
bed.

In addition to the buildings turned over to the Public Health, which
have already been enumerated, the Medical Department has turned over to
that Service supplies approximating a value of $12,336,000.00. It has
been a source of gratification to the Medical Department, and I am sure
to the War Department, that the Army was in a position to assist in
rendering aid to the American soldier disabled in the World War.

The total number of all cases treated in our general hospitals during
the last year was approximately 30,000; of these 10,000 were local cases
and 20,000 were general cases, and of the latter 15,700 were our own and
4300 pertained to the Veterans’ Bureau.

A brief summary of the Veterans’ Bureau cases treated in our hospitals
may be of interest. Of the 4,300 cases treated during the year (October
1, 1920, to October 1, 1921) 180, or about 4% were suffering from either
nervous or mental conditions; 2195 or about 51% with tuberculosis; 770,
or about 18% with diseases or injuries of the osseous system; 75, or
nearly 2% with heart or vascular diseases, and the remaining 25% was
made up of all other conditions combined.

In addition to this work, much assistance has been rendered in making
physical examinations for that Bureau to determine the right to
compensation or the necessity for hospitalization. Over 2,000 of these
examinations were made during the year, many of which necessitated
admission to hospital for varying periods to permit a thorough survey in
order that correct diagnosis or physical condition might be
established.”


GENERAL SAWYER: “I am sure it must be gratifying to you to obtain a more
intimate knowledge of the conduct of these affairs. I have pleasure in
introducing to you Rear Admiral Edward R. Stitt, Surgeon General of the
United States Navy, who will inform you as to ‘The Navy’s Part in the
Hospitalization of the World War Veterans’.”


ADMIRAL STITT:

“The Medical Department of the Navy has been able to work with the
Veterans’ Bureau along the following lines:

_First_: the turning over to the Public Health Service for the care of
the Veterans of the World War of the Naval hospitals at Philadelphia,
Pa., Cape May, N.J., Gulfport, Miss., and New Orleans, La. and quite
recently to the Veterans’ Bureau itself of the hospital at Fort Lyon,
Colo. used for tuberculosis patients. These institutions were completely
equipped when transferred, so that no additional expense was involved.
The hospital for tuberculous patients at Fort Lyon has been operated by
naval personnel since November first, but this institution will be taken
over by the Public Health Service on March 1st. With the great reduction
in naval personnel and the discharge from the service of large numbers
of the tuberculous, the needs of the Navy did not seem to justify the
maintenance by the Navy of so large a hospital, there being at present
735 beds with possibilities of expansion. Upon his return from a recent
inspection the Surgeon General of the Public Health Service expressed to
me his admiration for the institution. We should not have been able to
turn over this hospital had it not been for the generous offer of the
Surgeon General of the Army to take care of the naval tuberculous at the
Fitzsimmons General Hospital at Denver. The bed capacity of these five
hospitals totaled 2229.

_Second_: The caring for the veteran patients in the same hospitals in
which the sick of the Navy are being treated. In assigning
accommodations to the patients of the Veterans’ Bureau there are many
problem which complicate this matter. Manifestly it is necessary for the
Navy to be prepared to receive the patients from its own personnel, and
when it is considered that the fleet may at one time be in the port of
New York and sending its sick to the New York Hospital during such time
and then sail away for another port to then transfer its sick to another
hospital the difficulties are apparent. If we could divide the ships
between different ports and their sick between different hospitals the
matter would be easy of adjustment.

Again we have only a limited number of beds in our three hospitals on
the Pacific Coast and at the present time a large fleet is based on this
station so that we are unable to offer accommodations in those hospitals
to the Veterans’ Bureau and at the same time make adequate provision for
the naval sick.

As a general rule we are only able to provide hospital facilities for
general medical and surgical cases, but much of our work is in studying
cases of suspected tuberculosis and where a positive diagnosis is made
the determination of the extent of the process.

At Great Lakes, Ill. owing to the urgent needs of this section of the
country, we have agreed to care for approximately 300 neuropsychiatric
patients, this in addition to 300 beds for general patients. In order to
obtain medical personnel trained in the supervision of such cases it was
necessary to withdraw our psychiatric specialists from various stations
where their services were needed, but it was felt that this was a
greater need. To provide for additional men trained in this specialty we
now have a number of young medical officers under training at St.
Elizabeths Hospital.

The Navy is not only indebted to Doctor White for this service but it
owes him obligations for his many years of instruction to the classes at
our Naval Medical School. At the present time there are under
consideration plans for the establishment under Doctor White of a school
for the training of psychiatric personnel for other services caring for
veterans, taking advantage of the abundant clinical material at St.
Elizabeths.

At our hospital at Chelsea, Mass., we have been able to offer 539 beds
to the Veterans’ Bureau and from the letters I receive, as well as from
a personal inspection, I can attest the care that is there being given
our veterans.

The Navy is particularly proud of its good food and I think our
hospitals lead the Navy in this important service, which not only makes
for contentment but aids convalescence. We have just agreed to receive
the patients from the Polyclinic Hospital of New York and expect in a
short time to be caring for approximately 350 patients in the naval
hospital located in Brooklyn. We are very proud of the physio-therapy
installation at this hospital, which has been pronounced by experts as
one of the most complete equipments in the country.

In our hospital in Washington we are offering 250 beds. In this
institution we are peculiarly well equipped for the diagnosis and
treatment of obscure cases by reason of its association with the
laboratories of the Naval Medical School. These naval hospitals are
geographically so situated that large numbers of patients can be treated
near their homes. Although most of our hospitals in our island
possessions are small yet we can take care of a limited number of
veterans who might be in such localities.

The mental environment at these hospitals is admirable from a standpoint
of cheerfulness, amusement and when indicated occupational recreation,
our rule has been so far as possible to treat veterans and sailors
alike. To the Red Cross we owe much of the measures for contentment
among the patients, although we also owe obligations to the morale
division of the Navy Department for assistance along the lines of
recreational and educational opportunities, especially as regards well
conducted libraries. The number of beds now available in our hospitals
approximates 2900. Adding the 2229 beds transferred to the Public Health
Service makes approximately 5172.

_THIRD_ In the transfer to other agencies caring for veterans of
hospital supplies and equipment. As noted previously we have turned over
not only the beds of five hospitals but in addition surgical, X-Ray,
laboratory and other facilities as well as store rooms full of varied
supplies. In addition we have from time to time given various medical
and surgical supplies. I may state that we are now turning over to the
Public Health Service $1,375.00 worth of stock from our Supply Depot and
stand ready to transfer another million dollars worth of medical stores
when called for.

_FOURTH_ On board ship and at our various stations medical officers have
examined claimants by the thousands, assisted them in making their
applications and aided them with advice.

In the Bureau of Medicine and Surgery one of our most important
activities is in supplying data to the Veterans’ Bureau for use in the
adjudication of claims for compensation. The reports at present are more
comprehensive than formerly made, and include in addition to the name,
rank or rate and claim number, the date and place of birth, enlistment,
discharge or release to inactive duty, together with a detailed medical
history. The maximum number of reports sent out by the Bureau has been
250 in a day with an average daily completion of about 100 cases. At
present we are up to date in answering claims. Notwithstanding the
reduction of the clerical force in some divisions to the point of
extinction of the activity in the effort to make the furnishing of
records to the Veterans’ Bureau our first consideration we should have
been far behind in furnishing records had it not been for the hearty and
willing cooperation of the Veterans’ Bureau in assigning clerks from
their own forces to assist in this most important and imperative work.

Where by reason of law or otherwise we have been unable adequately to
provide for the veterans either in personnel or material Colonel Forbes
has ever stood by to give us hearty cooperation and assistance. I am
also indebted to General Sawyer, the Chief Coordinator of the
Hospitalization Board for encouragement and advice whenever asked of
him.

In reciting the activities of the Navy in providing hospital care for
veterans, I trust it has become apparent that I have the honor to
represent an organization, equipped to aid the Veterans’ Bureau in
fulfilling the pledges of our government to its veterans, disabled in
the Great War, and manned by a personnel actuated in all ranks by an
earnest desire to contribute in the discharge of our obligations.”


GENERAL SAWYER: “I do not know exactly what impression you get from this
information that is given out here by the heads of these great
departments, but to me it seems that here is a spirit, a whole-souled
determination to put everything at the command of the Government at your
service to help you, that we may help the World War Veteran to the best
that can be given. The recitation of these things by this Admiral and
this Major General shows how much really comes through a closer
affiliation,—how much we get that is worth the while from a better
understanding; and that is what we really believe we have in this new
Board of Hospitalization.

We have with us this morning the man who has been personally responsible
for the largest number of these patients; in fact, he is responsible for
more of these patients than all of the rest of the departments together;
and if you do not know him, I should like to introduce to you a man whom
I have found, by close contact and personal observation during the
months I have been in Washington, to be a man who is giving everything
within him to make of the Public Health Service of the United States of
America the best Public Health Service in the world and to give to the
World War veteran the best hospitalisation service that can be rendered.

I have pleasure in introducing to you Surgeon General Hugh S. Cumming,
of the United States Public Health Service, who will speak on the
subject of “The Service Rendered World War Veterans by the Public Health
Service.”


GENERAL CUMMING:

In presenting even a brief outline of the services which have been
rendered, and are being rendered, to disabled veterans of the World War
by the Public Health Service, it is necessary, for a proper
comprehension of the subject, to state, at least in general terms, the
genesis of the relationships which the Public Health Service has
sustained, and now sustains, to this very important responsibility.

The Congress, before the close of the war, had given consideration to a
comprehensive plan for the care of disabled veterans totally unlike the
previously existing pension systems, and had passed legislation putting
into effect this program.

In doing so, use was made of existing agencies rather than the creation
of new ones. Among these existing agencies was the U. S. Public Health
Service. This Service, on March 3, 1919, was given authority to furnish
medical care and treatment to veterans, acting in this capacity as an
agency of the War Risk Insurance Bureau. The Director of that Bureau was
charged with the real responsibility, but was permitted, under the
legislation, to make use of the Public Health Service in discharging his
responsibility with regard to medical care and treatment.

Peace having come unexpectedly and demobilisation following shortly
thereafter, the problem of the care for the disabled veteran became at
once very pressing. The Public Health Service had under its control only
a few hospitals, with a total bed capacity of about 1,500. The Director
of the War Risk Insurance Bureau looked to the Public Health Service to
supply him with the necessary medical services, and the Public Health
Service, therefore, found itself faced with the task of supplying, in a
short space of time, an extensive system of medical relief.

It undertook this problem and, under the legislation, sought to meet the
responsibility in several ways. By the transfer to its jurisdiction of
facilities used by the Army and Navy during the war, by the purchase of
such facilities as were available and within the moderate appropriation,
by the leasing of fairly suitable places and their conversion to
hospital purposes, and by making contracts with civilian hospitals all
over the United States for the care of veterans, this Service was able
to furnish facilities with rapidity. These facilities were by no means
always desirable, but at least it may be said that the Public Health
Service was enabled to keep pace with the demand and to supply to all
veterans who applied some form of hospital care and treatment.

The administrative organization, which had been formed under the law,
for the care of veterans, included three bureaus, namely; the Bureau of
War Risk Insurance, the Federal Board for Vocational Education, and the
Public Health Service. This organisation, while it was the best that
could be formed under the circumstances, left a good deal to be desired,
and was the cause of much criticism and no little dissatisfaction.

Matters became so urgent finally that, under the President’s direction,
certain changes were made, and later, by act of Congress, even more
radical changes were made, all with the ultimate tendency of
concentrating in one organisation the entire responsibility for all
matters affecting veterans of the World War. This culminated in the
passage of legislation creating the U. S. Veterans’ Bureau and charging
that Bureau with the full responsibility for all matters affecting
veterans. (Aug. 19, 1921.)

In the legislation creating this Bureau, however, the Director of the
Newly created Bureau was authorized, in giving hospital care and
treatment to his beneficiaries, to make use of certain official
agencies, and among these the Public Health Service, which at that time
was carrying most of the medical work for veterans, and in fact this
Service is still supplying by far the largest number of hospital beds
for their care.

Under this new legislation, adjustments were made as rapidly as
possible, and are still going on, with the result that the present
situation of the Public Health Service in this responsibility is fairly
clearly defined for the first time since it has undertaken this work.

The U. S. Veterans’ Bureau has now taken over, or will shortly take
over, from the Public Health Service all of the responsibility and all
of the work involved, with the exception of the operation of hospitals.
The work taken over by the U. S. Veterans’ Bureau includes the entire
responsibility for the operation of all outpatient departments for the
care of veterans. Thus the Public Health Service is now left simply as a
hospitalizing agency for the use of the Director of the Veterans’
Bureau.

The Public Health Service, therefore, stands in the same relationship to
this work as other official agencies, namely; the National Homes for
Volunteer Soldiers, the Army, the Navy, and St. Elizabeth’s Hospital of
the Interior Department. That is to say; it operates independently a
system of hospitals for the use of the Director of the Veterans’ Bureau
in the care of his beneficiaries. It has no responsibility with regard
to meeting the demands for hospital facilities and it has no
responsibility with regard to the distribution of patients to those
hospitals. Its responsibility is limited simply to the operation of such
hospitals as the Director desires, and, to the admission of such
patients as he may desire to send to the same.

When the Public Health Service was suddenly charged with the large and
important responsibility for supplying medical care and treatment to
veterans of the World War, it proceeded at once to organize, on a
commensurate scale, to meet a problem the character of which was unknown
and the magnitude of which could only be surmised.

The first and greatest problem faced by the Public Health Service was,
of course, to determine as soon as possible the character and the
magnitude of this problem. In conjunction with the War Risk Insurance
Bureau, there was compiled and finally published a public document (481
of the 66th Congress, December 5, 1919). In this document, this entire
problem was analyzed, and certain very definite conclusions were stated
as to the need for medical and surgical facilities for the proper care
and treatment of discharged disabled veterans.

It is unnecessary at this time to attempt any analysis of this document,
but it is worthy of some comment. It indicated that within two years
from the date of its publication there would be needed for patients of
the War Risk Insurance Bureau 7,200 beds for general medical and
surgical cases, 12,400 beds for tuberculous cases, and 11,060 for
neuropsychiatry cases, making a total of 30,660 beds.

Recommendations in this document were made for the expenditure of a
large sum of money for necessary construction, and a draft of a bill was
offered which would appropriate the money for this purpose. The bill
contemplated that this money should be expended in annual installments,
extending over a period ending June 30, 1923. This document also
indicated that the peak of the load, at least for neuropsychiatric and
tuberculous disorders, would not be reached for some years.

The conclusions reached in this document were the subjects of a good
deal of criticism. It was rather generally felt that the facilities
which had been provided during the war for the medical care and
treatment of soldiers and sailors could be made use of very readily and
very satisfactorily in the care of discharged disabled soldiers and
sailors at the termination of the war.

It was not clearly appreciated that the war program for the care of sick
and disabled could, by no means, be converted into an adequate and
satisfactory system of hospitals for the care of sick and disabled
persons under peace conditions. At all events, no money was appropriated
for purposes of constructing hospital facilities until March 4, 1921.

It is highly significant at the present time to note that the needs
foreshadowed in this public document have, since the date of its
publication, been more or less verified by subsequent experiences.

Making due allowances for discrepancies, which might have been expected,
and for developments, which could not have been readily foreseen, it may
be truthfully said that this document indicated quite clearly and more
or less accurately the hospital needs for the care of sick and disabled
ex-service men and women, if these patients were to receive the
character of medical service which, in the judgment of the best medical
minds, was necessary for their restoration to health and which could not
be satisfactorily given in other than suitably constructed institutions.

Leaving aside these considerations, it was apparent that, when the
Public Health Service was charged with responsibility, it was
immediately necessary to meet the urgent demands suddenly created by the
termination of the war.

The Public Health Service, in the manner indicated above, attempted,
therefore, to formulate and put into execution a temporary program for
the purpose of meeting immediate needs, leaving a permanent program to
be developed in accordance with the appropriations and legislation.

Without going into any more detail, it will suffice to state in very
general terms the work which the Public Health Service has done in this
connection and which it is still doing.

Since the inception of the work, it has created a hospital system of
considerable magnitude, and is now operating some 68 hospitals, with a
total bed capacity of over 21,000, and expects, within the more or less
near future, to open additional hospitals and increase present
facilities by something less than 5,000 additional beds.

This Service now has under its care about 13,500 veterans of the World
War in its hospitals. In addition to this, it is also caring for 3,000
to 4,000 Federal beneficiaries, with whose care and treatment it has
long been charged, making a total of nearly 17,000 hospital patients
under its care at the present time.

In the development of this hospital system, the Public Health Service
has divided its hospitals into three large groups, namely; hospitals for
general medical and surgical cases, for cases of tuberculosis, and for
cases of neuropsychiatry. It has been unable to develop this system of
hospitals with the uniformity desirable under the circumstances, and
has, therefore, found difficulty in meeting the needs of those suffering
from neuropsychiatric and tuberculous disorders. This demand, however,
has of late been far more adequately met, especially with regard to
tuberculosis.

In addition to the development of its hospital system, the Public Health
Service, soon after assuming its responsibilities in this work, created
what was designated as the District Supervisors’ organization. The
United States was divided into fourteen districts and, in some large
center of population in each of these districts, there was established a
district headquarters, with a sub-district organization reaching out
even to the individual counties.

This organisation constituted a decentralizing agency, and, as such,
served a most useful and important function, not only in the work of the
Public Health Service, but also in the work of the War Risk Insurance
Bureau. This entire organization, which had grown enormously, was
transferred to the Bureau of War Risk Insurance in April, 1921, with its
complete personnel. It is now operated by the U. S. Veterans’ Bureau as
its decentralizing agency and is still performing a necessary and
important function in the work of that Bureau.

It was also necessary to create a greatly extended purveying service for
supplying the necessary equipment, etc., to the hospital system which
had been inaugurated. The Purveying Service has grown enormously and, at
the present time, is not only purveying to the hospitals of this
Service, but is also rendering assistance to the U. S. Veterans’ Bureau
in purveying for its offices and its medical facilities.

The creation of an Inspection Service also became a necessity, in order
that the hospitals of this Service might be kept under constant
surveillance, and that all complaints might be carefully investigated.
This Inspection Service has now been reduced somewhat, but still is
functioning satisfactorily and has also rendered a great deal of
assistance to the U. S. Veterans’ Bureau in making certain inspections
for that Bureau.

In addition to these matters, the Public Health Service also began the
creation of a large system of out-patient dispensaries for the care of
veterans of the World War and developed this work considerably. Up to
recently, it had in operation some 58 of these dispensaries, many of
them equipped and staffed for all forms of out-patient diagnosis and
treatment.

The development of this dispensary system was a matter of supreme
importance in furnishing the medical examinations of veterans required
for the purpose of establishing their compensation ratings. This entire
Service, as stated, is about to be turned over to the U. S. Veterans’
Bureau and will, in future, be operated by them.

In carrying out all of this work, the Public Health Service has, of
necessity, been obliged to assemble a large personnel. The personnel at
the present time is somewhat less than it has been previously, by reason
of the transfer of certain activities to the U. S. Veterans’ Bureau,
but, with the anticipated opening of many new hospitals and the increase
of its facilities, this personnel must, of necessity, slowly increase.

At the present time, the Public Health Service has in this work about
1,700 medical officers, not including attending specialists. Of these,
about 950 are officers of the Reserve Corps. A Dental Corps has been
created and numbers, at the present time, about 180 dental officers. A
corps of female nurses has been assembled and numbers, at the present
time, about 1,800. A Reconstruction Service has been formed and numbers,
at the present time, about 580 reconstruction aides. A Dietetic Service
has been organized and numbers about 165 trained dietitians. These
figures will give some idea of the large personnel necessary in the
performance of this work.

It is difficult to draw distinctions between the various classes of
personnel, but it may perhaps be said in general terms, at the present
time, that the most difficult qualified personnel to secure is the
medical officer. The Public Health Service was peculiarly fortunate in
assembling a large Reserve Corps. At the close of the war, many medical
men who had been in the military forces were demobilized. Finding
themselves somewhat adrift, and having broken completely old
associations, they were inclined, if opportunity offered, to continue in
the Government service. A special appeal was made to these men by the
Public Health Service and inducements were offered to them to accept
service in the care of disabled discharged veterans. As a result, the
Public Health Service was able to assemble a much larger number of
reserve officers than could have been done under any other
circumstances.

It has been a matter of great difficulty to maintain among these
officers the necessary morale, by reason of the difficult circumstances
and conditions under which they are employed. Having only a limited and
somewhat uncertain tenure of office, with many uncertainties as to their
future, it is worthy of note that they, nevertheless, have, given to the
Government a service which could not easily have been secured from any
other source. They have shown a fine spirit in the performance of this
duty, and, as much as any set of men assembled under such conditions and
circumstances, have delivered a service the quality of which is
comparatively high. The retention of their services seems to me a matter
of importance.

From the inception of this work up to date (Jan. 16, 1922), there have
been cared for in hospital by this Service about 245,000 veterans, who
have been furnished a total of about 12,831,000 hospital relief days.
Also, about 1,945,000 outpatient treatments have been given and a total
of over 1,427,000 medical examinations have been made. Many special
services of various kinds have been rendered. For example; about 175,000
patients have been given dental treatment. Several thousand patients are
being given occupational therapy and several thousand patients given
physiotherapy every week. Prosthetic appliances of various kinds have
been furnished to thousands of patients.

The important matter of medical social service in its hospitals has not
been neglected by the Public Health Service. In cooperation with the
American Red Cross, there has been organized an efficient medical social
service, which has administered to the needs of the discharged disabled
soldiers and sailors. These activities of the American Red Cross have
been supplanted by many other agencies, including the American Legion,
Knights of Columbus, Jewish Welfare Society, and others. All of these
agencies have rendered valuable assistance in the prosecution of this
important phase of the work.

The Public Health Service accepted a share in the responsibility for the
care of discharged and disabled ex-service men, with a full
comprehension of the privilege which had been conferred. It has taken a
pride in attempting to give to disabled ex-service men the very best
service possible. While its ideals have not always been realized, it
has, nevertheless, I believe, always treated the ex-service man with
consideration and given him good professional service. It is my endeavor
that the character of this service shall continue to improve, and I
believe that it does improve constantly. No effort will be spared to
render the very best service possible under the circumstances and
conditions imposed.

Just what the future will hold for the Public Health Service in this
work, it is now impossible to say. It appears, however, that the Public
Health Service for sometime to come will be one of the designated
agencies for furnishing hospital care and treatment to beneficiaries of
the U. S. Veterans’ Bureau. This responsibility of supplying hospital
facilities, with all that is implied, will be as adequately met as
possible. The Public Health Service at the present time is operating a
number of hospitals which, from many standpoints, are not suitable to
the purpose to which they have been put. To attempt to operate hospitals
in unsuitable buildings, unsuitably located, subjects the Public Health
Service to unmerited criticism, but, since these facilities are needed
for a time, it will be necessary to continue such places in operation.
It is not possible, under such circumstances, to render the highest type
of service, but every effort will be made to render the best service
possible.

With the construction which is now going on, under appropriations which
have been made available by Congress, it is anticipated that, in the
more or less near future, it may be possible for the Public Health
Service to close some of its unsuitable plants and open others of a far
more satisfactory character. This will relieve the present situation a
great deal and will do much to obviate the criticism which has been made
against the National Government because it has not supplied suitable
hospital facilities for the care of men who have given so much to their
country.

In conclusion, it seems appropriate to say that the Public Health
Service, in all of this work, has realized fully the necessity for the
most complete and cordial cooperation with other governmental agencies
engaged in it. It has been a firm policy of the Public Health Service to
stimulate an attitude of cooperation on the part of all of its
employees. It is a matter of peculiar satisfaction at this time to say
that the Public Health Service feels that, in the present Director of
the Veterans’ Bureau, it is receiving from him a most cordial support in
this policy of cooperation and the relationships which exist between
these two Bureaus daily grow better, as they must if the work is to be
properly accomplished.

It is also to be noted in this connection that the recent creation of
the Federal Board of Hospitalization has added to the administrative
machinery a piece of co-operating mechanism, which will, undoubtedly, do
much to stabilize and coordinate, as well as standardize, many necessary
things, which, up to this time, have been carried on more or less
independently. A governing body of this character, which can lay down
broad policies, influencing all of the official agencies engaged in this
work, must of necessity be in a position to subserve a very useful
purpose. The sympathetic consideration and support of this body should
have a fine moral effect.”


GENERAL SAWYER: “Representing General Wood we have Colonel Mattison.”


COLONEL MATTISON read the following article prepared by General Wood:
relative to the N.H.D.V.S. and its Relation to the World War Veteran:

“Of all the various agencies utilized by the Federal Government in
caring for disabled men of the World War, the National Home for D.V.S.
is probably the oldest in this line of work, dating back over fifty
years in its care for disabled soldiers. Immediately after the close of
the Civil War, the necessity for some organization of the government to
care for the many thousand disabled soldiers of that war became
apparent, and in 1866, by act of Congress, the National Home for
Disabled Volunteer Soldiers came into existence with a Board of Managers
selected by Congress to carry out the purposes of this Act. Prior to
this, several of the States, civic and benevolent organizations had
taken up the work locally in many parts of the country, but the creation
of a National Board superseded the local work and for quite a number of
years prior to the time that State homes were established by various
States the burden of caring for disabled veterans of the Civil War fell
on the National Military Home.

The first Home established was located at Dayton, Ohio and was known as
the Central Branch, but as the necessities of the question developed,
other branch Homes were established by Congress until at present there
are ten different institutions under the control of the Board of
Managers, scattered from Maine to California. But as the Civil War was
practically a war between sections of the country, all the Homes, with
the exception of the one at Johnson City, Tennessee, are located either
in the North or on the extreme Northern border of the South. For example
the Home at Hampton, Virginia.

Membership in the Home was originally confined to disabled soldiers of
the Civil War, but gradually as the need developed, this privilege was
extended to soldiers of the Mexican War of 1846, the Indian campaigns,
the Spanish American War, and the Philippine service, so that by the
year 1917 when the World War occurred, practically all disabled soldiers
who had served in any of the wars of the Republic, were eligible to
membership in the Home. The high tide of membership in the Home was in
1906 when over twenty one thousand disabled soldiers were members of the
various Branches. After the peak of the load had been reached there was
quite a decided downward curve in membership owing to the advancing
years and heavy death rate among the soldiers of the Civil War, so that
by 1917 the membership had decreased to about thirteen thousand men, and
there were in the various branch Homes many thousand vacant beds, both
in barracks and in hospitals.

In this connection, attention is called to the fact that the Home
functioned in a two fold capacity. It furnished hospital service to the
man who actually needed such attention and it also furnished domiciliary
service to men who were disabled and prevented from taking care of
themselves in the active competition of life but who were not actually
patients. This latter service is called our domiciliary service and is a
service that probably will increase very materially in its scope with
the passage of time, as men who have served in the World War, owing to
disability will find themselves unable to meet the active competition of
the world outside and will therefore need this domiciliary service in a
very acute way.

By the Act of October 6, 1917, eligibility in the Soldiers’ Home was
given to men who had served in the World War, on exactly the same terms
and conditions as it had been given to the veterans of the other wars,
and therefore today the disabled soldiers of the World War stand in
exactly the same position in their rights to care and treatment in the
National Home as does the soldiers of the Civil, or Spanish American
Wars. But few men of the World War had taken advantage of this privilege
prior to the year 1920 when the Sundry Civil Bill for the F. Y. 1921
gave authority to the Director of the Bureau of War Risk Insurance, now
the Director of the U. S. Veterans’ Bureau, to make allotments to the
Board of Managers of the National Military Home for alterations and
improvements of existing facilities to meet the demand of
hospitalization from the Bureau of War Risk Insurance. Such changes were
thought necessary as a large amount of space available was barrack space
which while satisfactory for domiciliary service, was not satisfactory
for hospital service.

Acting in accordance with the desires of Congress, as shown in this
bill, the Board of Managers at once entered upon an energetic campaign
of construction to prepare their plants for this work. Conferences were
held with the Director of the Bureau of War Risk Insurance, and the
statement made by him that the greatest need of the Bureau of War Risk
Insurance at that time was for tuberculosis and neuro-psychiatric beds.
To meet this need, and to grant to the fullest the wish of segregation
on the part of the World War men, two branch Homes were set aside and
their domiciliary and hospital population moved to other branch Homes,
and acting under the advice of the most competent experts, the Board
could find, the branch at Johnson City, Tennessee was changed into a
tuberculosis sanatorium, and the branch at Marion, Indiana was changed
into a neuro-psychiatric sanatorium.

In addition to the complete change of two branch Homes, numerous and
extensive improvements and alterations were made at a majority of the
other Homes so that the fullest cooperation might be given to the Bureau
of War Risk Insurance in its great work, and today outside of the Home
at Hampton, Virginia, and the one at Danville, Illinois, which have been
practically set aside for the older class of veterans, adequate
facilities have been prepared for the hospitalisation of such soldiers
of the World War as may be assigned to them for hospitalization.

But in this connection especial attention must be called to one very
peculiar and unique feature of the service furnished by the National
Military Home, and that is the fact that under the law, the Home must
care for the victims of peace as well as the victims of war and
furthermore, that the gates of any branch Home are open to any disabled
soldier of the World War and that for admission, it is not necessary
that the disabled soldier be sent there by the U. S. Veterans’ Bureau or
any other organization. If he presents himself with his honorable
discharge and the medical examination shows disability, under the law
the Home must take care of him as long as such disability exists, this
whether the disability be one of war or one of peace. To give a concrete
example, if a World War soldier presents himself at any branch Home with
a leg or arm amputated, under the law, the Home must take care of him
whether he lost the limb in the Argonne or in a saw mill, and this
feature is one that I think should be carefully considered because it
leads up to the question spoken of above, of domiciliary care. Now a man
with a leg gone is naturally crippled in the battle of life and cannot
compete on equal terms in almost all professions or trades, but still
when the operation is completed and the wound healed, he does not
require hospital treatment but comes under the domiciliary class, and I
cannot help but feel that there are probably many hundred of cases along
this line of disability which if transferred from the active hospitals
of other branches of the service to the National Military Home for
domiciliary care, will lighten the load very materially of hospitals
where active curative work is being done, and increase the number of
beds available for active hospital work, and at the same time give the
domiciliary case the best of care and attention.

This brief summary of the relation of the National Military Home to
disabled soldiers of the World War, leads one to the inevitable
conclusion that the work of the Home in caring for these disabled
soldiers is one that will increase from year to year and if the results
of the Civil War can be relied upon, the peak in caring for these men
will not be reached for twenty years, possibly thirty would be a more
correct estimate of the time. In other words while it is probable that
the hospital peak will be reached by 1923 or 1924, and then fall off,
the domiciliary load is one that will grow from year to year and become
more and more important as time goes by.

In conclusion, speaking for the National Military Home, I wish to state
that the relations existing between the former head of the Bureau of War
Risk Insurance, Col. R. G. Cholmeley-Jones, and the present Director of
the U. S. Veterans’ Bureau, Col. C. R, Forbes, have in every way been
most pleasant and cooperative and every request made by the Home for
allotments and assistance in this work has been most generously and
promptly met.”


GENERAL SAWYER: “I have pleasure in introducing Dr. A. White, Secretary of
the Board of Hospitalization, who will address you on the subject of
“the Neuro-Psychiatric Case and How to Meet its Requirements”.”


DR. WHITE:

“The neuropsychiatry problem which the World War created and presented
to the medical personnel of the various branches of the Government for
solution, may be advantageously considered in three parts.

The first part of the problem consisted of dealing with the conditions
which developed in our armies during the war, more particularly those
conditions which developed as a result of the stresses of actual
service, particularly, of actual fighting. This large, and as you well
know, very heterogenous group, in some mysterious way came to be
labelled with the diagnosis of “shell shock”, a term which
neuro-psychiatrically was most unfortunate, and which continues its
vexatious existence.

This group of cases, while a very heterogenous one, consisted largely
and perhaps most characteristically, of a multiplicity of types of
conversion hysteria, cut aside from any attempt to diagnose in detail
the various forms that “shell shock” took, it is sufficient to say that
this group as a whole was a group of acute psychoses developed under the
severest of stresses of service conditions and that when these stresses
were relieved, and particularly after the signing of the Armistice,
these patients got well and to all intents and purposes this group as a
whole ceased to exist and so is not today one of our problems.

The second group is the group of what I shall call the ordinary State
hospital type of psychosis. This includes the type of individual that we
ordinarily find in State hospitals, that has always been recognized,
that is usually called “insane”, and that for the most part was
discovered by the army rather than created by war conditions, although
it must be recognized that a certain number in this group might, under
the ordinary circumstances of life, have remained stable, at least much
longer than they did. However, there is nothing unusual or extraordinary
or unfamiliar in this group to the average physician of State hospital
experience.

With regard to the treatment of this group, however, it should be said
that the great stimulus which came to psychiatry because of the war came
because the country discovered, and was astounded by the discovery, that
it had distributed throughout the length and breadth of its population a
vastly greater proportion of defective and mentally ill individuals than
it had the remotest dream of. Because of this stimulus which psychiatry
received, the matter of treatment has received very much more intensive
thought with the net result that there are today more well recognized
agencies for dealing with this class of patients than ever before. Very
briefly these agencies may be considered under the following heads, some
of which of course are not only well known and well recognized, but have
been used for many years, whereas others that are perhaps equally well
recognized have only received wide application recently.

The _first_ of these agencies, perhaps, is the application of the
general principles of medicine and surgery to the treatment of the sick
individual. In other words, the patient’s general health becomes a
problem for inquiry and appropriate consideration, irrespective of his
mental state, on the general theory that physical health is at least the
best condition precedent for undertaking a restoration to mental
equilibrium.

The _second_ of these agencies is the complement of the first, and is
best designated under the general term of psycho-therapy and consists in
the recognition of the mental disease as such irrespective of whether
there can be found any physical foundation for it or not, and on the
basis of such recognition endeavors to deal with it as a thing in
itself. In passing I may say that theoretically the best results would
come if these two agencies could work hand in hand each with sufficient
understanding of the other.

The _third_ agency, which has been very much broadened in its activities
in recent years, I may designate as the social agency. It recognizes
implicitly at least, if not consciously, that mental disease at any rate
the kind of mental disease included in the second group, the so-called
“insane” is a disorder of the individual as a member of the social group
and that it manifests itself largely by disturbances of his relation to
his fellows, and therefore it becomes a legitimate therapeutic endeavor
to attempt a readjustment of these relationships. To this end the social
agency has been developed in many directions. In the first place, we
have amusements. The simpler amusements may be called, speaking from the
point of view of the patient, the passive variety,—the type of amusement
that is brought to the patient, such as theatrical performances, moving
pictures, and the like, whereas the second type of amusement, which is
more advanced and more valuable, is the type in which the patient
himself takes part, such for example as theatrical performances in which
he is a performer, musical programs, in which he plays or sings. Then
there is the group which is not after all very widely separated from the
amusement group and yet is somewhat different, and that is the group
which we might term athletic activities and which demand upon the part
of the patient some initiative. These range all the way from the
simplest activities, which are imitative in nature, such as calisthenics
under the instruction of the athletic director, to mass games, where a
large group of patients are all engaged together in a common purpose,
such as push ball, to games of contest requiring not only initiative but
a relatively high degree of efficiency, such as the tug-of-war and the
various types of races and stunts, boxing and wrestling, and which are
from time to time advantageously staged on a field day and receive the
added stimulus of an audience. In addition to such activities as the
above there are also many minor ones of a similar nature, the principle
of which, however, is the same,—the social give-and-take of patient
between ward and ward, the instruction in such things as folk-dances,
and the like.

The _fourth_ agency, which has been very largely developed recently, but
which has always been used, is the agency of work. This has been applied
in approximately three ways. The first of these is known as diversional
occupation and comprises practically the whole field of what is thought
of by many as occupational therapy. The activities in this field consist
of such work as basket weaving, leather tooling, bead stringing, rug
weaving, and a thousand other similar activities. The object of this
activity is to assist in the re-direction of the patient’s interests, to
turn them away from infantile and regressive objects, and to project
them again into the outer world of reality. Then there is the industrial
type of work therapy in which the patient is carried still further along
the line of personal initiative and given an opportunity to do creative
work which is at the same time useful and which helps him to keep in
form pending the time of his ultimate discharge from the hospital. And
finally, there is the vocational education work, which undertakes
definitely and systematically to give a man training in some specific
direction which he can utilize, after he leaves the institution, and
which will have a definite economic value. For this latter work of
vocational training there is needed such psychological advice and
assistance which will at least prevent the wastage of time and effort
upon unprofitable or impossible tasks, whereas the vocational
psychologist cannot by any rule-of-thumb-tests tell that a man will make
a success in this or that direction, he can tell within reasonable
limits that a certain patient cannot profitably undertake a certain type
of training, that his capacities do not measure up to the minimum
requirements that would make success possible. In this way the work of
vocational education for the neuropsychiatric case can be narrowed down
so that it can be applied more intensively and more effectively to
selected groups that can be reasonably assumed to be good risks.

The _fifth_ agency, which can be advantageously brought to bear upon the
neuropsychiatric case, is the agency for extra-mural social adjustment,
and the personnel consists of the psychiatric social worker. With her
help the patient discharged from the hospital can have the maximum
amount of assistance for relating him again with the problem of
self-support and self-sufficiency. She, through her study of his family
situation, his economic status, his industrial placement and social
contacts can assist to these ends.

The third group of neuropsychiatry cases is like the second,—a group
that has always been with us, but unlike the second it is a group that
never before has been systematically hospitalized. It is the group of
what might broadly be termed borderland states, comprising all sorts of
types of defective, delinquent, psychopathic, neurotic, and mildly
psychotic individuals. Whereas they perhaps present no new problems when
one is speaking from the platform of neuropsychiatry, they do present a
distinctly new group of problems from the standpoint of hospitalization.
Here all the agencies which have been described in connection with the
second group need to be brought into action, but beyond them there needs
to be a definite intensive study of methods for the new hospital
problems involved. I mention only one aspect of the problem because it
is one which has forced itself repeatedly upon the attention of hospital
authorities and that is the need for an intelligent, and I may say, a
therapeutic utilization of discipline in dealing with these cases, in
this group there very probably are contained a reasonable number of
individuals of unusual equipment, who, if our ingenuity and our breadth
of vision are great enough, may perhaps be saved for some work of more
than ordinary usefulness.

One of the medical agencies which it is contemplated to bring to bear
upon this third group of neuropsychiatry cases is the dispensary because
it is recognized that there is actual danger in hospitalizing a certain
proportion of this group, and therefore it is much better to deal with
them as ambulant cases. They can be dealt with in the dispensaries which
are equipped not only to take care of them, but for all other medical
and surgical conditions, and so will get the very best possible
attention. There should, however, be connected with these dispensaries,
especially the larger ones in the more densely populated districts, a
psychiatrist with psychotherapeutic training who should have a
psychiatric social worker to help him. If there are enough patients to
warrant it perhaps additional assistance might be needed.

And finally, I would emphasize that in this great scheme, which
contemplates the hospitalization of from ten to fifteen thousand
neuropsychiatric cases of the general type above referred to there
should be included all of the armamentarium for scientific research and
all of the opportunity for individual endeavor and initiative which is
calculated to bring the brighter professional minds to bear upon the
subject and to illuminate it with the light of their genius. In order
that such results may be effected as promptly as may be, and with the
highest possible efficiency, I believe there should be established a
training center for neuro-psychiatrists where our younger men, who are
recently graduated from our medical colleges, and who have the
inclination to specialize in this branch of medicine, can fit themselves
in a minimum period of time to take it up as their life work. And that
this result may be accomplished I think it important that in extending
an invitation to the younger medical men to enter this branch of the
service that it should be possible to give them some assurance of
permanency in their respective jobs.”


GENERAL SAWYER: “The subject with which Dr. White has dealt is so important
that it will have more consideration later in the program, as you will
notice.

It is quite necessary in the operation of all affairs with which
Americans or even any of the human family deal, to have somebody who
knows something of the legislative procedure that is necessary to the
conduct of their affairs.

Honorable Charles H. Burke was added to the Hospitalization Board for
two reasons: first, because he does represent in his great family many
hospitals, the services of many doctors, likewise of many nurses. He
therefore comes to us, being a Congressman of long experience, as a man
who can deal with the subject partly from a professional aspect or view
of the matter, and again with a thorough and complete understanding of
the legal side of the affairs with which we are dealing.

So I have great and special pleasure this morning in presenting to you
the Honorable Charles H. Burke, Commissioner of Indian Affairs, who will
address you briefly on the statutory regulations affecting the
hospitalization of the World War Veteran.”


BURKE: “Mr. Chairman, fellow members, ladies and gentlemen:

I think in the introduction of General Sawyer I learned for the first
time how it happened that I was accorded the honor and the privilege of
being a member of an organisation made up of such a distinguished
membership as is this Board, barring your humble servant.

It would hardly be expected, after listening to these discussions by
these eminent experts in their particular lines, that I would undertake
to say anything along the scientific side of this proposition, and I am
going to be rather general in what I state in the short time I shall
talk to you.

Government activities can only exist by reason of the law, and so it
will be proper to consider perhaps or discuss briefly the application of
the law with reference to the activities that are being conducted, of
which you, each of you, are a part.

The responsibility for whatever the Government may do in this or any
other matter rests largely upon the Congress. I have hastily gone
through the legislation that has been enacted in the last few years with
reference to taking care of and providing for the ex-service men, and
during the war for their dependents, and for those who might become
incapacitated or disabled from any cause. There has been much
legislation, demonstrating that the Congress is keenly alive to the
importance of the situation. There has been one act after another, and
hardly an act but what has been amended within a very short time after
its enactment.

The recent law is what is known as the Sweet Bill, the law under which
we are now operating. Within the memory of many who are here present the
appropriations for all purposes of the Government were under a billion
dollars, and there is being and is appropriated at the present time
nearly half of that amount for the purpose of caring for the
hospitalization, etc. of these ex-service men. Am I correct, Colonel
Forbes, in the amount of money that is being appropriated? It is a vast
and large sum of money, and it is the duty of those charged with the
responsibility of expending that money to see that we get a hundred
cents’ value for every dollar that has been appropriated. This requires
economy and efficiency, and this gathering and this organization which
General Sawyer is the chairman, was created for the purpose of getting
better results from the moneys that are appropriated by the Congress;
and you, each and every one of you, have been brought here, as I
understand, for the purpose of coming in closer contact with those who
are charged with the responsibility, in the first instance, of
administering the expenditure of this large sum of money; and you owe to
this responsibility exactly the same responsibility as does Colonel
Forbes or anyone else occupying a higher station than you may occupy.

Therefore, I am confident and I am certain that when this conference
shall have concluded, every person that has come here will go back to
his respective place where his duty requires him, with a better
understanding and with a more determined disposition to try and render
better service and get really more for the money that is being expended
for the purpose for which it is being expended.

Speaking of legislation, we shall undoubtedly require considerably more
legislation because, as I have stated, in the short time since this
subject was first taken up by Congress think of the progress that has
been made.

As I understand, in 1919 the Public Health Service were hospitalizing
something like two thousand persons. General Sawyer stated here today
that we are now caring for twenty-two thousand; and I think it has been
stated—and it is generally considered—that the maximum will soon be
thirty-two thousand. So you see that it is more than likely that we are
going to have to have additional legislation and more appropriation; and
I may say to you generally that I have that confidence in the American
people—I have that confidence in the Congress of the United States—to
know that there need be no uncertainty nor hesitation on any one’s part
with reference to what may be done to provide for caring properly for
these dependents and these ex-service men who are entitled to every
consideration.

I believe, as the result possibly of this conference, it may be brought
to the attention of this Board that there is some legislation amending
the so-called Sweet Bill. I think Colonel Forbes, as the head of the
Veterans’ Bureau, has already discovered and suggested some very
necessary amendments to the law, and I have no doubt that he will be
able to secure those additions to the law. It looks now as if we may
have to provide for additional hospitals by the enactment of further
appropriations of money. It will not be done unless it is necessary, but
I am sure if it is necessary that adequate provision will be made and
made promptly by the Congress.

One of the policies of this administration is coordination and
cooperation, and endeavor to avoid duplication in administrative
matters; and if there is a bureau charged with a certain responsibility
and with certain duties to perform, if it may be possible for them to do
what may be under the jurisdiction of another bureau, to centralize and
have this work done by one rather than two; and so in the work of
coordination in the administration of this particular activity there has
been a great saving. The Public Health Service, I believe, makes certain
provision and takes care of certain persons at the request of the war
Veterans’ Bureau and vice versa. I think it has been said,—if it is true
it ought to be corrected,—that when the Veterans’ Bureau takes care of
patients for the Public Health Service, there has been no provision made
for reimbursing the Veterans’ Bureau. That will undoubtedly be taken
care of by Congress, either by increasing the appropriation for the
Veterans’ Bureau, or providing that when they render service for the
Public Health Service, the Public Health will reimburse them for such
moneys as they may expend.

Now one of the things that I want to particularly bring to your
attention, and to perhaps admonish you, in the two or three minutes I
have left, is to remember, as I stated at the outset, that governmental
activities exist only by authority of the law, and that we must keep
within the law; and remember, if there are some things in connection
with your duties that are not operating just as you would have them,
that they cannot be changed without changing existing law. The
responsibility for the law is upon the Congress of the United States.
The responsibility for this great undertaking is upon the Congress of
the United States, and if you have not sufficient money to properly take
care of these men, the responsibility is not yours; the responsibility
is upon the Congress.

It is your duty;—it is our duty to bring to the attention of the
Congress the money that is necessary in order to properly handle this
subject. Then it is for the Congress to say whether or not that amount
will be appropriated. Under this present administration, those of us who
are in Bureau positions have been admonished that we must keep our
expenditures within the appropriations, and we have had brought to our
attention the statutes upon this subject. I am going to read them to you
for your information, and I want to say to you who may have charge of an
institution and have had a certain allotment of funds for a given
period, that it is up to you to see that your expenditures do not exceed
that allotment. If you have not sufficient money to do what you feel you
ought to do, you must reduce your expenditures for the time being,
regardless of its effect upon the service, because under the law you
have no right to create a deficiency or incur any liability on the part
of the Government in advance of an authorization and an appropriation
therefor.

I want to call your attention to the statutes on this subject because
they are being brought to our attention not only by the President and
the head of the Bureau of the Budget, but by the Congress; and so I want
you people to understand that we are expected to follow the law.

 Mr. Burke read extracts from: Section 3679

                               Act of March 3, 1905.

                               Section 5503.

That, ladies and gentlemen, is the law; and so I want to impress upon
you that you so conduct your institutions that you will keep within the
limit of the allotment that has been made for your institution; and if
you have not sufficient money, then bring it to the attention of the
head of the Veterans’ Bureau or someone else connected with the
administration. They will consider it, and if it shall seem that more
money is necessary they will not only recommend it, but I think I can
say for the Congress that the Congress will generously respond.

I congratulate this conference upon its start. I hope that there may be
a general discussion,—that those who have come from long distances will
tell their experiences and make suggestions with reference to anything
that will improve this service; and I am very certain that when the
conference shall conclude on its last day it will adjourn with a feeling
that the time has been well spent, and that in the future we are going
to profit, and profit materially, as to the result of what may be done
in this conference and by it.”


GENERAL SAWYER: “Fellow workers, I certainly hope that this introduction
this morning has given you two things; first, that it has given you the
impression that the men engaged at the head of the affairs of this
Government in this subject are capable, worthy men. I hope it will have
given you the same inspiration that I carry away this morning,—to go on
with this conference and with your work after you leave here more
earnestly if possible, more sincerely if you may, and certainly with
more determination to bring about the results we all have in mind.

This morning you have heard the various members of the Board of
Hospitalization make their addresses, brief of course as they have been
and in many instances not entirely fair to them, considering the
subjects they have to handle; but they have done as well as time will
admit.

This afternoon this conference, under the chairmanship of Colonel Forbes
will take up a special subject or two, and will then go into the matter
of the general discussion of the affairs as they have been presented
today. We want you to feel that we are here to listen as you have
listened this morning; and so we are going to ask each one of you to
participate in the discussions. We want this to be an active meeting, of
men in motion, so that when this conference does close we may have the
satisfaction that has been expressed here by the Commissioner of Indian
Affairs.”

General Sawyer asked that, upon adjournment, the members of the
Conference assemble outside the building in order that a group
photograph might be made.


                  The meeting adjourned at 12:15 P.M.




            _Second Session_      Tuesday, January 17, 1922.


At 2:00 P.M. the meeting was called to order by Colonel C. R. Forbes.

The roll was called by Dr. W. A. White.


COLONEL FORBES:

“The first paper of the afternoon was to have been read by Colonel
Patterson, Medical Director of the Veterans’ Bureau; but in his absence,
Dr. Rawls, of the Public Health Service, will deal with the subject of
‘Operation of Dispensary and Dental Clinics’.”


DR. RAWLS:

“I regret very much that Colonel Patterson cannot be here today, because
he had some very definite statements to make about the dispensary
problem of the Veterans’ Bureau. It was only last night that his
physical condition warranted his telephoning to the Bureau his
impossibility to come. In his absence I shall attempt to give you
briefly a plan of the dispensary service of the U. S. Veterans’ Bureau.

The Veterans’ Bureau plans to establish a chain of dispensaries
throughout the United States, located in the fourteen District Offices
and in the hundred and twenty six sub-offices.

This is a new idea but is the logical result of past experience in
furnishing service to the patients of the Veterans’ Bureau and in
providing adequate medical facilities. It may not be amiss to trace the
development of this idea from the time when the Veterans’ Bureau was in
its infancy as the Bureau of War Risk Insurance and when the problem of
securing examination reports on claimants for compensation and providing
treatment to patients amounted to a grave emergency.

No ready made medical service existed to which the Bureau could turn for
its needs. The problems of demobilisation confronted the Army and Navy.
The Public Health Service was presented with the needs of the Bureau of
War Risk Insurance and undertook the difficult task of forming a medical
organization throughout the Country to meet these needs. The United
States was then divided into fourteen districts with the District
Headquarters and a medical officer of the Public Health Service in
charge, called a “District Supervisor”, who was directly responsible for
the organization of a medical staff throughout his District. The first
plan for medical service was the appointment of physicians as designated
medical examiners on a fee basis wherever there were claimants of this
Bureau to be examined and treated, the ultimate object being to have at
least one designated examiner in every county of the United States. By
January of 1920 this object had been attained and designated medical
examiners had been appointed in every city and town and in almost every
village of the county.

The District Supervisors soon found this a most expensive method of
accomplishing the work. The Bureau concurrently found it increasingly
unsatisfactory in its result—an army of physicians widely scattered,
whose work was difficult to control and well nigh impossible to
standardize. The requirements of the Bureau were very definite. As a
result, the Public Health Service developed the _medical unit_ plan of
organization, which, in brief, was the formation of groups of physicians
in the larger communities to make complete general and special
examinations and to give careful study to cases requiring treatment. The
results were so far superior to any previously obtained that the Bureau
of War Risk Insurance urged the District Supervisors to complete the
organization of their Districts along these lines and to use the
designated medical examiners as little as possible.

The next step in the development of the dispensary idea was the
establishing in the District Offices of large examining clinics staffed
by officers and appointees of the Public Health Service devoting their
entire time to this work and reinforced by the consultant services of
the best specialists which the cities afforded.

The growth of the District Offices had passed all expectation and a
serious problem faced the Public Health Service in enlarging these
offices in accordance with this plan. However, there was no question of
the wisdom of establishing in the District Offices adequate facilities
for making examinations, as this feature was one of vital importance to
the Bureau because on the accuracy and completeness of the examination
reports depended the award of disability and the determination of
compensation.

The Public Health Service faced this problem squarely and, loyally
supported by the Bureau of War Risk Insurance, demonstrated the wisdom
of this move. The Surgeon General went even further and established real
outpatient dispensary service in connection with certain examination
clinics in the District Offices and hospitals of his Service.

The Bureau of War Risk Insurance then assumed direct control of the
entire District organization and the Director, Colonel Forbes, after an
extended survey of this organization and the methods of furnishing
service to his patients, which took him into practically every District
Office and many of the larger cities served by medical units, evolved
the plan of extending dispensary service to every section of the
Country. With his keen insight into organization problems, one of his
first moves was to obtain Congressional authority to further divide the
Districts into sub-districts. He appreciated that each sub-district
office was a potential dispensary, the examination clinic in each
District Office and the medical unit at each sub-office being the
nucleus upon which to build a U. S. Veterans’ Bureau Dispensary Service.

Under the terms of the Veterans’ Bureau Act, the Director is charged
with the responsibility for proper examination, medical care, treatment,
hospitalization, dispensary and convalescent care, necessary and
reasonable after care, welfare of and nursing service to beneficiaries
of the Veterans’ Bureau, and since he is so charged, the manner in which
dispensary and reasonable necessary after care can be afforded is a
matter of immediate importance. It is therefore proposed to establish in
each District Office and sub-district office a dispensary of standard
type which will vary only in size according to the amount of work in the
city and surrounding territory which it serves. It is proposed to
establish a type of dispensary to be used as a standard which will
provide facilities for a medical clinic, a tuberculosis clinic, a
neuro-psychiatric clinic, a surgical clinic and an eye, ear, nose and
throat clinic. In addition, there will be a dental unit, primarily for
the purpose of making accurate dental examinations, and secondarily for
the purpose of furnishing dental treatment. It is proposed to establish
an X-ray laboratory and a small clinical laboratory and pharmacy. These
are the facilities of the standard type of dispensary proposed.

In the District Offices, and in a few of the largest Sub-offices, this
standard type will be developed to the greatest extent as these offices
bear the greatest burden of making examinations and furnishing
out-patient treatment. In addition to the clinics above mentioned these
Offices will be equipped with complete Physiotherapy Clinics.

The initial expense involved in establishing dispensaries will
necessarily be large, but once established, will not only furnish
medical service of the highest type to patients of this Bureau, but
will, it is believed, result in an actual economy when compared with the
present method of providing similar medical service practically on a
contract basis. X-ray service alone costs the Government large sums
annually which, with the establishment of the dispensary, can be
practically eliminated. Laboratory service is also an expensive item of
out-patient service when performed by contract, which can also be
eliminated. Dental treatment to which patients of the Veterans’ Bureau
are entitled under the law, is a matter of grave concern as it is
handled at the present time on account of the great expenditure
involved. This expense can be very materially reduced if the Bureau
establishes its own dental dispensaries where careful examinations can
be made and definite determination of the dental disability can be made
by trained examiners. Treatment to which the patient is entitled can
then be furnished either by the dispensary or performed by contract
under close supervision.

Every medical officer in charge of a hospital is faced with the problem
of de-hospitalization of patients of this Bureau who have reached the
maximum amount of recovery afforded by hospital treatment. I believe
there is not a medical officer here who is not facing this problem at
the present time and who knows that patients are in hospital not
actually requiring further hospital treatment but who do need further
medical attention and careful medical observation to enable them to make
a complete recovery.

It is believed that the dispensary with its trained professional staff
to render medical treatment and to provide medical follow-up and after
care during that period when the patient is undergoing the final stage
of his physical recovery and is making his social and vocational
recovery to a life of usefulness in the community, will meet a long felt
need. It is believed that the period of hospitalization can be
materially shortened if the patient can be discharged directly to a well
organized out-patient dispensary where his treatment will be continued
and his social and industrial rehabilitation made under the careful
surveillance of trained medical groups. The effects of hospitalization,
prolonged after the maximum benefit has been received, are injurious to
the average patient and if continued, soon makes of these patients
domiciliary charges upon the Government. This is to be deplored and
prevented.

As soon as the dispensaries are established, this Bureau is, and will
continue to place them more fully at the disposal of the hospitals for
the purpose of shortening hospitalization and hastening his physical and
social recovery. This is one of the most important functions of
dispensary service.

The Director is charged, under the law, with not only providing
treatment for compensable claimants of this Bureau, but he is also
charged with maintaining the physical condition of claimants who are
undergoing vocational rehabilitation during the period of their
training. The dispensaries have been located as far as possible to serve
the greatest number of trainees and will provide medical service to take
care of the so-called intercurrent diseases and accidents from which the
trainee may suffer as well as furnish him treatment for diseases or
disabilities connected with his service. With the increasing number of
claimants availing themselves of vocational rehabilitation, the problem
of medical service is one of no small import and it is believed that the
dispensary furnishes the best solution of this problem.

There is another class of beneficiary of the Veterans’ Bureau who is
entitled, under the recent Veterans’ Bureau Act, to medical
treatment—namely, those claimants whose disability is not sufficient to
warrant an award of compensation. Heretofore only patients who were
compensable were entitled to medical treatment and the claimant must
have a disability of ten percent or more to entitle him to compensation.
Under Section #13 of the Veterans’ Bureau Act, a patient with any degree
of disability is entitled to treatment for a disease or disability,
which is connected with or aggravated by service. This adds a class of
patients to whom the Veterans’ Bureau must provide treatment now and in
the future. The dispensaries, it is believed, will meet this demand.

The establishing of dispensary service by the U. S. Veterans’ Bureau is
therefore the logical outcome of past experience in the examination and
treatment of its patients. The Director is also enjoined by the
Veterans’ Bureau Act to furnish adequate medical care including
dispensary service, follow-up and after care to claimants of this
Bureau. The matter has been given and is being given careful
consideration in this Bureau and it is hoped that in the near future the
dispensary service of the U. S. Veterans’ Bureau will extend throughout
the United States, for the convenience of all disabled veterans of the
World War and for the betterment of the treatment which this Bureau is
endeavoring to give.”


COL. FORBES: stated that it was believed that the dispensary was the type
that could do everything but put the man to bed; that it was decided
that it would require an appropriation of seven million dollars to put
over the dispensary program; that the Bureau has a dental bill of 435
thousand dollars; that the dental work is one of the big items, as is
the x-ray service under the present contract system; that heretofore the
examiner was the workman; that the patient would go for examination, and
the examiner would say: “You have two teeth out on this side, and it is
no use to put one in on this side unless you have the other two put in
also; that the bureau has had bills come in for dental service for one
mouth in the amount of $350.00; that that service has been abused; that
x-ray bills for one mouth have ranged from $15 up; that $3.50 was
decided upon as a general figure.

“We shall now have a half hour’s discussion of the topics presented in
today’s program so far.”


DR. LAVINDER: suggested that explanation be made to the officers present
concerning out-patient relief, stating that shortly the Veterans’ Bureau
will assume entire responsibility in that connection.


COL. FORBES: repeated the statement that the Veterans’ Bureau will assume
the entire responsibility.


COL. EVANS: Called attention to the part of General Sawyer’s address which
summarized the personnel for a 200–bed hospital, and stated that he
believed there was an error in the numbers as he had formerly compiled
them;—that 14 people would be sufficient to cover the three phases of
work (Occupational Therapy, Social Service, and Vocational and
Prevocational Training).


GENERAL SAWYER: stated that the correction would be made.


SURGEON CHRONQUEST: asked if the personnel just mentioned applied to all
types of hospitals, general, T.B., and N.P.


COLONEL FORBES: stated that they do.


SURGEON BAHRANBURG: stated that he thought there must be an error in the
figures as given; that at St. Louis they have a 650 bed hospital, with
an average of 600 patients; and that with the use of aides in greater
proportion than here mentioned, they cannot do as much work as is
required of them in that line.


COL. FORBES: asked for his recommendations concerning additional aides.


SURGEON BAHRANBURG: suggested 12 as the number of physio-therapy aides; and
the same number for occupational aides. He added a few words concerning
the clinic at St. Louis, stating that they had 162 cases last month;
that they have an x-ray laboratory, etc., and that the cost of operation
of the dental clinic was a little over $8000 a month.


SURGEON YOUNG: inquired as to the basis on which were derived the figures
for total per diem cost.


COL. FORBES: that the Bureau has a complete analysis of the cost of
operation, and that this matter would be discussed later in the
conference.


DR. SANFORD: stated that he was interested in the dental clinic in Denver,
and remarked that the dental clinic was the hardest to handle. He added
that their dental bill for one month was $3760, but that their expenses
in that connection were much less now; that they have a personnel of
eight full-time doctors—three men in the laboratory; and that the clinic
there is a complete one.


COL. FORBES: “There is no question but what the fee basis is costly. Our own
clinics are the most economical.”


COL. BRATTON (Army & Navy Gen. Hosp.): asked how long this expense for
dental treatment was to continue,—if it were to continue during a man’s
life.


COL. FORBES: stated that the law provides that any man who has 8% disability
has a dental disability; that the x-ray is largely responsible for this
dental treatment; that the matter is one to be adjusted by those present
who are responsible for having the x-rays made and for prescribing
dental treatment.


SURGEON McKEON: made reference to Colonel Patterson’s paper and the
necessity for removing men from hospitals as soon as the need for
hospital treatment ceases to exist. He stated that men are retained in
hospitals longer than is necessary, due largely to the fact that they
want to take up vocational training. He recommended that the
Rehabilitation Division make a survey of a patient about three months
prior to discharge, so that when the patient is able to be discharged
from the hospital, he may enter training at once.


COL. FORBES: Read Section 2 regarding vocational training; but added that in
the rearrangement of the Veterans’ Bureau now in process there will be a
closer liaison between the Rehabilitation Division and the Medical
Division, and the Rehabilitation Division will be represented in the
hospitals.


COL. EVANS: stated that a recommendation is to be presented to Col. Forbes,
for his approval or disapproval, to the effect that the educational
director in a hospital will be the Bureau’s representative there in
regard to rehabilitation work and will furnish data regarding the man as
to what he has done and what he can do.


GEN. SAWYER: said he understood that this representative was accounted for
in the list presented formerly by Col. Evans.


COL. EVANS: answered that that was the provision made.


COL. FORBES: said that he believed that the rehabilitation proposition is
much more of a medical problem than an educational one; that there must
be a closer medical observation of the men and not quite so much
education; that if the physical disability can be removed first, then
the man is better equipped for vocational work; that the man should have
the maximum of hospital treatment before he is put into vocational work;
that the problem is 90% medical and 10% educational.


SURGEON DEDMAN (Greenville): stated that his place had adopted the system of
sending a copy of the physical report of the Board of Medical Officers
to the social welfare part of the Red Cross, and one copy to the
educational department of the Veterans’ Bureau so that the Bureau might
be in constant touch with the man’s physical condition. He recommended
that there be in the sub-offices experts on T.B., etc., and thereby
eliminate the sending of men to hospitals when they have no trace of
such disease.

He expressed appreciation of the work of the Red Cross in his community.


COL. FORBES: added his appreciation of the splendid service rendered by the
Red Cross, and stated that that organization had recently made available
to the Bureau $175,000 for recreational purposes.


SURGEON STITES: stated that the educational director at the Alexandria
hospital is kept in constant touch with every patient there,
particularly those approaching discharge. He also stated that he was
particularly impressed with what was contained in General Wood’s paper
with reference to the care and treatment of disabled veterans whose
disability is in no way connected with the service; that there are
veterans in his community who need treatment, but whose disability is
not connected with service.


COL. FORBES: emphasized the fact that the law provides that the disability
must be in line of duty or during the period of military service.


COL. FORBES: in answering a conferee, stated that the law providing for
admission to Soldiers’ Homes was amended to apply to veterans of the
World War; and that all that is required of the man is to make
application to any National Soldiers’ Home and present an honorable
discharge from the service.


SURGEON MILLER: expressed his interest in Dr. White’s address; that it
called to mind a condition which exists at some of the T.B. hospitals.
He said that a case of Dementia Praecox is often found with active T.B.,
and that where such a patient is accustomed to taking convulsions, it is
very disturbing to the other patients at the hospital.


COL. FORBES: said that the N.P. cases could be sent to Marion, Indiana.


SURGEON MILLER: said he had a telegram saying that admittance was refused to
active T.B.-Dementia Praecox cases.


COL. FORBES: recommended that he take this up with his Surgeon General.


SURGEON WILBOR: spoke concerning the patients at Gulfport, and stated that
many of these men lack confidence in themselves as regards training and
have to be encouraged. He recommended that the men be given a partial
course of training in the hospital, after discharge, in order to give
them sufficient confidence.


COL. FORBES: said that he believed that if a man were able to pursue six or
seven hours of educational activity, he should not be hospitalized; that
heavy machinery, etc. should not be in hospitals.


COL. FORBES called upon Captain Blackwood, U.S.N.


CAPTAIN BLACKWOOD: stated that he did not have anything special to say, as
he had intended reserving his remarks until later. He said that he was
discouraged at hearing so many exaggerated adjectives used by the
conferees; that it should be realized that the patients came from all
walks of life; that the physical examination upon entering the service
was superficial in many cases, and the men are only now being examined
as thoroughly as they should have been before; that they are now
receiving better treatment than they would in civil hospitals, as the
Government is trying to eliminate the possibility of the patient’s
having a disease of which he is not aware, and thereby save future
trouble and expense for the Government.


COL. FORBES: “Would you say that in all cases of medical doubt, a man should
be x-ray’d?”


CAPTAIN BLACKWOOD: “Yes.”


CAPTAIN BLACKWOOD: stated, in addition, that he considered the matter of
dispensaries a very good one.

He also recommended that the amount of paper work for medical office be
reduced, as it seemed that the work they are trying to do in medical way
will be subservient to the clerical work. He stated that he had
reference to both Navy and Veterans’ Bureau papers.


COL. FORBES: asked for his recommendation in this connection.


CAPTAIN BLACKWOOD: replied that he could not make any sweeping statement.


COL. FORBES: called upon Colonel Kennedy, U.S.A.


COL. HANNER: represented Colonel Kennedy.


COL. FORBES: inquired as to the number of patients at Letterman Hospital.


COL. HANNER: answered that they have 84. He inquired concerning a few
patients sent to them by the proper authorities, where the disability
has no connection with the service.


COL. FORBES: inquired as to what had been done in such cases.


COL. HANNER: replied that the men had been taken in and that some of them
had been hospitalized and some not—pending authority from the District
Manager to discharge them from the hospital.


COL. FORBES: stated that if there is a question of doubt, the man is to be
given the benefit of the doubt and his hospitalization continued; that
if it believed that the disability is not due to service, the officer is
to be guided strictly by Regulation 27, and he should inform the
District Manager; that the Sweet Bill provides very liberally for the
care and treatment of ex-service men, and that he would see that
everyone present received a copy of the Sweet Bill, a copy of the
Vocational acts, and the original War Risk Act and its amendments; that
he wanted all to read them very carefully. He added that it is the
medical advice and decisions that the Bureau has to depend upon
regarding the care and treatment of the men.


DR. SNELL, (N.H.D.V.S.) asked if a man should be hospitalized if he
presented himself to Dwight, Illinois, for example, but his disability
was not of service origin.


COL. FORBES: said that the man is to be hospitalized, and his case
determined later; that is he has a contagious disease the city will take
care of him.


COL. FORBES: called upon Surgeon Quick (P.H.S.)


SURGEON QUICK: stated that he was connected with a Marine Hospital, which
did not take T.B. or N.P. cases; that the patients were beneficiaries of
the Veterans’ Bureau and were mostly of the surgical type; and that he
felt there was very little he could add to what had already been brought
to the attention of the gentlemen present. He stated that he believed
the large percentage of medical men would agree that rehabilitation was
more of a medical matter than an educational one.

He also expressed himself as being in favor of the dispensary plan for
the Districts; but added that he felt there must be a great deal of
cooperation between the District Managers and the Medical Officers in
hospitals; also, that medical officers in dispensaries should use a
great deal of judgment in referring cases to the attending specialists.


COL. FORBES: said that that was a medical question; that the District
Medical Officers should go the limit in providing hospital care if in
their judgment it is the proper thing to do.


COL. BRATTON: stating that he had charge of the Army and Navy General
Hospital at Hot Springs, spoke concerning the discharging of patients
from government hospitals by reason of disorderly conduct. He stated
that when such men were discharged they were not granted transportation
to their homes, and therefore became nuisances to the community there.


COL. FORBES: stated that there is a General Order providing for the payment
of such transportation.


COL. FORBES: inquired of this officer regarding the paper work of his
hospital.


COL. BRATTON: answered that he found it very cumbersome; that he has to make
triplicates; that two of these copies go to the District Manager who
sends one to Washington.


COL. FORBES: said he wished he would suggest to General Ireland a medium for
reducing this.


COL. BRATTON: said that he was running two sets of records,—Bureau and Army.


COL. FORBES: replied that he was dealing with two distinct sets of men.


COL. BRATTON: stated that he had just made out his annual report. He said
his place had treated 851 Veterans’ Bureau patients the last year, and
he told the different diseases involved. Added that in many cases
referred to them no trace of disease was found; also, that one man was
sent from Oklahoma and the only ailment discovered was one decayed
tooth.


COL. FORBES: replied to the effect that that man is entitled to vocational
training under Section 2.


SURGEON GARDNER (St. Paul): expressed himself as being in favor of the
dispensary project, as it would assist the medical officers greatly. He
added that he has two patients suffering from paralysis, and does not
know where to place them.


LIEUT. COMMANDER HIGGINS: stated that he is not in a hospital, but one thing
that impressed him in his contact with men in hospitals was Dr. White’s
“third class”, the border-line mental types. He said this type gave the
most trouble in hospitals, but that they do not get the sympathy of many
medical officers not accustomed to dealing with that type.


COL. FORBES: asked if he believed there were a lot of men hospitalized,
drawing compensation and taking vocational training from the Government,
who are not entitled to such.


LIEUT. COMMANDER HIGGINS: replied that it would be a very hazardous thing
for him to say because he had not been in contact with them; but that
from a civil standpoint that might be true.


COL. FORBES: asked Captain Blackwood if everyone in his hospital had a
disability.


CAPT. BLACKWOOD: answered in the negative; and added that at his hospital
they got diagnosis varying anywhere from baldness to flat feet; that the
man claims the disability, and when the hospital cannot find it, the man
is discharged. He cited one instance where a man came to the hospital
claiming that he was suffering from “Compensation”.


COL. FORBES: called upon Captain Dunbar, U.S.N.


CAPTAIN DUNBAR: said that he came prepared to offer statistics on the League
Island Hospital, and added that he thought that that hospital had been
doing as much work for the Veterans’ Bureau as any of the naval
hospitals; that out of so many sick days, one third of them had been
devoted to the patients of the Veterans’ Bureau. Remarked that during
the past year it had not been necessary to discharge a patient for
disciplinary action, but that so far this year two had been discharged
for peddling drugs. He also brought up the subject of treating patients
for disabilities other than those mentioned in the diagnoses upon
admission to the hospital, and gave as example a case diagnosed as
“chronic gastric catarrh”, but found to be an “ulcer” case. He said that
in emergency cases they went ahead and operated.


COL. FORBES: instructed him to go right ahead and operate completely.


SURGEON COBB: stated that he did not think that any of the gentlemen present
were aware of any General Order allowing the payment of transportation
after disciplinary discharge.


DR. LLOYD: gave information to the effect that that General Order was just
being printed.


COL. FORBES: stated that he would see that the proper authorization was
given, and that the travel blanks were placed right in the hospitals.


SURGEON COOK (Houston): asked if such transportation would take the man to
his home or to place of hospitalization.


COL. FORBES: replied that transportation would be to the legal residence or
to place hospitalized.


COL. FORBES: called upon Dr. Guthrie to inform the doctors present
concerning the difficulties in the Veterans’ Bureau.


DR. GUTHRIE: said he had been inclined to listen because he felt that the
reactions from the field had been more than the Bureau’s. He informed
the doctors that Col. Patterson had deemed it necessary to place a
Bureau representative in each hospital—the larger ones—in order to take
care of the very things that the doctors had been bringing up in the
conference. He added that many such matters would be discussed later in
the conference in addresses.


SURGEON KOLB (Waukesha): suggested that a hospital to take care of less than
100 patients be established, preferably on an island, for the care of
drug addicts and pronounced psychopaths.


COL. FORBES: suggested that Surgeon Kolb present that as a resolution a
little later when such were in order.


COL. DE WITT, (U.S.A.): expressed a need for a Bureau representative at his
hospital at Ft. Sam Houston, where there were 246 patients,
beneficiaries of the Veterans’ Bureau.


COL. FORBES: assured him that a representative would be placed there.


SURGEON RIDLON (New Haven): remarked that the Sweet Bill made provision
concerning Pulmonary T.B., but that he felt that T.B. of the bone should
be considered in the same class. He also suggested that the period of
two years be extended to three, stating that in many cases a boy is not
examined for two years; he comes to the medical officer shortly after
the two years have expired; the medical officer is pretty certain he has
had T.B. within the two years after discharge, but by reason of the two
year limit, the claim cannot be settled in favor of the boy.


COL. FORBES: replied that that was a matter for the medical men to decide,
but that he could see no reason why the boy’s claim should not be
adjudicated.


GENERAL SAWYER: “Many times I have complaints coming through my office. I
wonder if you gentlemen would really like to know what my office
represents. I am the liaison officer between yesterday and tomorrow. Any
difficulties of any kind that ever come through my office are those that
do not get through anybody or everybody else. So a number of these
complaints about the extensive and exhaustive records and the paper work
that is being carried on in the various departments come to me. I think
the matter is of such importance that I should like, Sir, to make this
motion:

          ‘That a committee of five, representing each of the
          departments, be selected to take under advisement the matter
 _MOTION_ of the paper work of the various departments and to make such
          suggestions and recommendations as they may deem advisable;
          this, regarding hospitals’.”

Motion was seconded by Surgeon General Cumming.

Motion carried.


SURGEON KOLB: offered a resolution:

‘That there be established a special hospital of 100 beds for treatment
of beneficiaries of the Veterans’ Bureau who are pronounced psychopaths
or drug addicts.’

Then followed a general discussion by Dr. Klautz, Dr. Cobb, and others
regarding drug addicts who have T.B., regarding the manner of retaining
such patients in hospital contemplated.


DR. GUTHRIE: stated that the Bureau is investigating such a matter and
invited suggestions from the doctors.

The above resolution was offered as a Motion, and was seconded by Dr.
Wilbor.

Motion carried.


DR. FOSTER: suggested the cutting of the man’s compensation as a means or
help toward keeping him in the hospital,


COL. FORBES: replied that when a man has become hospitalized, and his
disability has been connected with service, he is entitled to $80 a
month.

It was here remarked by a conferee that General Order No. 27 would take
care of such patients; that if he left the hospital his compensation
would be cut and he would not be readmitted within so many months.


SURGEON CHRONQUEST: offered the resolution that action be taken by the
Hospitalization Committee toward the establishment of a Federal
commitment law in psychopathic cases.


COL. FORBES: replied that there had been decisions made against such a
suggestion, by reason of the fact that it interfered with the
prerogative of the States.


SURGEON CHRONQUEST: mentioned the possibility of a suit being filed against
the commanding officer of a hospital for the illegal detention of a
patient.


DR. WHITE: explained that a man in the service—Army, Navy, etc.—could be
sent by the Secretary of War, of the Navy, to St. Elizabeths as well as
anywhere else; but that the courts in the District state that as soon as
the man changed to civilian status his commitment ends, and he is
illegally detained.


COL. FORBES: suggested that the question be referred to the Legal Division
of the Veterans’ Bureau.


COL. FORBES: “The conclusion of this session precludes me from any further
activity here. There is a little lack of enthusiasm here. I want you to
remember that we have asked you gentlemen here by and under proper
authority, and that it cost a good deal of money to bring you here,
which money is coming out of my appropriation. Now you have got to come
through with everything that is in your systems; you have got to give us
resolutions, advice, etc., and as long as I am coming to these meetings
I want to see lots of interest and enthusiasm shown, especially by you
gentlemen who are commanding large institutions. Surely you have known
lots of improvements you could suggest. I want you to make such
suggestions.

During tomorrow’s session when we are having motions and resolutions,
have something to offer. We are here to serve the Government and the
ex-service men. I want you to help me, because in helping me in my work
you are doing what the law has provided for the ex-service men.

I have been in your hospitals, most of them and I am wonderfully well
satisfied with the work you are doing. I am wonderfully happy because of
the spirit shown and the accomplishment you have made. You have worked
against odds many times, and I know there has been lack of appreciation.
What moneys you need for medical service it is my duty to see you are
allotted. I want you to know that we are not opposing any of the medical
activities, because as I said, I believe and I am satisfied that our
greatest problem in this work is one of a medical nature. Of course the
Veterans’ Bureau must properly operate through its doctors, and those of
you who are handling this big medical problem must help me, and I must
do what you decide is best to be done in the interests of the men.”


              MEETING ADJOURNED—4:30 P.M., Jan. 17, 1922.




           _Third Session_      Wednesday, January 18, 1922.


At 10:00 A.M. the meeting was called to order by General Sawyer.

The roll was called by Dr. W. A. White.


GENERAL SAWYER: Called attention to the fact that is had been discovered
during yesterday’s afternoon session that a number of resolutions would
probably be presented during the Conference, some of which would require
very close attention, and that the Federal Board of Hospitalization is
of the opinion that it is quite necessary to appoint a Committee on
resolutions, whereupon the following Committee was appointed.

                          Committee on Resolutions.

              Major General Merritte W. Ireland, U. S. A.,
              Rear Admiral Edward E. Stitt, U. S. N.,
              Surgeon General H. S. Cumming, U.S.P.H.S.

In accordance with a resolution passed during yesterday’s session, the
following Committee was also appointed:

                         Committee on Forms:

             Captain Norman J. Blackwood, U.S.N.,
             Surgeon M. C. Guthrie, U. S. Veterans’ Bureau,
             Asst. Surg. Gen. J. W. Kerr, U.S.P.H.S.,
             Colonel James A. Mattison, N.H.D.V.S.,
             Major L. L. Hopwood, U.S.A.

General Sawyer urged that the Committee on Forms meet at the earliest
possible moment in order that plans may be devised to take up
immediately the work involved in this connection and that suggestions be
obtained from the Committee, which will necessarily be brought to the
attention of the heads of the Departments represented in the Federal
Board of Hospitalization. He stated that every endeavor will be made to
simplify matters in order that clerical work may be reduced to the
lowest point consistent with the requirements of law. He pointed out in
this connection that the requirements of this nature had recently been
modified by over fifty per cent and that the Internal Revenue Service is
now taking up this same subject.

General Sawyer introduced Major General Merritte W. Ireland, who
presided over the morning session.


GENERAL IRELAND: requested those present to make extensive notes as to the
points brought out by the various speakers relative to such matters it
was desired to discuss later, stating that the papers would first be
read and would then be open for discussion.


COL. P. S. HALLORAN: read a paper on the subject of “U.S. Veterans’ Bureau
Inspections, U. S. Veterans’ Hospitals”, as follows:

“The inspections of the U. S. Veterans’ Bureau hospitals were formerly
made by the General Inspection Service of the U. S. Public Health
Service.

In October 1921, the Director authorized in General Order #39, the
organization of an Inspection Service of the Medical Division of the
Bureau under the provisions of sections 2 and 9 of the Act of Congress
approved August 9th, 1921, commonly known as The Sweet Bill.

In carrying out Section 6 of the Sweet Bill which authorized the
decentralization of the Veterans’ Bureau, the Inspection Section was
organized to consist of the Chief and several assistants located in the
Central Office, and an Inspection Section in each District Office.

The Section in the Central Office functions under Assistant Director of
the Medical Division, and the Inspectors of the District Offices
function under the immediate supervision of the District Medical
Officer.

The Chief of the Inspection Section directs and co-ordinates the duties
of all personnel assigned to Inspection Section including those
temporarily assigned to it for special duty, for example, various
specialists at the Central Office are available to investigate matters
pertaining to their specialty, and for this purpose, are temporarily
assigned to the Inspection Section and work under the direction of the
Chief of the Section to whom their report is submitted.

Ordinarily the District Inspectors make all inspections and
investigations within their respective districts when directed by the
District Manager or the Director of the U.S. Veterans’ Bureau. Only
special cases are investigated by the Central Office.

In general, the duties of the Inspection Section are to make such
inspections and investigations as may be necessary in order to
standardize the character of examinations, medical care, treatment,
hospitalization, dispensary, and convalescent care, nursing, vocational
training, and such other services as may be necessary for the welfare of
beneficiaries of the U. S. Veterans’ Bureau.

Upon the organization of the Inspection Service in each District,
instructions were given from the Central Office, that the work of the
Inspection Service would first be to make complete inspections of all
Contract Hospitals caring for ex-service men. The inspection of
Governmental Hospitals to be delayed until the Contract Hospitals had
all been inspected. This course was taken due to the fact, that is was
generally known Governmental Institutions were well organized, and had
recently been inspected by Officers of their respective services.

The inspections of Governmental Institutions made by the Inspection
Section of the Bureau are limited to matters which directly concern the
welfare of the beneficiaries of the Bureau. Investigations of the
official conduct of acts or officers of Governmental Services ordinarily
are conducted through the regular agencies of those services which are
organized to guide and control their own personnel, and to whom such
matters are referred through proper channels to the Director of the
Bureau for transmission to the services concerned, for their
investigation and administrative action.

See General Order No. 28—U. S. Veterans’ Bureau.

It is the policy of the Director to cause an investigation to be made of
all complaints received which concern the welfare of the ex-service man,
although it is realized that often complaints are grossly exaggerated.

During the comparatively short period which the Inspection Section has
been functioning, the following are a few of the principal complaints
received and investigated:

  (1) Loss of property such as valuables and clothing of patients.
      Investigation has shown, that patients were not informed of the
      hospital regulations regarding the disposition to be made of these
      articles upon admission; adequate lockers not available, or total
      disregard by patients of existing hospital regulations.

  (2) Preparation and shipment of remains of deceased;—casket too small,
      shabby lining; no flag furnished; shipping-box broken, due to lack
      of reinforcements; shroud of cheap material.

      Investigation usually shows gross exaggeration. In some instances
      specifications for the casket, shroud and shipping-box have been
      such that cheap material is provided. Due to this fact the
      contract price has been too low. The Director is willing to
      provide sufficient amount and desires that presentable casket and
      substantial shipping-box be furnished.

      Investigation has also shown that record is not always kept that
      the remains have been inspected by a medical officer, before
      shipment.

  (3) Poor food, especially weak coffee, and food cold when served.
      Investigation usually shows fares as a rule, are good, the
      complainant usually being tired of institutional menus.

  (4) Cooks and other food handlers not examined for venereal diseases
      and carriers.

  (5) Mixing colored and white patients in wards and dining rooms.

  (6) Rough handling of patients by attendants. Reports are usually
      greatly exaggerated, or without foundation.

  (7) Arrogance and overbearing on the part of Medical Officers towards
      the beneficiaries. Such charges have not been substantiated.

  (8) Sputum of T. B. patients not examined routinely at stated
      intervals. Temperature of T. B. patients not taken.

  (9) Rest periods not enforced.

 (10) Insufficient bed clothing. Investigation has shown a few instances
      where blankets through long service are much worn and have lost
      their warming properties.

 (11) Insufficient heating. In a few instances, it has been shown that
      T. B. patients have no warm place to dress and undress in, when
      taking open air treatment.

 (12) Fire drills not held, and regulations not posted.

 (13) Delay in making physical examination after admission of the
      patient to hospital.

 (14) Beneficiaries claiming they were not informed of the provisions of
      General Order #27, U. S. Veterans’ Bureau, 1921, upon admission to
      a hospital.

 (15) Bed linen not changed sufficiently often.

In general, the above list of complaints are rarely received from
Governmental Institutions. When Inspectors have found unfavorable
conditions effecting the welfare of the beneficiaries of the Bureau in
Governmental Institutions, prompt remedial measures are usually
instituted to correct the conditions by the Commanding Officer of the
Hospital.”




                                                          File No. 89960

        UNITED STATES VETERANS’ BUREAU.      September 9, 1921.


                         _GENERAL ORDER NO. 28_

           Subject: STANDARD OF REQUIREMENTS FOR HOSPITALS.

The following General Order is hereby promulgated, effective this date,
for the guidance of all officers and employees of the United States
Veterans’ Bureau:

Minimum requirements have been adopted for all institutions furnishing
medical care and treatment for patients of the United States Veterans’
Bureau, including hospitals under contract, as follows:


                    _REQUIREMENTS FOR ALL HOSPITALS_

   1. The hospital should maintain a service whereby at least one
      resident physician is on duty at all times.

   2. There should be an organized medical staff composed of men
      competent in their respective fields of medicine and actively
      meeting their responsibilities for the direction of the
      professional policies, for the medical work of the institution and
      also for the professional care of the patients in the hospital.

   3. Provision for examination and treatment by dentists and
      specialists in eye, ear, nose and throat and genitourinary work.

   4. Resident trained nurses—not less than 1 for each 10 or any part of
      10 bed patients.

   5. There should be facilities and personnel for the proper
      administration of dietetics.

   6. There should be periodic staff meetings to discuss—

       1. Errors of diagnosis.

       2. Unsatisfactory results of operative or medical treatment.

       3. Autopsy results.

   7. Adequate supply of non-professional personnel for all needs of
      hospital.

   8. Satisfactory fire protection for all classes of patients and
      perfect fire protection for bed-ridden patients.

   9. Satisfactory sanitary conditions as regards heat, light, sewage
      and garbage disposal, toilets, baths, water supply, laundering,
      cooking, dishwashing, refrigerating, handling and serving of food,
      care of clothing and valuables, cleanliness of buildings, etc.

  10. One hundred square foot of floor space for each bed and distance
      between beds of 3 feet.

  11. All rooms and porches to be screened against flies and mosquitoes
      during the season.

  12. Satisfactory record should be made of personal histories, physical
      examinations, all professional treatments, all clinical,
      serological, bacteriological or other Laboratory work done for
      patients, also all x-ray, fluoroscopic and other special
      examinations made, progress notes, working and final diagnoses,
      and these records should be kept in a form permitting ready
      reference.

  13. There should be surgical operative facilities provided with
      sufficient equipment and competent organized personnel to meet
      properly all ordinary surgical emergencies and to perform all
      ordinary surgical operations in a manner and with results which
      meet general professional approval.

  14. There should be clinical laboratory facilities or definite
      arrangements for these facilities to properly carry out clinical,
      bacteriological, serological, x-ray and fluoroscopic examinations.

  15. Physiotherapy: provision for special treatment, such as
      hydrotherapy and electrotherapy.

  16. The systematic use of occupations for their therapeutic effects,
      under the direction of workers specially trained for this duty.

  17. Special attention to recreation and diversion with reference to
      their therapeutic value.

  18. Patients to be taught the elementary principles necessary to
      secure co-operation in treatment.

  19. No charges to be made for patients absent from hospital for more
      than 24 hours.

  20. No extra charges to be made the patient for thermometer, sputum
      cups, reclining chairs, blankets, medicines or special diet, nor
      for any other article of a similar nature furnished without charge
      to a patient in Government sanatoriums.


          _ADDITIONAL REQUIREMENTS FOR TUBERCULOSIS HOSPITALS_

   1. Resident physicians skilled in tuberculosis—if not living actually
      on the premises, to be available in five minutes or less. (Not
      less than 1 for 50 patients.)

   2. Outdoor sleeping facilities, or in lieu thereof, provisions for
      unlimited ventilation of rooms.

   3. Suitable rules prescribed for conduct and published rules
      providing for a satisfactory regimen of treatment in tuberculosis
      hospitals.

   4. Satisfactory treatment conditions, including measures for
      enforcing suitable discipline and to prevent absence without leave
      and to prevent excessive exercise, whether from amusement or
      otherwise.


       _ADDITIONAL REQUIREMENTS FOR NEURO-PSYCHIATRIC HOSPITALS_

   1. Direction of the administration of the hospital and leadership in
      its medical work by physicians trained in the diagnosis and
      treatment of mental diseases.

   2. An adequate medical staff organized so that duties are divided in
      accordance with the training of its different members and with the
      requirements of the clinical work.

   3. Regular and frequent conferences of the medical staff at which the
      diagnosis, treatment and prognosis of each new case admitted are
      considered and at which cases about to be discharged are
      presented, training in psychiatry for new members of the staff
      being considered as a special object.

   4. The reception of all new cases in a special department or in
      special wards where they may receive careful individual study and
      where those with recoverable psychoses may receive continuous
      individual treatment.

   5. Classification of all patients with reference to their special
      needs and their clinical condition, such classification being
      flexible enough to permit frequent changes.

   6. A system of clinical records which permits study and review of the
      history of cases even after they have been discharged.

   7. When possible, the maintenance of a school of nurses under the
      direction of a supervisor of nurses, who should have, not only the
      training in general nursing, but special training in nursing
      patients with mental diseases.

   8. The employment of female nurses in all reception and infirmary
      wards.

   9. Liberal use of parole for quiet, chronic patients who can live in
      farmhouses.

  10. Special provision for the tuberculous.

If, after written notice has been given, any institution furnishing
medical care and treatment to patients of the United States Veterans’
Bureau fails or refuses to make reasonable effort to meet the foregoing
requirements, such institution will be deemed to be rendering
unsatisfactory service, and if under contract with the United States
Veterans’ Bureau, such contract may be cancelled, and the Director will
refuse to make contracts when the care and treatment offered do not
substantially meet the requirements specified herein.

[Illustration:

  LEON FRASER
  Acting Director,
  U. S. Veterans’ Bureau.
]


SENIOR SURGEON B. J. LLOYD, (U.S.P.H.S.,(R)): presented the second paper,
entitled “Admissions to, Transfers and Discharges from Hospitals of
Beneficiaries of the U. S. Veterans’ Bureau,” which is given below:

“I do not often speak in public. Occasionally I attempt to speak
extemporaneously, but today I shall claim your indulgence and confine my
remarks strictly to what is written in this manuscript, for the reason
that if taken in a disconnected sense some of the things I shall say
might sound sensational, whereas if taken in a connected sense and in
the way I shall say them, I think you will agree with me that there is
absolutely nothing sensational in my remarks.

Attendance at this conference is indeed both a privilege and an
opportunity. To be asked to address this gathering is a distinction
worthy of the best that can be said on the topic assigned.

I take it that you are already familiar with the rights and benefits to
which the disabled ex-service man is entitled; that you are familiar
with the usual routine of paper work and other procedures in admitting,
transferring and discharging, and I shall therefore omit some of the
more or less definitely settled, fixed policies in this discussion.

I fully realize that my subject is an extremely important one and that
it is in a measure connected with nearly every benefit extended to the
ex-service man or woman, and with every service that is rendered in his
or her behalf. On the intelligent administration of the functions of
admission, transfer and discharge to, or from our hospitals, as the case
may be, depends, in great measure, not only the economical and efficient
administration of our entire hospital program, but in equal measure the
recovery, the health, the happiness, the future usefulness, even the
very lives of men and women, many of whom have made great sacrifices and
passed through great agonies.

When I make these assertions, do not think for a moment that I am
comparing these functions with the actual volume of work that is done in
the hospitals, with the relief that is given therein, nor with the
benefits which accrue to the patient, but, just as victory in a great
battle may depend on the placing of the right troops in the right place
at the right time, so victory, in the struggle of the disabled
ex-service man for rehabilitation, for health, or for life, may depend
on his being sent to the right hospital at the right time. Neither must
he be discharged too soon, nor kept too long, and when he is transferred
from one hospital to another there should be sound medical reasons
therefor, barring those unfortunate cases, where the beneficiary may be
transferred to a hospital near his home when it is seen that death is
inevitable.

Going back now to the contact which hospitalization makes, or should
make, with the other benefits extended to the ex-service man, let me
picture to you the state of our past, and to a great extent, our present
organization, by recalling to your minds the old story of the six blind
men of Hindustan who went to see the elephant, each trying to tell what
the elephant was like. The first man got hold of the elephant’s ear and
said that the animal was very like a fan; the second got hold of his leg
and said, “No, I can’t agree with you; this elephant is like a young
tree.” The third man got hold of the elephant’s trunk and said, “The
elephant is like a snake.” The fourth man grasped a tusk and said that
the elephant was like a spear; the fifth fell against his side and said
he was like a wall; and the sixth got hold of his tail and said he was
like a rope. Now all were partly right and each was mostly wrong, and a
somewhat similar condition exists with regard to our work.

This meeting, gentlemen, is an attempt to further co-ordinate the
efforts of all the agencies that are at work for the ex-service man.
Ours is a tremendous responsibility, both from the standpoint of our
duty to the ex-service man and of our duty to the taxpayer as well.

No man except the man in the field knows better than I do that you have
been circularized and regulated and instructed and uninstructed,
informed and misinformed, ordered and dis-ordered, until I have no doubt
you have been tempted to slam your fist down on your desk and say,
“Well, for Heaven’s sake, how many bosses have I, anyway, and which lead
had I better follow.” And as for reports, no doubt you have wondered,
“Well, what _will_ they want to know next?” And yet there has generally
been a fairly good reason for every question you have been asked and a
reasonably intelligent, honest, and often an enthusiastic, and sometimes
an efficient man or woman behind the interrogation point.

In addition to having all these things done to you, I suspect that you
and your colleagues in the hospitals, some of you at least, feel that
you have been libelled and slandered by newspapers whose editors thought
they were telling the truth, and by newspapers whose editors probably
did not stop to consider whether they were telling the truth or not. You
probably feel that you have been libelled and slandered, unintentionally
of course, by men inside of legislative halls, and also, again perhaps
unintentionally, if carelessly, by men and women outside of legislative
halls, and by men and women both inside and outside of well-meaning
civic organizations. And, I may say that in the Arlington Building in
this city there are reams of evidence which might be cited in support of
your beliefs, and at “C” Building at 7th and B Streets, there are
tri-remes of such evidence, and these reams and tri-remes of evidence
have cost the Government of the United States thousands, tens of
thousands, yes, hundreds of thousands of dollars for investigations,
when, as a matter of fact, the majority of the complaints that have been
filed against hospital administration need never have been investigated
by the Government at all if the individual who submitted the complaint
had taken the trouble to do a little honest investigating on his or her
own account.

The fact that these statements have been made with the best intentions
in the world does not lessen the injustice contained in many of the
charges, nor does it remove the sting which has accompanied these
charges, and you, gentlemen, have listened to the soft pedal on the
inside and to jazz on the outside until you have probably said, “For the
love of justice, is there not some man who has grit enough to get up in
public and tell the truth and say what he thinks?”

But, gentlemen, it will not always do to talk back. Actions speak louder
than words, even though they do not make as much noise, and Solomon was
right when a few centuries ago he remarked that “A soft answer turneth
away wrath.” We must _always_ maintain a courteous, gentlemanly,
dignified attitude. We must never for a moment allow our sympathies for
the deserving unfortunate ex-service man to become in the least
weakened, and we must continue to give him the benefit of the doubt in
border-line cases, and finally we must maintain our equanimity under the
most trying circumstances.

And now that we have you here, we are going to ask you some more
questions, and I hope you know the answers, because I don’t know the
answers to some of these questions myself, nor do I intend to answer
them.

In passing, I might remind you of the fact that in times past we have
spent money very freely on our hospital program, and that while we still
desire to give our beneficiaries what is perhaps a little more than
reasonable medical and surgical care and treatment, at the same time we
must be able to show Congress that we are operating economically under
present conditions, and certainly, when not in conflict with the
patients’ rights or interests, the question of economy of administration
must be considered in admitting, transferring and discharging. Are we
giving this question of economy of administration the proper
consideration in performing these functions, and if not, what are the
reasons? We want to know. This I will label “Question No. 1,” and let
you think it over for a while. It is perhaps not the most important
question I shall ask but it is important.

Now, having delivered myself of this question, and not having answered
it, I suppose you are ready for Question No. 2. Well, I am not. I want
to talk a little before I spring the next question. Of course we all
know that the primary object in placing a man in a hospital is to give
him a chance to get well, or as nearly well as possible. This, however,
is not the only thing to be accomplished in the hospitalization of
patients of the Veterans’ Bureau, and, if I may speak frankly, I may say
that, while theoretically, hospitalization, rehabilitation, and the
awarding of compensation ought to dovetail into each other without any
overlapping or getting in each other’s way, as a matter of fact they
won’t do it,—at least they haven’t done it so far; but, nevertheless,
we’ve got to make the best possible connection between these functions.

Let us hark back to Regulation No. 57 of the old Bureau of War Risk
Insurance, which gave temporary total disability to the beneficiary
whose disability showed Service connection, together with compensation
at this high rate as soon as the man entered the hospital, and which cut
down this compensation anywhere from $80 per month to nothing at all as
soon as the beneficiary left the hospital. Although this Regulation has
been somewhat modified recently, it is still a very strong incentive for
men to seek hospitalization. It takes an unusually patriotic citizen to
take $30 to $60 a month or less when he can get $80 a month and board
and lodging if he can remain inside of a hospital.

Apropos of this provision, I recall the circumstances of a young man who
came to me quite some time ago, having left the hospital at Fort
McHenry. He presented himself in a courteous, dignified way, was
perfectly serious and absolutely frank. He began the interview by
handing me the card of a U. S. Senator. Then he told me his story, and
it was a good story. I shall try to recall it as nearly in his own
language as possible. “Doctor”, said he, “I have just left your hospital
at Fort McHenry. I do not like it. I realize that the Public Health
Service is not to blame for conditions which I found there. It is not
suited for a hospital. It is badly located. There are odors which it
seems impossible to overcome. The walls and floors are dingy, and while
they are clean, they cannot be made to look clean.

“I was shot through the stomach by a machine gun. Here are the scars. If
I do not work hard I feel fairly comfortable, and yet I am not well, I
receive $30 a month when I am outside the hospital, I receive $80 a
month and my board and room when I am in the hospital. Personally I
would much prefer to remain at home, but when I work hard enough to make
a living I break down. I have seen so many men in the hospital who are
receiving their board and lodging and their $80 a month who are not as
deserving of this as I am that I do not propose to remain at home and
work on my present compensation, and I would just like to see you keep
me out of a hospital. And furthermore, I demand to be sent to the
hospital of my choice. What are you going to do about it?”

I replied, “Young man, you have been unusually frank in what you have
said. I shall be equally frank with you. If I had been wounded as you
have, and if I had the information which you have gained from your stay
in different hospitals, I should probably make the same demands. You can
have your transportation whenever you want it.”

I saw this young man later at No. 38 in New York and he told me that he
was about to get what he considered a satisfactory rate of compensation,
and that as soon as he could get it he would go home.

Question No. 2. How many men are there in our hospitals today who would
voluntarily leave if we did not, by providing total disability rating
and compensation while in the hospital, place a premium on their
remaining there? How many of those who would leave really ought to
leave? What can be done to correct the defects in the operation of
Regulation No. 57, modified as it has been? Perhaps you think I am
giving you several questions in one, but we will still label if
“Question No. 2.” I am not alone in desiring to know the answer to that
question.

Before I go any further let me say that I regard admissions, transfers
and discharges as such closely related operations that I shall not
attempt to treat them separately, but shall discuss them in any sequence
that may be convenient.

I assume that all of you have been advised that under General Order No.
59, the allocation, distribution and transfer of patients of the
Veterans’ Bureau are functions and prerogatives of that Bureau.
Theoretically, none of the Services has anything to say about these
matters. Practically, if I have not misunderstood the intent of this
General Order, it does not mean that, altogether. The actual authority
for and the right to refuse transfers certainly is vested in the
Veterans’ Bureau and its representatives, but the Veterans’ Bureau and
the District Medical Officers and District Managers depend on you to
tell them when you think transfers ought to be made. Admission to a
given hospital is the prerogative of the Veterans’ Bureau within certain
limits; that is, the Service concerned must be able to take and care for
the class of patient sent by the Veterans’ Bureau.

With regard to the discharge of patients from hospitals, the Veterans’
Bureau is continually encroaching, perhaps unavoidably, on what was once
the prerogative of the Medical Officer in Charge and the Service which
operated the hospital. Blanket authority for field transfers from one
district to another has been entirely withdrawn, and District Officers
must either place immediately in an authorized hospital in an adjacent
district, as specified in General Order No. 59, or, having placed for
observation or diagnosis a patient in a hospital within their own
districts, must apply to the central office if it is desired to transfer
later. It is, or should be, understood that under the present regime,
that Medical Officers in charge of hospitals who regard transfers as
necessary must request the District Office to make these transfers if
within the district, and must request the District Offices to obtain
authority from the Central Office if it is desired to transfer outside
of the District.

Several questions suggest themselves with regard to General Order No.
59, and perhaps I should label this series of questions “No. 3.”

(a) Has General Order No. 59 lessened the number of ill-advised and
unnecessary transfers, which is one of the objects, I believe, that were
intended to be accomplished.

(b) Has General Order No, 59 caused any marked fluctuation in the
patient personnel of any of the hospitals? I notice, for example, that
Public Health Service Hospital No. 53, Dwight, Ill., has recently
dropped from      occupied beds to 65 in number, giving a surplus of 165
unoccupied beds. Houston, Texas, has dropped from      occupied beds to
443 beds, giving a surplus of 528 unoccupied beds. At No. 32, Mount
Alto, Washington, there is a ward for colored patients which will
accommodate 30, in which there are only 6 colored patients at the
present time. Are these fluctuations coincidences or are they the effect
of the Veterans’ Bureau having assumed the functions under discussion.
Of course if we could be sure that these reductions in-patient personnel
are going to be permanent it would not make any difference. We could cut
down our working personnel at a hospital like Houston, Texas, and with
the consent of the Veterans’ Bureau we could close a hospital like
Dwight, Ill., but will the pendulum swing in the other direction again,
and what advance information can the Veterans’ Bureau give these
fluctuations and of their approximate duration?

(c) Have you received very many patients who, owing to their condition
or to the nature of your facilities, or both, should never have been
sent to your hospital?

(d) Has General Order No. 59 tended to delay the turnover in those
general hospitals having special wards for psychoneurotic and psychotic
patients, who are detained for a short time only until they can be
otherwise disposed of?

(e) Should General Order No. 59 be modified, and if so, in what
particulars?

Having delivered this third volley of questions, I shall talk a little
more. I have no idea what opportunities you gentlemen have had to become
familiar with the facilities at hospitals other than your own. I have no
idea what information District Managers and District Medical Officers
have of hospitals and conditions in Districts other than their own.
General Order No. 59 of course attempted to convey some idea of the
facilities in all of the hospitals used by the Veterans’ Bureau, but it
was impossible to incorporate anything like a comprehensive statement
with regard to these facilities. Quite recently, at the request of Dr.
Guthrie, and with the assistance of men in both Bureaus, I prepared a
questionnaire for all the hospitals, asking what your general conditions
and facilities were like. Most of the hospitals have answered this
questionnaire, and the information obtained is exceedingly valuable.
Practically without exception the answers have been concise, complete
and exactly what was asked. Those of you who have not answered please do
so as soon as you can. I wish it were possible to print or mimeograph
these reports and distribute them. Certainly anyone who is charged with
the responsibility of placement and transfer of patients should have
access to these reports.

While I am on this subject of facilities, let me invite attention to the
fact that there are marked differences in the kinds of facilities
offered by different hospitals and by the hospitals of the different
Services. Let me also invite attention to the fact that we have patients
who, if properly distributed, would fit into these different
institutions possibly in a much more satisfactory way than at present
and at a smaller expense. Particularly I suspect that there are many
patients in Public Health Service hospitals that do not need the highly
specialized and necessarily expensive care that these hospitals are
giving, and I also suspect that there are many vacant beds in our
Soldiers’ Homes where these patients can be given all they need at a
much less expense than is possible in the highly developed hospitals of
the Public Health Service, and possibly those of the Army and Navy as
well. Why would not this be a good time to arrange for the prompt
transfer of such patients? Europe has found the Convalescent Home to be
an economical institution, being much less expensive than the hospital.
Why may not our Soldier’s Homes be used for convalescents and those who
need relatively little medical care and treatment, but who are still not
well enough to be thrown on their own resources? These questions I shall
not number. They just crept in.

There is one class of beneficiary that none of the Services seems to be
prepared to handle satisfactorily, possibly due to the fact that
legislation is needed to deal with this class. There may be a solution
other than legislation but none of us has thought of it as yet. I refer
to the drug addict who is entitled to hospitalization for some Service
connected disability. We haven’t any place to put such patients and we
do not know what to do with them after we put them there. We do manage
to take care of some of them but at great inconvenience, and without
being able to treat them for their own best interests. We cannot get
them admitted as irresponsibles by the Courts. We have no such thing as
involuntary commitment, and if one of them desires to walk out of the
hospital, out he walks if he is persistent enough about it, and we
cannot stop it. This is a good time to say something about what we might
to with these cases.

I have said very little about discharges for the reason that
disciplinary discharges are to be treated by another speaker, and
Regulations Nos. 26 and 26–A, bearing on this subject are to be
discussed by Doctor Guthrie, who follows me on the program. I will say,
however, that this subject is an important one and I can easily
understand that from the standpoint of the man in charge of a hospital
present procedures with regard to discharges are unsatisfactory. On the
other hand, I can understand that when a man is in a hospital it affords
an excellent opportunity to settle once and for all his claims for the
various benefits provided by law, and yet I think it is right that the
Veterans’ Bureau should accomplish these objects before the man is ready
to be discharged. As yet this is not being done.

In conclusion, Gentlemen, I may say that as I see it, those of you who
are in charge of hospitals are, if you will pardon the expression,
between the devil and the deep blue sea. You are told one minute that if
you exceed your allotment you will go to jail, and in the next breath
you are told to go the limit if it is for the ex-service man. You have
been told that there is room for improvement in your hospitals. No doubt
there is, but in my humble opinion there is also room for improvement in
the laws providing these benefits, in the orders, regulations and
procedures designed to administer these laws, and last but not least,
there is a crying need for some means of creating a sane public
sentiment that will enable the public servant to discriminate between
the man who really has a serious disability which he got in the Service
who deserves our help and our sympathy, and to whom you and I would give
the shirts off our backs if need be, and the man who spent a few days or
a few weeks in camp who is not really disabled but who proposes to live
at the expense of the tax payer just as long as he can get away with it.

We, Gentlemen, are not responsible for the law, nor is the Director, and
the Director has men who tell him what the law is and he has to obey it
and so do we, but it is our duty to point out defects in the law and try
to get them remedied.”


SURGEON M. C. GUTHRIE (U.S.P.H.S.) had for his subject, “Discussion—General
Order No. 26”, and spoke as follows:

“The subject assigned to me for discussion is General Order No. 26. This
refers to U. S. Veterans’ Bureau General Order No. 26, dated September
6th, 1921, the subject of which is: “Admission to and Treatment in
Hospitals of the U. S. Veterans’ Bureau Beneficiaries.” You are
doubtless all familiar with the general provisions of this order.

It goes without saying that any definite order or instruction which
effects the policies and functions of the U. S. Veterans’ Bureau and
which may be issued to the field is sure of a series of return
re-actions from various parts of the country, both as to the manner in
which such an order is applied and as to the consequences of its
application. These reactions are naturally good, bad, and indifferent;
exact and truthful statements or colored as to the manner in which they
affect the various individuals in its application, but coming from all
parts of the United States they afford many valuable and effective
criticisms of the order in question and are illuminating as to the
original intent of the order and the amount of deviation or variation
from its original purpose brought about by the manner in which it is put
into effect.

The criticisms of General Order No. 26 had to do very largely with the
“Four Days’ Notice” clause, and because of the fact that large numbers
of beneficiaries in hospitals were being discharged without provisions
having been made for out-patient care, dental care, physiotherapy, or
other treatment where such was indicated and necessary; that patients
were being discharged without having proper arrangements made for
vocational training where the patient in question was feasible for some
kind of training and was anxious to get it; that many such patients had
to leave a hospital when they were receiving no compensation or where
adjustments or readjustments of matters related to compensation needed
to be carried out here.

These were the dominant and outstanding criticisms which followed the
issuance of General Order No. 26, and as a result of these criticisms,
it was considered advisable to issue a supplemental order correcting the
defects complained of. Accordingly General Order No. 26–A came out under
date of November 17, 1921.

The re-actions to General Order No. 26 were as I have just stated and
came largely from the Bureau beneficiaries, from friends, relatives, and
allied agencies working in the field. The criticisms of General Order
No. 26–A, however, came largely from the hospitals and the District
offices, the hospitals particularly. There was an apparent contradiction
between the two orders. No. 26–A seemed to largely or entirely
contradict the provisions of the original Order No. 26. General Order
No. 26 stated that patients not requiring further hospital treatment
should be given four days to complete personal arrangements and then be
discharged.

General Order No. 26–A requires that before a patient is discharged from
hospital it should be determined whether or not he is in further need of
out-patient care; whether or not he is feasible and eligible for
vocational training and if he wanted training, that this should be
arranged before he is discharged, and that the necessary adjustments or
re-adjustments of all matters pertaining to a claimant’s compensation be
entirely completed by the time of his discharge from hospital; and
further it must be distinctly understood in carrying out all of this
that no unnecessary delay in discharge of patients would be allowed. A
pretty complex and contradictory situation you might say. However,
between the time of the issuance of General Order No. 26 and of General
Order No. 26–A—to be exact, on October 14, 1921, a general order was
addressed by the Medical Division of the U. S. Veterans’ Bureau to the
several Government services—the Surgeons General of the Army, Navy, U.
S. Public Health Service, the Superintendent of the National Homes for
Disabled Volunteer Soldiers, the Superintendent of St. Elizabeth’s
Hospital, and to the fourteen District Managers. The essential parts of
this letter are as follows:

                                                       October 14, 1921.

                                                       PSR/jcs L 10–DMO

 District Manager,
 District No. 1,
 U. S. Veterans’ Bureau,
 101 Milk Street,
 Boston, Mass.

 Dear Sir:

Referring to General Order No. 26 and to Paragraph No. 2, which reads as
follows:

“All patients now in hospitals in your District, who do not require
further hospital treatment, will be given four days notice to make their
personal arrangements and will then promptly be discharged from
hospital. Each patient discharged under existing Regulations will be
furnished transportation to his bona fide legal residence in the United
States or to the place from which he was hospitalized. Notification of
such discharge will be sent immediately by the Officer in Charge of the
Institution caring for beneficiaries of the U. S. Veterans’ Bureau to
the District Manager of the District in which the institution is
located.”

In complying with these instructions and before authorizing discharge of
patient of the U. S. Veterans’ Bureau from hospital, district Managers
will determine:

 1st. Whether the patient is in need of out-patient, dental,
      physiotherapy, or other treatment, or convalescent care. If so,
      District Managers will make the necessary arrangements to continue
      the treatment indicated after discharge of the patient from the
      hospital.

 2nd. Whether the patient desires vocational training: If so, his
      eligibility and feasibility will be determined and arrangements
      made for placing him in training promptly upon his discharge from
      the hospital.

 3rd. Necessary adjustment or readjustment of all matters pertaining to
      his compensation will also be completed promptly upon his
      discharge from the hospital.

In order to accomplish the above patients of the U. S. Veterans’ Bureau
will not be discharged from hospitals until District Managers have been
notified and the necessary arrangements made by them for the determining
of the above factors upon which the District Managers will approve
discharge and notify the hospital accordingly.

Instructions contained in this communication do not apply to the
Provisions of General Order No. 27, regarding the discharge of patients
for disciplinary reasons.

                        Very truly yours,

                        ROBERT U. PATTERSON,
                        Assistant Director,
                        U. S. Veterans’ Bureau.

This supplementary letter—perhaps it did not reach you all—was not as
susceptible of misinterpretation as General Order No. 26–A. The needs of
the patients about to be discharged with reference to after-care
out-patient treatment, etc., are not matters which should take long to
determine; feasibility for training is also a matter capable of prompt
determination; eligibility or the right of a patient for training is a
matter that can be handled either before or after a patient’s discharge
has been effected, and the necessary adjustments or re-adjustments of
matters relating to compensation, while necessary of establishment
before discharge from hospital do not require that such patients must
remain in hospital until actually in receipt of compensation. It simply
means that the important steps leading up to this action should be
properly gotten under way, and having done this, the completion of the
compensation status can be as readily carried out after discharge as
before. Notwithstanding the supplementary instructions following General
Order No. 26 still further conflict regarding the application of the two
orders in question in the District offices and in the hospitals was
apparent from reports received in the Central Office, and it was decided
to insert a further explanatory notice in the U. S. Veterans’ Bureau
Field Letter No. 20, of December 24, 1921. This notice was as follows:

Judging from letters that have reached the Bureau, there has been some
confusion with regard to the exact intent expressed in General Orders
Nos. 26 and 26–A.

Rightly interpreted, these orders are in no wise contradictory.

The intent of General Order No. 26–A is fivefold, namely:

(1) To determine the eligibility of claimants for vocational training.

(2) To determine their feasibility for training.

(3) To arrange for training when eligibility and feasibility are
established.

(4) To accomplish everything necessary to adjudicate claims.

(5) Provision for outpatient treatment when required.

“All of these matters ought to be attended to before the patient leaves
the hospital, and with close co-operation and efficient administration,
both in the field and in the Bureau, this can be done, and of course
must be done without keeping the patient in the hospital after his
treatment is completed. Manifestly there is only one way to accomplish
this, and that is, to anticipate the discharge of the patient a
sufficient length of time in advance to provide for these objects.”

“_Feasibility_ of training is to be determined preferably by the Medical
Officer in Charge of the hospital, or his assistant, and means only
that, in his opinion, the patient is physically and mentally fit to
receive vocational training.”

“The other requirements must be met by the Bureau or its field
representatives, but with the co-operation of the hospitals. A
representative will shortly be named at each hospital, who will keep
himself informed of the status of each patient’s claim to the benefits
enumerated and who will follow up all cases in which there may be
delay.”

“Again reminding all concerned that anticipation is the key-note of the
action desired in these General Orders, the hope is expressed that the
objects outlined may be obtained, as nearly as possible, before the
patient is ready to be discharged.”

Any discussion of the instructions of General Order No. 26 and No. 26–A
must take into consideration the reasons which led to the issuance of
those orders. The officials in the U. S. Veterans’ Bureau had been
convinced for sometime that a high percentage of patients were being
cared for in hospitals, and this applies particularly to contract
hospitals, whose necessity for remaining in hospital was not based upon
sound medical reason, and in many instances upon no real medical
indication at all. A number of factors were responsible for this
situation,—the rapid growth and development of the District offices
required the personnel therein to work at high pressure at all times; it
has been a continuous struggle to keep abreast of the volume of incoming
correspondence, with requests for hospitalization, application for
compensation, claimants crowding the doors, and a thousand and one other
subjects. It has been a struggle on the part of the District personnel
to keep from being swamped by the tremendous and ever increasing daily
load. Hospitalization was authorized and carried out both in contract
and Government institutions in cases of all character for treatment
where the indications for such were great and immediate, or were slight
or nil, for ailments, objective and subjective, imaginary and real, for
physical examination and report, for determination of compensability,
and for information concerning the connection with military service of a
claimants disability. The list grew so rapidly that patients were lost
sight of. Many claimants were hospitalized for examination and
treatment, and overlooked after examination and treatment had been
completed. Contract hospitals particularly, through lack of a proper and
direct connection in channels of communication between such hospitals
and the District offices, were carrying patients over long periods of
time. Patients got into contract hospitals for whom no proper
authorization was ever provided, and the records of whom were never
clearly defined in the District offices. The scattering of patients
anywhere from one to a considerable number in several hundred contract
institutions in each District extended the lines of communication
between the Government and the District Offices until it was practically
impossible to keep the contact clear. The Central Office in Washington
felt that it was time to take stock, and stock-taking at almost any time
is an enlightening process. The Director desired to remove claimants
from contract hospitals; he desired further to utilize as much as
possible the existing Government facilities which have been provided for
this purpose.

Under date of September 1st, about the time of the issuance of General
Order No. 26 there were 9,592 patients in _862_ private hospitals; there
were 18,698 patients in _92_ Government hospitals. Today there are
_8924_ patients in 757 contract hospitals and _20339_ patients in _92_
Government hospitals. From these figures it would appear as though the
clearing out of hospitals, as provided for in General Order No. 26, has
not been productive of results. This, however, must be viewed in the
light of what is actually taking place in the field. About the time of
the issuance of General Order No. 26, or a little before, every District
was putting into the field a Clean-up Squad for practically every state,
the function of which Squad was to make contact with all potential
beneficiaries of the U. S. Veterans’ Bureau for the purpose of
establishing claims, of offering hospitalization for examination, for
emergency treatment, and for other situations. These Clean-up Squads
served to feed a considerably increased number of patients of all types
into hospitals. Anticipating that such period of hospitalization would
be brief, they have used contract hospitals because of this fact, and
because of their location in the near or immediate vicinity of the
patients handled. The turnover has thus been largely increased. The
increase of patients in Government hospitals has risen steadily at the
rate of approximately 600 a month until it has reached the figure of
_20339_ patients, as against _18698_ patients in the early part of
September. There has been a slow but gradual decline of patients
hospitalized in contract institutions, notwithstanding the very material
influx into the hospitals by reason of the Clean-up Squads just spoken
of. It might appear to you who are actually caring for patients in your
institutions that notwithstanding the explanation of the meaning of
General Order No. 26 and 26–A, that the holding of a patient in a
hospital until all of the several matters necessary can be taken care
of, will result in undue delay in discharge. This doubtless would be
true if each hospital were required to assemble data called for and make
the other necessary provisions and forward the reports to the District
office to await return and receive transportation before a patient could
be discharged.

In the issuance of General Order No. 26–A and the supplementary
instructions it was contemplated in the Bureau here in Washington that a
representative of the District Manager would be necessary in each
hospital, at least, in those of considerable size, and some distance
away from the District office, in order that direct liaison between the
District Manager and the hospital in question might be maintained, it
being the business of this representative to see that matters of
after-treatment, convalescent care, feasibility for training, and
necessary adjustments of compensation matters will be properly taken
care of prior to the time that it is actually necessary to discharge the
patient. This representative will keep contact with the appropriate
District office and handle transportation for returning a claimant home
or to point of hospitalization. Anticipation on the part of the medical
officers actually taking care of claimants in hospitals, of the needs of
each patient in respect to these necessary details would enable the
District Manager’s representative located in the hospital to carry out
the proper adjustments of these important matters and the patient made
ready for discharge at the proper time without delay. To make effective
the services of the Government hospitals in the functions which they are
carrying out, a thorough understanding of the problems involved is very
necessary and a sympathetic understanding of each other’s problems, as
between the District Managers and Hospitals together with a spirit of
co-operation and fair play is essential to the desired results, if not
an absolute prerequisite to the success of the undertaking.

Many features of our work are, I recognize, trying and a thousand and
one annoyances are a part of each day’s work. Keeping before us at all
times the meaning of the work involved is a great aid to the elimination
of misunderstanding, and personal conferences serve to smooth out and
adjust overlapping of authority. One ex-service man maimed or injured,
replaced into his particular niche of our social fabric should make us
feel appreciative of what our work means, and the knowledge that we are
rebuilding men who have suffered in the service of our country, should
fortify us very strongly against the annoyances and trials which must
sink into insignificance when compared with the work done. I know that
you all realize this and that your every effort and energy is bent to
the accomplishment of the purpose for which we are all working together;
that we are making headway in the proper direction is beyond question;
that we are helping to rebuild the disabled is becoming more apparent as
our work goes along, and we all, I know, are not only proud that we are
having a part in this work, but feel privileged that our services are
helping to bring about these ends.”

Upon the conclusion of Dr. Guthrie’s paper, the subject-matter of the
several papers read during the morning session was thrown open to
discussion, the presiding officer remarking in this connection that full
opportunity would be given to all to freely express themselves. With
reference to the matter of the issuance of so-called conflicting orders,
which had been referred to, he stated that the administration of the
Veterans’ Bureau is regulated by certain laws upon which these orders
were based, and that when such laws are changed, it of course becomes
necessary to revoke certain orders in force at the time. He added that
the matter of hospitalization, thrown suddenly upon the Public Health
Service and the U. S. Veterans’ Bureau is a tremendous undertaking and
that those who carry on this work are entitled to the sympathy of all
good people.


COL. BRATTON: wished to place himself on record as saying that there is
nobody who is in greater sympathy with the wounded soldier, whom he
would like to see receive all that a grateful Government can give, but
that due to the very liberality of the Sweet Bill, cases have crept in
whereby compensation is being received for disabilities in no way
connected with the service. He stated that the Sweet Bill does not
clearly define what the line of duty shall be and that he is amazed at
the number of cases that are being carried along and hospitalized; that
he is of the opinion that the gentlemen in Congress do not realize how
liberal this act is and that men would receive compensation for diseases
which existed prior to their coming into service. He offered the
following motion amending section 300 of the Sweet Bill, to be
incorporated in a resolution to Congress as coming from this body, which
resolution was adopted:


                                Motion:

    RESOLVED, that in considering the question of line of duty, it
    should be understood that an officer of the Army or Navy, or an
    enlisted man of the Army or Navy, who has been accepted on his first
    physical examination after arrival at a military station as fit for
    service shall be considered to have contracted in line of duty any
    subsequent determined physical disability, unless such disability
    shall be shown to be the result of the patient’s own carelessness,
    misconduct, or vicious habits at any time, or to have been
    contracted while absent from duty without permission, or unless the
    history of the case shows unmistakably that the disability existed
    prior to entrance into the service.


DR. G. H. YOUNG: stated that it has frequently been a shock to his
sensibilities to see the manner in which compensation has been awarded
to certain ex-service men who are not in any sense deserving; that
assuming John Doe had a disability when he came into the service, it is
now going on four years since his discharge and if such disability was
exaggerated in service he should be compensated just as if he had been
wounded in action; that the question comes up as to how it can be
determined as to whether the exaggeration of his disability arose say
during six weeks, six months or eighteen months of his military service
or in the period of nearly four years which has since elapsed? That he
is of opinion that this applies especially to the in-patienthiatric
cases.


DR. COBB: suggested that general discussion of the other subjects be taken
up and that this very important matter be brought up later.


DR. BREW: referred to the case of a man in hospital with a fracture of the
thumb, which was operated upon with the result that it functioned
properly and the man was not handicapped in the least. After the
operation, which resulted in his total rehabilitation the man was
awarded vocational training and drew $80 a month. He referred to the
case of another man who had been in every hospital he could reach,
obtaining transportation from the Red Cross when he could not otherwise
obtain it; this man was inducted into service at Jefferson Barracks and
had a military service of 28 days, of which 28 days he was in hospital
14 days, and his disability was amoebic dysentery, which he could not
have incurred at Jefferson Barracks; this man was in hospital for 18
months and has been drawing $130 a month for training, which he has been
taking for two years. Dr. Brew also referred to the case of a negro, who
had syphilis before he went into the service; that he is as well as the
average man of his type and is receiving a compensation of $110 a month;
that this man has benefited by his military service because he has had a
line of treatment that he would not have received in civil life.


DR. WHITE: (Speedway Hospital) thought that the matter of allowing the space
of six feet between beds should be adjusted, as this space will greatly
reduce the hospital capacity. He also referred to the matter of rations
for absentees and stated a man may be away a matter of seven days
without leave and asked whether or not the hospital shall charge for
that patient’s rations, as the dietary service must prepare for him
whether he is there or not, and there is always the possibility of his
return the next day; that it also happens that a patient on leave may
return two days before he is expected. He thought that if meals are
prepared they ought to be paid for.

Dr. White also referred to losses of clothing which take place and
thought it was unfortunate that individual lockers were not supplied for
use of patients, as if they were supplied they could be rented to
patients at a nominal cost, thereby relieving the institution of the
custody of the clothing.

The large amount of paper work was also mentioned by Dr. White. He
stated that he understands that when a patient is sent to a hospital he
receives a compensation of $80 a month automatically, in which case he
cannot see the necessity for making additional physical examinations.

With reference to the matter of admissions, transfer and discharges, Dr.
White expressed the opinion that officers should require a patient to
state whether or not he is receiving compensation; that in the matter of
transfers as well as admissions, officers should be required to state in
writing, specifically and distinctly, the reason why they desire cases
transferred. He mentioned one instance wherein it was stated that a
patient had a gunshot wound of the left thigh, and he simply had a scar
to show for it. He thought that officers should be required to state in
writing the hospitalization needed. Dr. White also referred to cases
where it is desired to discharge a man from a hospital for certain
offenses, stating that if this is done, compensation of course would be
stopped and the man will not feel kindly toward the particular hospital
which discharges him. He was of opinion that in such cases a hospital
should be required to terminate its own cases and not dump them off on
other institutions and stated that at the Speedway Hospital there is no
hesitation about reporting such cases as they are found, and if officers
who transfer patients would give specific reasons as to why patients
need hospital treatment, there will not be so many men coming into
hospitals who do not require treatment anywhere.

In regard to G. O. 26, Dr. White inquired as to who is to decide the
feasibility and eligibility of patients who are ready to be discharged,
stating that he had been waiting for a representative of the Veterans’
Bureau to be sent to his hospital empowered and authorized to make
awards of compensation, as if medical officers are expected to do it,
their number will have to be increased; that a man should be sent from
the Veterans’ Bureau to attend to matters relating to training and who
could say definitely to a patient that he can have such and such
training, as it is absolutely necessary to have such a man and if he is
provided it will prevent a large number of complaints.


DR. GUTHRIE: stated that he would like to have some discussion as to whether
the representative referred to by Dr. White should be a medical officer
or a layman; that Dr. White stated that he had expected the arrival of
such a representative for some time, and as the doctor is a
young-looking man, he thought that if he lived long enough he will see
this representative get there.


GEN. SAWYER: mentioned that the Board of Hospitalization has an
understanding with the various Departments and the Veterans’ Bureau that
these things are to be settled by the Vocational Director, who, it is
understood, is to become as quickly as possible a part of the hospital
personnel; that he was of the opinion that the Board of Hospitalization
came to the conclusion that it was not material whether the vocational
representative was a layman or a medical man, but that he personally was
of the opinion that upon the judgment of a medical man a great deal
depends for the answer that is finally given; that he would like to
encourage Dr. White with the thought that the Hospitalization Board has
this matter very definitely in mind in order that the man needed may be
provided.


COL. EVANS: stated that the matter just referred to was a part of the
program had been approved and was now awaiting the signature of the
Director; that the individual designated as Vocational Director in a
hospital will be responsible for contacting the men with regard to their
compensation and their preparation for vocational training; that he will
confer with the medical officers and of course should be directed by
them, but he is responsible for the work.


DR. GUTHRIE: was of the opinion that the location of these men in the
hospitals in connection with the work referred to is most valuable.


DR. DEDMAN: Stated that General Order No. 26 has been a wonderful help. In
connection with the matter of discharged he thought that four days would
be enough, because a man’s discharge can be anticipated and arrangements
made for his vocational training, provided a representative from the
Veterans’ Bureau is furnished. He stated that everyone has the same
ideals as to the restoration to health of these ex-service men but that
this matter cannot function properly and we cannot attain the maximum
for these men unless we do work together in harmony and peace in
hospitals; that when these representatives come, it should be distinctly
understood that they are members of the official family and staff of the
hospital; that these representatives should not be medical men as a
medical board can determine the means and advisability of training, but
that they should be well versed in the subject in order that they may be
competent to judge as to what is best for a certain man to take up.

Dr. Dedman added that difficulty had been experienced in getting men to
leave the hospital. He mentioned the case of a boy who had been admitted
to the hospital with active tuberculosis, who was eventually rated as an
arrested case and told that he had received the maximum benefit, that
this boy did not want to leave the hospital and made a protest to his
Congressman.


DR. COOK: stated that he was going through his hospital one day and met a
big husky and asked him where he worked; that he replied he did not work
but was a patient; that this incident set him to thinking and he got his
discharge board working with the result that he reduced the number of
patients from 910 to 500; that in connection with existing requirements
to the effect that no patient would be discharged from a hospital
without going through a contact man, he was fortunate in having a man
assigned to him from the Veterans’ Bureau and every case of discharge
goes through his hands; that under this arrangement he has no difficulty
in discharging patients.


DR. EVANS: informed the Conference that there was on the Director’s desk a
ruling stating that personnel from the Veterans’ Bureau will be under
the commanding officers on hospitals.


DR. YOUNG: referred to G.O. 26, authorizing discharges from hospitals and
mentioned experiences where difficulty had arisen in this connection due
to the lack of adequate means being provided to enforce such order. He
mentioned cases that had come up where men who had received the maximum
benefit, would state that they were not going to be discharged; that
these cases would generally occur on the eve of a holiday, or on
Saturday night and the men would go into a ward and get into bed. He
believed that in such cases the hospital authorities should be given
some means of enforcing this order by the Veterans’ Bureau, as aid can
not be had from the local police who will not enter upon a Government
reservation; that another way would be through swearing out a warrant,
but as these cases generally occurred on Saturday and a warrant could
not be sworn out until the following Monday, a man is thereby enabled to
stay four days longer.


DR. CHRISTIAN: stated that in his experience the police had not refused to
go upon the reservation and that he has had one of his staff sworn in as
a deputy sheriff; also, that upon the date named in the discharge order
the man affected is not officially in the hospital and is not rated as
present for the purpose of being fed.

Concerning transfers, Dr. Christian mentioned that authority for
transfers has changed a number of times and was of opinion that it would
be advantageous if stations like his could be given blanket authority to
transfer mental cases when they are not prepared to take care of them,
as it would relieve the medical officers of great anxiety and would save
the family of the man a great deal of torture; that this could be
accomplished in a few hours by telephoning to the nearest mental
hospital and receiving an answer in a short time as to whether or not a
bed was available, all of which would expedite the transfer of the
patient; that it is now taking too long to get transfers.

He also stated that he appreciated the importance of the Inspector’s
Department, which is of wonderful benefit to the commanding officers.

With reference to G.O. 26, he thought that the length of time prescribed
is too long, as with the generality of patients who have received the
maximum amount of treatment, it does not make a great deal of difference
as to how much notice they have as to when they are going to be
discharged, as the necessary arrangements can be made in a very short
time without any inconvenience; that there is, however, a certain class
of cases which very often takes advantage of the four days’ notice; that
it has been his experience that when four days’ notice is given it
apparently has no effect on the first day, on the second day the patient
will begin to develop symptoms, on the third day the symptoms are very
much increased and on the 4th day you get a letter from the patient’s
Congressman.


DR. LASCHE: was of the opinion that all the authority needed is given by
G.O. 27 of the Veterans’ Bureau, which gives the medical officer in
charge considerable authority to enforce discipline; that the average
patient, however, chafes under the word “discipline”; that the gentlemen
from the Army and Navy have referred to the advantages of discipline. He
stated that he was on a discharge board for soldiers after they came
home from Europe and frequently heard them say: “Well, by Jove, we are
away from this —— discipline now;” that with all due respect to
discipline that is necessary in Army and Navy organizations, he does not
believe that the same degree of discipline is necessary after these men
become beneficiaries of the Veterans’ Bureau; that in a year’s time he
has only had to apply the provisions of G.O. 27 on one patient who was
A.W.O.L. three times for the period of twenty-four hours or more within
thirty days; that he finally discharged this man, who, however,
subsequently applied for readmission and was successful in obtaining it
within two weeks and all the patients at the institution know that this
man got back after he was discharged.

With reference to the question of Dr. Guthrie as to whether a layman
would serve successfully, Dr. Lasche was of opinion that the layman is
the only desirable person, as the medical man’s function is exclusively
to determine the vocational disability and after this is determined all
the other matters should be left to a layman, as they are more or less
in the nature of an investigation and a layman who is properly selected
would be much better able to run down and ferret out such matters; that
it is important, however, to select a man for this particular function
who has shown an adaptability for research along these lines, and, some
of the men who have been in charge of vocational centers do not possess
the requisite qualifications to decide as to visibility or eligibility
in the matter of vocational training.


DR. T. R. PAYNE: thought that the hospital brand had been placed on a great
many men in cases where it should not have been; that once you get a man
in a hospital he is going to repeat as long as he can. He referred to a
class of so-called gas bronchitis patients and stated that it is well
known that during the war all a man had to do was to say he had been
gassed and receive a wound stripe, and this same man is now coming in to
our hospitals; that the office of The Adjutant General of the Army has
no record of such men being gassed; that he has no chest pathology. He
thought that these men should never have gotten into the hospitals and
should have been handled outside more by psychology than by doctors and
hoped that the dispensaries are going to keep these men out of
hospitals; that there is no doubt in his mind that a great many
neurasthenics should never have gotten into general hospitals; that the
great trouble is the compensation given those men places a premium upon
their hospitalization; that men are in hospital who have been discharged
as having received their maximum hospitalization; that these men have
been taken out of vocational training; that they would rather go back
into hospital and get $80 a month and three meals a day and be
entertained several times a week; that more care must be taken by
doctors regarding the men they send in to hospitals.


GENERAL IRELAND: stated that it has been found that there is no after effect
from gases and that Lieut. Col. Gilchrist, M.C., U.S.A., representing
the Medical Department of the Army in the office of the Chief, Chemical
Warfare Service, has data relative to this subject, which can probably
be obtained by writing him.


DR. LLOYD: offered the following resolution, which, however, was not
adopted:

“That it is the sense of this body that the Federal Board of
Hospitalization recommend to the Director of the Veterans’ Bureau and to
the Surgeon General of the Public Health Service the designation of an
officer of each service to receive special suggestions and
recommendations from the field, criticisms also of instructions
contained in field orders, circular letters and similar communications;
these designated officers to constitute a board for the consideration of
these recommendations, with the view of recommending to the Director the
adoption of such as are believed to be of value.”


DR. CHRISTIAN: offered the following amendment to Dr. Lloyd’s resolution:

“That these officers be detailed to the Veterans’ Bureau for a limited
period, say six months; that they be field officers.”


DR. JOHNSON: moved that the resolution of Dr. Lloyd be laid on the table
indefinitely, which resolution was adopted.


DR. LLOYD: suggested that it would be well to have one man of each service
who could be advised as to what is the matter with certain general
orders and know that such matters will not be pigeon-holed but will
receive action.


COL. BRATTON: was of the opinion that all suggestions relating to
improvement of service should go through the chief of the service. He
stated that no difficulty was experienced in this connection in the Army
and that it seemed to him that the chief of a bureau should know what
was going on.


GEN. IRELAND: stated that contemplated changes affecting the hospitalization
of patients of the Veterans’ Bureau in the Army are always referred to
his office for review before they are issued.


DR. BLISS: thought that there should be a representative of the Veterans’
Bureau in all Government hospitals where there are Veterans’ Bureau
patients, which representative would not have anything to do with the
internal administration of the hospital.


DR. WILLIAMS: with reference to the matter of bed space in hospitals offered
a resolution to the effect that the question of floor space and distance
between beds be reconsidered by the Veterans’ Bureau, with a view to the
revision of the present requirements; that unnecessary bed space is
being provided and it should be cut down; that he believes the allowance
of six feet is necessary in respiratory cases and in infectious cases,
but that in the ordinary general ward he believed that a little less
space would be quite sufficient, as the larger requirement will cut down
the hospital capacity very materially. This resolution was duly
seconded.


DR. BARLOW: With reference to space allowed per patient, thought that there
should be a difference in accordance with the classes of patients; that
he has charge of a hospital for mental cases, and it would be necessary
to arrange for 100 square feet; these men are not suffering from
physical disabilities. He stated that the State Hospitals cannot provide
even fifty square feet of floor space and that it was absolutely
necessary for the Veterans’ Bureau to take out of the State hospitals
every insane patient they have.


DR. BLACKWOOD: concerning the allowance of six feet between beds, asked if
this was not intended to mean six feet between bed centers.

The following motion was adopted:

“That the Federal Board ask the Veterans’ Bureau to reconsider the
question of bed space.”

A motion was offered, which failed of adoption, to the effect that the
Director of the Veterans’ Bureau set aside a certain amount for the
reimbursement of unavoidable losses of property of ex-service men in
hospitals.


DR. KRULISH: was of the opinion that if the foregoing resolution was
adopted, that more trouble would be experienced than before.

It was further brought out that such a motion would carry no weight;
that it was thought the service had this question up once before and the
Comptroller’s office advised that no money arrangements could be made
and it was not believed that the Veterans’ Bureau could make allowance
for losses of clothing.

It was also stated in this connection that in some institutions steel
lockers had been provided, a small deposit being required, which was
given back when the key was returned, under which arrangement very
little clothing was lost.


DR. HETERICK: stated that his institution is equipped with steel lockers and
a small deposit required, which is returned when the patient is
discharged; that the patient is told that due preparation has been made
for taking care of his clothing and it is in his custody; that the
installation of these lockers has reduced the theft of personal property
to a minimum; that some times, however, lockers will be broken into.


                  The meeting adjourned at 12:30 p.m.




           _Fourth Session_      Wednesday, January 18, 1922.


 Present: Members of the Federal Board of Hospitalization; also, about
            one hundred conferees.


GEN. CUMMING, presiding, called the meeting to order.


DR. WHITE called the roll, and read the following announcement:

    “It is requested that, at the first available opportunity, the
    following officers confer with Dr. Maddox, “C” Building, Room 1–319,
    concerning urgent construction work going on at their stations:

              Dr. W. H. Allen, of Boise, Idaho.
              Dr. W. C. Billings, of Ellis Island, N.Y.
              Dr. R. L. Allen, of Arrowhead Springs, Cal.
              Dr. A. P. Chronquest, of West Roxbury, Mass.
              Dr. E. R. Marshall, of Detroit, Mich.”


GEN. CUMMING: “This afternoon we are going to consider administrative
policies. The first paper will be “Professional Service,” by Dr.
Lavinder,”


ASST. SURGEON GENERAL C. H. LAVINDER:

    “The subject that has been assigned to me is very broad in its
    scope, and the time is so limited, that if I may be permitted I wish
    to tender a written paper.” Dr. Lavinder read the article on
    “Professional Service”,

“In a discussion of professional service, however brief, no thoughtful
medical man could forbear some comment on the present general status of
clinical medicine and its developments within the last few years. The
steady trend towards greater educational requirements, the development
of refinements in diagnosis and therapy and the straining after what are
believed to be higher scientific standards, creates in many minds some
uneasiness as to whether the medical profession may not, by such things,
be led astray and forget the very purpose for which clinical medicine
exists, that is, the comfort, welfare and relief of the patient. Such a
fear is by no means a groundless one. There is always a possibility that
the medical man may become so enamored of his refinements and of his
scientific methods as to forget that his business is the treatment of
the sick. It is a truism so trite as sometimes to be overlooked, that
all organization and all methods in clinical medicine have for their
ultimate end the care of the patient and everything else must be
subordinated to his interests.

Leaving this aside and omitting much, there are some things which may be
stated in a general way concerning professional service, understanding
that it is presumed such service is administered in hospitals properly
constructed, properly located and equipped, and operated for the
particular purposes which we have in mind.

1. There are certain broad policies in this matter which are worthy of
some comment.

The flexibility of hospitals is a matter of importance. The Public
Health Service has divided its hospitals into three general groups, that
is, hospitals for general medicine and surgery, for pulmonary
tuberculosis and for neuro-psychiatry. We have striven, however, even in
these broad groups to make such hospitals available, at least
temporarily, for any class of case which seeks admission. This has been
especially true with regard to pulmonary tuberculosis and we have been
rather insistent that every general hospital should set aside a certain
number of its beds for the care of such cases. A similar policy has been
followed with regard to neuro-psychiatric disorders. Even if the general
hospital can be made no more than a distributing point for these special
classes of cases it is, nevertheless, wise that such provision should be
made. Consideration has been given to the possibility of adopting a
method which was followed by the Army during the war, that is;
specializing in hospitals to much greater degree and organizing certain
hospitals on such a basis that they might be especially prepared, both
in personnel and equipment, to care for one or two classes of disorders.
The patients with which we have to deal, however, are by no means so
easily transported and so easily congregated in special groups. This
method, therefore, while it deserves much consideration, has not been
found feasible in our work. Consideration has also been given to the
establishment of convalescent hospitals, and while such institutions
have much to commend them, they also possess some very serious
disadvantages, especially with the class of patients with which we are
now dealing. We have opened one such hospital which is still in
operation and is giving satisfactory service.

It has been a general policy of the Public Health Service, of course, to
seek in every way to establish in all of its hospitals standards of
professional service in full accord with the best modern practice. At
the same time we have sought to avoid the fostering of radical methods
which might verge on the field of fads. We have preferred to adopt a
somewhat conservative attitude in this regard and have been unwilling to
make use of methods until they had been fairly well tried out and
established as useful.

It has also been a policy, as far as possible, to establish a uniformity
in professional service, at the same time doing nothing which might
interfere with individual initiative. General Uniformity in professional
service is desirable not only for administrative reasons, but for
professional ones as well.

It goes without saying that we have felt the absolute necessity of
establishing a professional service which would be reasonable in cost.
The expenditure of money in professional service is, of course, wise. At
the same time it has seemed to us that any professional service which
could not be justified on the basis of economy was probably more than
necessary.

There is one other matter of general interest, which seems to us of the
highest importance, and that is the creation in all hospitals, so far as
possible, of a broad spirit of human charity and the stimulation of any
agency which would help in the creation of such an atmosphere. We have,
therefore, done everything we could to assist in the formation of an
efficient medical social service and in the furtherance of recreational
activities. It has seemed to us that the creation of such an atmosphere
in any hospital is a matter worthy of every effort.

One other consideration of general significance is the ideal of not
discharging a patient from hospital until he has reached the maximum
benefit to be derived from such a form of treatment, and was ready for
discharge in a condition which would permit him to return to the outside
world prepared to assume, as far as possible, the burdens of daily life
and ready to make social readjustments. In other words, it has seemed to
us unwise simply to discharge a man upon recovery from an acute or
chronic illness without taking pains, through a medical social service,
to see that he was readjusted to the community on a basis which would
prevent his reversion to a state of ill health and perhaps his
readmission to hospital.

2. With regard to the application of professional service to the actual
treatment of sick in our hospitals, we have had in mind, in a general
way, some rather definite things. In the organisation of our hospitals,
whatever the type, we have arranged all of the professional services to
meet the demands of the institution. We have attempted to adjust these
professional services, so for as possible, to the need of the particular
hospital and the particular class of patient treated therein and then
properly to coordinate all of these various services under competent
chiefs, supplemented by attending specialists. An organization so
established should, we feel, meet any reasonable demands which might be
made upon the institution without an undue expenditure in the matter of
professional personnel.

We have established many highly specialized services, including
dentistry. We have not overlooked such things as occupational therapy
and physio-therapy and, of course, have taken care to supply the
necessary modern laboratories, X-ray equipment and other matters which
are essential in the best modern professional service.

We have, of course, not neglected such necessary accessories, in the
proper care of a patient, as good nursing and an adequate system of
supplying a well balanced ration, properly prepared and served.

We have believed in doing much of this work that it was a matter of
economy as well as expediency to furnish as complete medical examination
as possible. These cases are compensable cases and the matter of records
as to their physical condition is of especial importance. The veterans’
Bureau has felt the need of careful and complete examinations as well as
records which are dependable. Pains have been taken, therefore, so far
as possible, to take such examinations and keep such records of all
cases.

In some of our hospitals we have felt the need of establishing special
services for special classes of cases, but have not extended this any
further than was necessary. For example: we have in one of our general
hospitals a special service on gastro-enterology. In another we may have
a special service on surgery, as applied to tuberculous processes.
Similar special services have been located in several places to meet
special demands and such a policy will, of necessity, continue.

Most important of all we have striven in every way to secure a qualified
medical personnel, a matter of no small difficulty. The demand for
competent medical men is greater than the supply. In the operation of
such a large hospital system it is by no means easy to secure men
skilled in special lines of endeavor. We have, therefore, felt the need
many times of establishing some system of educating our medical staffs
in various matters and, while funds have not permitted the extension of
this system, we have availed ourselves of educational methods as far as
possible. Schools of various kinds have been held for short periods of
time and men have not infrequently been transferred temporarily to
situations where they might acquire a special knowledge. We have also
encouraged staff conferences and attempted to supply working libraries
and medical magazines to each of our hospitals—all with the idea of
stimulating among our entire medical personnel the desire to increase
their professional efficiency as much as possible.

3. Finally, we have not overlooked the necessity for research. Our funds
have been too limited to do a great deal in this line, but we have felt
keenly the responsibility which rested upon us to do all that was
possible. Such activities have been carried on in a very small way with
the exception of one or two hospitals which might be really called
research hospitals, notably such a hospital as the one at Waukesha,
Wisconsin, where every effort is devoted to the diagnosis and treatment
of a definite class of Neuro-psychiatric disorders. This hospital has
been so organized as to permit the very highest type of modern diagnosis
and therapy.”


GEN. SAWYER: “This seems to me to be on opportunity to say a thing or to
which have been in my mind that I wish to express now. First, this
present administration has as one of its ambitions the best Public
Health Service in the world. I want you to know that, in your
engagements here, trying as they are, behind you is a determination to
help to develop an ideal Public Health Service, and every man who is
engaged in the service of the Public Health of the United States should
feel that he is engaged in the greatest service that can be rendered to
his country.

For myself, I have a great ambition that somewhere there should be
established a post-graduate training department to which the members of
the Public Health Service of the United states could come for
post-graduate training. We want to be the highest type of doctors that
are to be found anywhere, and so today we have in contemplation the
establishment of a post-graduate training school in the city of
Washington, to which you can come to provide yourselves and equip
yourselves with all the new and better things that from time to time
must develop.”


SURGEON DEDMAN: stated that he felt that Dr. Lavinder’s paper was too
important to pass up without a comment or two; that one thing he was
struck with was the personal contact to be made with the patients
themselves. He said he believed this was a very important matter, as the
services of a doctor are absolutely worthless until he has gained the
patient’s confidence. He felt that the doctor should be looked upon just
as the family physician at home. He stated further that when he first
entered the work he made the following hospital rules: 1—Kindness,
2—Cheerfulness, and, 3—Duty. Said that the doctors should inject the
feeling of friendship into the minds of the men as much as possible. He
stated that there ought to be a system of uniform hospital regulations,
that some hospital rules are not so drastic as those of other hospitals,
and that he believed there should be a uniform regulation so that the
disciplinary regulations would be the same in one hospital as in
another.


ASST. SURGEON. L. L. WILLIAMS: stated that in reference to uniform
disciplinary regulations the character of the patients, the location of
the institutions and the construction of the premises are all factors
that affect the privileges to be given the patients. Believed there
could be no highly organized uniformity of regulations.

In regard to specialized attention, the hospital should be prepared to
furnish any sort of special care possible. He stated further that he
believed that the specialized patient in a general hospital is better
off than if in a special hospital, but that if he had a son who had a
special ailment he would much prefer him in a hospital which had upon
its staff men in active practice of the kind he was going to need.


CAPT. LOWNDES: said there was always some patient who would go out and make
trouble, that he had been investigated by the American Legion, by
ladies’ committees and by religious societies, all of whom he invited to
come to the hospital, as there was trouble if they were told not to
come. He said he had met with two criticisms: one was that the nurses
were particularly harsh, to which he replied that he generally had
trouble getting the patients to go out as some of them generally fell in
love with the nurses; the other that the patients would not pay any
attention to the Commanding Officer when he made inspections.


GEN. CUMMING: “The next subject “Nursing” will be presented by the
Superintendent of Army Nurses, Major Julia C. Stimson.”


MAJOR STIMSON: read the paper “Nursing”, as given herewith:

“The subject of nursing in relation to the care of the ex-service man is
a very big one and can scarcely be handled adequately in the ten minutes
allotted to it. There are, however, certain phases of it that can be
mentioned.

The response of the nursing profession to the call of the country during
the time of war is well known, and the character of the achievements of
the 25,000 trained women who entered the government services at that
time has been often recounted, but little has been told of the patriotic
devotion to duty that has been exhibited by nurses since the Armistice.
I have not come today to bring bouquets and laurel wreaths, but I do
wish to call attention to the marvelous development of one branch of
governmental nursing work under conditions that in many instances were
harder to bear than most war conditions, and to ask for the service the
recognition and cooperation it deserves. At the present time there are
more nurses in the U.S. Public Health Service, (1796), than there are in
the combined nursing departments of the Army, (774), and the Navy,
(488). The figure given me for the present Public Health nursing staff
is about 1800, an expansion from forty odd at the time the service was
authorized to care for ex-service men, on March 3, 1919 by Act of
Congress. To realize the full meaning of this expansion and the
development of the organization required to manage the service, it is
only necessary to recall the fact that in the spring of 1919 when the
Public Health Service called for volunteers for its Nursing Service, the
Army and the Navy were both discharging from their Nurse Corps great
numbers of women. In one month alone in that year 2500 nurses were
demobilized from the army. They were all tired, worn-out women. You all
recall the state of mind of both the soldier and the officer during
those months, when morale was at its lowest ebb, because of
homesickness, fed-upness, and desire to get back to civil life. Nurses
as well as men were full of complaints, and to be freed from
governmental control was the thing that to all of them seemed the
ultimate good. Moreover, many who came from overseas had been marking
time for weeks, awaiting orders for the breaking up of their units, and
embarkation, and upon their arrival home they found their communities,
which they had left so short of nurses, were clamoring for their
services.

Under such conditions was presented the need of the ex-service man. A
new federal nursing department asked them to give up their personal
desire for freedom, their longed-for plans, and to enter—what? and to
do—what? It is hardly necessary to describe the kind of hospitals these
nurses were asked to enter, nor the conditions under which they were to
live. You would scarcely believe the details that I could tell you
unless you, too, have heard the accounts of the able Superintendent of
Nurses of the Public Health Service. You know, perhaps, what some of the
old Marine hospitals are like, and some of you know some of the old Army
hospitals taken over by the Public Health Service were like. You don’t
know, I am sure, about the utterly unworthy and unsuitable quarters and
messing arrangements for nurses which many staffs have had to endure,
and still do endure in some instances. The fact that there are now 1800
nurses in the service bears witness to the clearness of her vision of
the need on the part of the Superintendent of the Corps, and her valiant
presentation of it, and to the assistance given her by the American Red
Cross Nursing Service which has spread the call and facilitated
recruiting.

The Nurse Corps of the Army and Navy were old, established departments,
with traditions and customs behind them, with a status recognized by all
in the service and honored by officers and men alike for their many
years of efficient work.

The nurse in the U. S. Public Health Service had no such advantage, and
to her and her associates and to the officials who have championed her
cause against what have at times seemed almost unbearable difficulties
too great praise cannot be given.

General Sawyer has asked me to present the difficulties that lie in the
way of the kind of nursing service to the veteran that ought to be
given, and to suggest if I can, a plan for meeting these difficulties.

The greatest problem of the nursing care of the ex-soldier is not in the
Army and the Navy, because the proportion of the veterans patient to the
regular Army and Navy patient in those services is so low that it
presents no particular problem. It is, of course, in the U.S. Public
Health hospitals that the problems exist most noticeably.

First we must consider the type of patient. We are told that
neuro-psychiatric, contagious, and tuberculosis cases predominate. Right
here is one difficulty as far as nurses are concerned. To contribute the
highest type of service to people so afflicted requires that the living
conditions, the mental and physical recreation and up-building of the
nursing staff, be of the finest order. I think that this is conceded by
all who consider the long hours during which the nurse is in close
contact with the patient and who realize that no individual, barring
none, has so large an opportunity for personal influence upon patients
as the nurse.

Nurses who are employed for the care of the veteran should be of the
highest grade. Not only should they meet all the professional and
technical requirements, but they should be especially qualified in all
phases of rehabilitation and reconstruction, both mental and physical.
They should have an especial knowledge of the problem of the
tuberculosis patient, not only as an individual sick man, but in his
relation to society. They should be thoroughly cognizant of the
magnitude and urgency of the problem of social diseases, and without an
ability to help the neuro-psychiatric patient redirect his interests
into the world of reality and to correlate himself and his environment,
they are failing in their whole duty to their patient.

Under the present conditions it is probably not an easy matter to get
such super-nurses in any great numbers, and even were it possible to
secure them, it is not likely that they could be long retained. The
turnover in the nursing service in hospitals caring for veterans is
unduly large, the reports show. This has been due in some degree to
physical breakdown, and also to dissatisfaction with conditions,
including uncertainty as to their status and fears for its future. What,
then, is to be done? The answer is not so hard to find. Locally, it is
comfortable living quarters, reasonable hours, good food, the right sort
of recreation, adequate pay, and opportunity for advancement and
improvement. Nurses, like all other professional workers, are coming to
recognize that in order to live up to their highest ideals and to give
their best services to afflicted humanity, it is essential to make
provision for continual growth, and that from time to time added
inspiration and education are necessary. Courses of special study are
advocated, therefore, for all nurses, especially for those caring for
veterans or any other particularly difficult group of patients.
Opportunity for post-graduate study is considered a necessity in the
Army for both officers and members of the Nurse Corps, and it is even
more important in the U.S. Public Health Service. In some hospitals of
this service special courses have been conducted for nurses with marked
success, but particular emphasis should be given to this phase of
meeting the nursers’ problems. For before a nurse can help to
reconstruct a distorted mental outlook and restore a normal attitude
toward life, she, herself, must have an understanding and a sympathy and
a power to help that can only come from steady inspiration, constant
study, and serenity of mind.

Second in importance locally is the recognition on the part of the
commanding officer of each hospital and each member of the hospital
staff of the real place of nurses in the endeavor to return the patient
to normal health and life, and emphasis upon an attitude of helpfulness
and cooperation in all matters concerning them. Only those who have
served in hospitals where the commanding officer was heart and soul in
sympathy with the problems of the nursing staff and concerned with every
detail that might work for its well-being, can know what a harmonious,
helpful atmosphere can exist, and how the spirit of courteous
recognition and mutual respect can permeate from the commanding officer
to every member of the personnel. For is not the nursing group usually
the largest group in every hospital, and will not the attitude of the
nurses give the tone to the hospital? Commanding officers should
remember that in their hands and their’s alone rests the regulation of
this tone.

In all the presentation of the general subject of the care of the
ex-service man, at this conference, little if any mention has been made
of the part of the nurse. Right here in this very fact, perhaps, rests
one of the largest snags that lie in the way of the best service to the
veteran. Think for one moment of the situation if there were no nurses
to work side by side with the medical man and to cooperate with him in
securing for the patient that which he, with his special preparation,
considers necessary for his healing. What results would be obtained? The
time has passed when the need of professional nursing in the care of the
sick is a debatable question. And yet nursing, as vital to the modern
scientific restoration of the war veteran, has not been mentioned.

Here at headquarters is where the greatest progress toward the solution
of the nursing problem can be made,—1st, in the recognition of the
problem and its importance, and 2nd, in a sympathetic, concerned,
business-like attempt to solve it by the method that is most sure to
bring about success,—namely the conference method, the collecting of
advice from experts on the subject, the formulation of their
suggestions, and an endeavor on the part of all concerned to put these
suggestions into practice.

You, in this new governmental organization, which has for its aim the
highest type of service to veterans and their restoration to complete
living, have a chance to develop a nursing department that should set
the standard for all the departments of federal nursing as well as for
civilian institutions.”


GEN. CUMMING: “Discussion will be offered by Mrs. Higbee”.


MRS. LENAH S. HIGBEE, Superintendent, N.N.C.: stated that the subject hardly
needed discussion, that it would almost seem that she could not amplify
it, but that was what she was going to attempt to do. She spoke on
“Nursing”, as follows:

“Since the nurse viewpoint of the treatment of patients under the
Veterans’ Bureau is considered sufficiently important to be discussed,
it is a matter of regret that the chief nurses of the hospitals have not
been summoned to this important conference. Of course, the nursing
subject comes directly under the Commanding Officers of the hospitals
but in presenting the more intimate views of the nurses, the opinions of
the chief nurses would be more helpful than the opinions expressed
through the medium of the superintendent whose knowledge of the
situation is obtained from reports.

My knowledge of the situation we are discussing is obtained from
reports. Letters have been sent to the various chief nurses requesting
definite information on this subject and asking if any particular
presentation could be made to this important body which would be
helpful.


                               _NURSING._

At the Naval Hospitals which have had the greatest success in treating
the Service beneficiaries, the Commanding Officers have put a frank
presentation of the situation to the patients, pointing out the
necessity for certain restrictions and discipline, and urging
cooperation. This preliminary presentation by the Commanding Officers
when followed by the kind yet firm supervision of the ward officers and
also by the tactful, helpful attitude of the nurses, who in turn
cooperate with the welfare and vocational workers, in time break down
the attitude of opposition, resentment, and destructive criticism which
many patients have when first hospitalized. The chief nurses have stated
that the care of the patients means only “more patients.” There is no
special problem in dealing with them and under the above conditions,
they accept the necessary discipline and restriction which are
fundamental if hospital treatment is to succeed.

It would seem, therefore, that the problem, as has already been pointed
out, exists chiefly in the U. S. Public Health Hospitals where the
greater number of patients from the Veterans’ Bureau are receiving care
and treatment. A large percentage of these patients would correspond to
our Navy ambulant cases and among the remainder (as has already been
stated) the neuro-psychiatric and tuberculous patients predominate.

There is considerable discussion among doctors, at present, regarding
the fundamental qualifications which the trained nurse should possess;
and there have been charges of over-education and a tendency to
commercialism which result in unrest and in losing sight of the basic
principles of their profession. The charge of commercialism is so
unworthy of the medical profession that I shall let it pass without
comment but I do not consider it beside the present question to touch
upon the statement of over-education. It may be conceded that a nurse,
possessing a preliminary graded school education, who has been carefully
taught for two or three years in an accredited hospital, is able to give
nursing care, under medical supervision, to the sick bed patient. Her
greater value to the physician and to the patient because of greater
knowledge due to higher educational standards need not be discussed
here. However, it should be conceded, also, that the influence of nurses
on the patients of the Veterans’ Bureau is more constructive mentally
and morally than is the influence of nurses who care for the acutely
sick; which is, usually, particular personal care for a comparatively
brief period. To care for convalescent and Veterans’ Bureau patients is
to serve long hours of duty in which little change in the physical
condition of the patients is noted; and yet so great is this
responsibility, so important is the work from humanitarian and economic
viewpoints that the nurses must ever be on guard against the insidious
lack of interest which comes from routine care; and they must keep
themselves so alert that their great opportunities for personal
influence among these men shall not be neglected in any particular. With
any degree of sickness, there is distorted judgment and predisposition
to give undue stress to trifles. The educated nurse knows this and knows
also that the semi helplessness of protracted convalescence and the
resultant sense of dependency, are among the chief factors which must be
considered in dealing with these special patients. She must influence
the patients to be receptive to hospital restrictions; she must
counteract the tendency to destructive criticism and disloyal statement;
she must be sympathetic but not maudlin; she must recognize that they
are ill but she must not encourage helplessness: she must suggest
activity and encourage pride in endeavor and accomplishment. She must
present the best viewpoint to the particular patient and this means an
individual understanding of him and his needs. Only educated nurses
(meaning that the aim of education is to develop the faculties of the
mind and body) who have courage, refinement and dignity, who are loyal
to their country without the stimulus of war, and who strive to maintain
the high ideals of their profession can be definitely successful in
co-operating with other agencies to restore these men to health.
Reconstruction and Rehabilitation of the ex-Service men cannot be an
affair of merely rearranging tangible elements, such as food, money and
clothes: It is by example, by encouragement to make an effort to
overcome helplessness, an explanation of the reasons for necessary
treatment and restrictions, that the nurse will succeed in helping to
replace quiescent dependence with the unsleeping desire and motive of
service as active citizens. More and more it is recognized that we must
look to education to destroy irrational suspicion and to restore to
health and sanity.

The Public Health Nursing Service has been established a comparatively
short time and yet under the Surgeons General of that Service and due in
a great measure to the indefatigable efforts of the present
superintendent and because of the high professional standard she has
always maintained, more qualified nurses are attached to this Service at
the present time than in the combined older services of the Army and
Navy Nurse Corps. Having procured these nurses who, for the most part,
it is believed, accept the additional responsibilities which the care of
such patients involve, every effort that is made to retain them is worth
while; since their value increases with length of service. From an
economic viewpoint, if for no other reason, efforts should be made to
give these nurses adequate payment for trained service; to provide
living conditions which they require as educated and refined women; to
recognize that rest and recreation are necessary if the physical
standards and morale are to be maintained; to acknowledge their
professional status and to give recognition to them as co-workers with
the medical profession. With these requirements satisfactorily adjusted
by those who have the power of formulating the necessary rules and
regulations, the work of the nurses who care for the maimed bodies and
sick minds of the patients of the Veterans’ Bureau will be productive of
even greater beneficent results than have already been obtained;—for
such nurses seek to maintain the fabric of the world; and in the result
of their unselfish efforts is their prayer.”


MISS LUCY MINNIGERODE, Superintendent of Nurses, U.S.P.H.S., gave a further
discussion of “Nursing”, as follows:

“Major Stimson has placed before you some of the most urgent problems
and difficulties existing in the Nursery Service of Public Health
Service hospitals dealing with the ex-service men.

The difficulties of the problem can be realized and understood only by
those who are in close association with the Services, and that the
Nursing Department of the Public Health Service has been able to
accomplish even a measure of success has been in a large manner due to
the co-operation, counsel and advice given by the Superintendents of the
established Nurse Corps of the Government.

On March 3, 1919, the Public Health Service had available 1500 beds in
23 hospitals, and practically no nurses. Chief nurses were unknown in
any of the hospitals. There was no machinery for the recruiting of
nurses. In regular Service hospitals, there were no quarters for nurses,
and the Service is still concerned over a solution of these
difficulties. At the present time, there are 1796 nurses in the
hospitals operated by the Public Health Service.

As has already been said, the problem of giving the most efficient care
to the disabled ex-service men in the hospitals of the Public Health
Service is a little different from that of the Army, due to the
fundamental differences in the organization of this corps of nurses.

The Nurse Corps of the Public Health Service is a civilian organization,
pure and simple, though 99%, probably, of the nurses now serving in the
Public Health Service are ex-service nurses and familiar with the
problems of the care of ex-service men.

The aim of the Nursing Department of the Public Health Service is to
give as efficient nursing care to the patients in these hospitals as can
be given, to see that the nurses cooperate in every possible way with
those responsible for the care of the patients—that is, the Medical
Officers in Charge,—to recruit a sufficient number of qualified nurses
to meet the needs of the Service, and to recommend the establishment of
such policies in the Nursing Department as will increase the efficiency
of the nursing corps. The co-operation of the Medical Officer in Charge
is essential; his sympathy with and support of the Chief Nurse must be
unquestioned, if the nursing service is to reach the greatest
efficiency. The place of the nurse in the administrative unit of the
hospital should be clearly and definitely defined, understood and
observed.

One great difficulty confronting this department is the lack of nurses
specially trained in the care of neuro-psychiatric and tuberculosis
patients, who constitute a large proportion of our patients. To partly
meet this need, a school for nurses conducted at Oteen in September
1921, was organized and, while this school was most successful, it
barely touched the fringe of our necessities. The Service is considering
a similar course in neuro-psychiatric nursing as soon as there is
established a station where all conditions, quarters, lecturers and
teaching facilities can be guaranteed to produce the desired result.

One piece of nursing work which has been far-reaching in its effects,
was the establishment of a Public Health Nursing Unit in the office of
the Supervisor of District #4, for the purpose of making contact with
the claimant of the then Bureau of War Risk Insurance, with a view to
giving the claimant, who for any reason was not hospitalized, the
benefit of health supervision and health instruction. The success of the
work of this unit more than justified its establishment by the U. S.
Public Health Service.

The type of nurse needed for this Service is the broad-minded woman,
cultured, well trained, with those qualities of mind and heart which
would enable her to grasp the tremendous responsibilities in the work we
are trying to do—who will be sympathetic, but firm—who will be able to
emphasize the need for obedience to orders for treatment—who can be
friendly, without familiarity, and loyal to the highest ideals of her
profession.

The turnover is too large, by far, and is due in some measure to
conditions which are unavoidable, since they are the result of the
sudden expansion of the Service, the need for immediate action, and the
great difficulty in securing desirable hospital stations, both from the
standpoint of construction and location. These conditions are adjusting
themselves gradually, and a distinct improvement in service and morale
in the Nursing Department, a clearer understanding of the many problems
which confront the administration and the Service in the effort to give
the best medical care and treatment to disabled veterans of the World
War, is evidenced; and, at the present time, the U. S. Public Health
Service is able to keep the nursing force up to the necessities of the
Service.

It is believed, however, that uniformity, throughout the organizations
caring for these patients would go far toward establishing a more
satisfactory service, and it is hoped that this meeting of all connected
with and interested in the care of ex-service men will succeed in
bringing about this desired result.

In the final analysis, however, it is conceded that the responsibility
for the proper and successful conduct of these hospitals rests with the
Medical Officers in Charge, and I can truly say in behalf of the nurses
of the Public Health Service, that the nursing section will cooperate in
every possible way to promote the successful organization of the
hospital program, and to assure this meeting that the nurses of this
Service will continue to “carry on” and to render all assistance in
their power toward the accomplishment of this result.”


GEN. CUMMING: asked for discussions, stating that only two minutes would be
allowed for each.


GEN. SAWYER: stated that the women were very anxious to have their
suggestions.


CAPT. BLACKWOOD: stated that he wished to pay his tribute to the splendid
work that has been done by the nurses. He said he had experienced
hospital work when they were dependent upon the most undesirable man
that could be found to take care of the sick. The man who could not do
anything else was the one that took the place of the nurse. He also told
his experiences in Boston when the influenza epidemic came, how in less
than a month over 1300 cases were being treated by a staff of nurses
scarcely larger than before, how the women worked day and night without
rest and often without food, and how many of them lost their lives in
the struggle.

He stated that one of the most important questions confronting us today
is the question of pay of the nurses, that they had not been recognized
in the way that they should be, that stenographers whose work is not as
valuable receive from $100 to $150 a month and nurses from $60 to $100,
and that effort should be made to pay them more in proportion to their
qualifications. He stated that the charwomen received more than the
nurses.

He stated further that the ratio of nurses to the number of patient
which had been stated as 1–10 was too much to expect in hospitals such
as his, where only about 15% of the patients were bed patients.


COL. EASTMAN: stated that this should be one nurse to every ten bed
patients.


SURGEON STITES[STITT?]: said he did not believe any Commanding Officer could
run a successful hospital without the cooperation of the Chief Nurse. He
spoke also on the statement previously made “Kindness without
familiarity”, stating that if too friendly some patients think others
get more attention because of familiarity with the doctor, nurse or
attendant.


SURGEON HEDDING: gave the situation at Ft. Bayard, ten miles from anywhere,
with 1100 patients and 86 nurses taking care of them. He stated that the
Public Health Service had authorized the keeping of 50 riding horses. He
said that the nurses were happy, that the men were happy, and that many
nurses were asking to come to Ft. Bayard.


GEN. CUMMING: asked Captain Wieber to talk.


CAPT. WIEBER: stated that he was from Ft. Lyon, Colorado, 7 miles from the
nearest city, an establishment with 400 patients at the present time and
nurse corps of 21. He said that the nurses were happy and content with
the work given them. He also wished to give his tribute to the field and
other nurses in the service. He stated he had had the same experience as
Dr. Blackwood in the early nursing service, and that some of the men who
took care of the sick were half idiots. He said he fully realized now
the value of female nurses, and believed he could not get along without
them.


GEN. CUMMING: “That next subject is a very important one—‘Diet’—to be
presented by Miss Clara M. Richardson, Asst. Supt. of Dietitians, U. S.
P. H. S.”


MISS CLARA RICHARDSON: read the following paper—“Diet”.

“The subject “Diet” is a rather broad term and would suggest a variety
of different phases, all of which might be equally interesting. Let us
consider the subject however in its relation to the ex-service man and
the care given him in hospitals established for his benefit.

Among these patients we find the necessity for a wide variety of diet,
ranging from the more common types as liquid, soft and light to the more
complicated pathogenic diets. In what are termed the General Hospitals
are found patients suffering from many ailments such as nephritis,
diabetes, colitis and many gastric disturbances. In some Public Health
Service Hospitals, as many as four hundred special diets are served
daily. In planning and equipping new buildings provision should be made
for such a volume of work. It is impossible to satisfactorily serve many
special diets from a general kitchen without proper facilities. Careful
planning is not only necessary in the kitchen, but also in the serving
and dining rooms. The patient on regular diet who may, perhaps, be
eating corned beef and boiled potatoes is not likely to see his neighbor
eating broiled steak and mashed potatoes, without making some comment.
If this is not handled carefully, serious trouble may result. Where
there are a number of small dining rooms it will be found wiser to use
some of them for special diets.

In one hospital the large mess hall was divided into sections. There
happened to be a number of doors, over each of which were placed signs
reading—Diabetic Diet, Nephritic Diet, etc. This arrangement worked very
satisfactorily, the patients filing in in an orderly manner wherever
their particular diet was indicated. This is a matter which is entirely
dependent on the construction of the hospital however.

Of course, care must always be taken that patients on regular diet who
want a few extras do not slip into a special diet dining room. In a
hospital too large for the dietitian to easily recognize her patients,
this may be regulated by a pass of some description. Often times the
Officer of the Day in making his inspection of meals may discover one of
these visitors.

Not only must we consider the patient who comes to the dining room, the
bed-ridden patient is perhaps worthy of even greater consideration. His
appetite must be coaxed, his tray must be attractive, and above all, his
food must be hot or cold, as the case requires. The satisfactory
conveyance of food from kitchen to patient is a problem in all
hospitals. Many institutions are so arranged that it is necessary to
serve a few trays in almost every corner of the building. In such cases,
it is well nigh impossible to attain the desired results. The ideal
arrangement is one whereby the sick patients are focussed at a point
near a kitchen. If Medical Officers would arrange this, other conditions
permitting, they would find that many of the difficulties of food
service would be eliminated.

A very successful development of this method in a hospital of a thousand
bed capacity was recently brought to my attention. There were probably
about two hundred patients on special diet, all served from a central
diet kitchen. Trays were all set up under the direct supervision of the
dietitian—a card bearing the patient’s name was placed in one corner,
and the tray was immediately taken from the kitchen directly to the
patient. As a result, patients from other parts of the hospital made
every effort to be put on wards thus served.

The preparation of satisfactory menus and procuring of the requisite
foods for special diet cases of course necessitates buying certain
fruits and vegetables out of season. It also increases the number of
chops, steaks, etc. used. It must be expected that the ration
expenditure of a general hospital where such cases are cared for will be
proportionately higher than where few special diets are served, as for
instance in a neuro psychiatric hospital. It must also be expected that
the ration of a hospital caring for tubercular patients will be higher
in accordance with the increased amount of eggs and milk consumed. It is
usually necessary to make special effort to tempt the appetite of this
type of patient—he often is not hungry and is apt to waste his food. The
market conditions in different localities will also be found to have a
very direct bearing on the cost of the ration. The central northwestern
states provide the best and cheapest market in the country. A menu which
might cost 54¢ in this section would perhaps run 20¢ higher in some
other locality.

In the preparation of menus, too much stress cannot be laid on the value
of fresh fruits and fresh vegetables. Of course, it is necessary to use
dried and canned goods to a certain extent, but care should be taken
that the fresh articles are not entirely eliminated. The patient will
probably say that he does not like salads. They are good for him,
however, and after a little persuasion he will learn to like them, and
will often ask for them. The personality of the dietitian counts for
much. If she will go among the patients, talk with them in the dining
room and let them know that she is really interested in them, they on
their part, are ready to cooperate. Such cooperation is absolutely
necessary, for upon the attitude of the patient depends the atmosphere
of order and quiet in the dining room. An undercurrent of
dissatisfaction is sure to result disastrously.

Another important factor in the success of the dining room service is
the appearance of the room itself. I once saw a group of patients moved
from a big barn of a mess hall, which was too large for the number
accommodated and which could not be made attractive, to a smaller dining
room, new and freshly painted, with curtains at the windows, and flowers
on the tables. Those boys who had been noisy and boisterous in the first
room, were as quiet and orderly as one could wish in the second.

We find in these hospitals every kind of patient from the boy who on
account of religion does not eat certain foods, to the boy who eats
anything he can procure, regardless of whether he is on a diet or not.
Dietetic treatment in the latter case is practically impossible, while
the former is usually very reasonable and gives little trouble.

Again we find the patient who is earnestly trying to improve his
condition. If his ailment requires careful feeding, he may come to the
dietitian to talk over with her the question of his diet. Here is an
opportunity for the trained dietitian to give helpful instruction
concerning the dietetic value of different kinds of food as they pertain
to his particular case.

The ward surgeons may in may cases render valuable assistance to the
dietitian in her problems, by instilling in the patient a confidence in
her judgment. Of course, the doctor must himself feel sure that his
confidence is not misplaced. There should be the closest cooperation
between the ward surgeon and the dietitian. She should confer with him
as to special diets, and thru him should ascertain the progress of the
patients on those diets.

There should also be a complete understanding of just what is meant by
liquid, soft and light diets. Experience has taught us that doctors,
nurses and dietitians from different localities do not always give the
same interpretation to these terms. It will save much confusion for all
concerned if some standard is agreed upon.

The question of diet in these hospitals therefore resolves itself into
three problems—first, an effort to secure the foods necessary for a wide
variety of diet; second, an effort to serve these foods in a wholesome,
appetizing manner amid attractive surroundings; and third, an effort to
instill in the ex-service man a feeling of contentment and satisfaction
which will go far as an aid to dietetic treatment.”


MR. J. D. SULLIVAN, of St. Elizabeths Hospital, gave the following
discussion “Diet and the Service of Foods, at St. Elizabeths Hospital”.

“In preparing menus and estimating the amounts of foods needed for the
population of St. Elizabeths Hospital, we base our calculations on the
standard dietary tables, as published by the office of Home Economics,
and the experimental stations of the department of Agriculture.

From extensive investigations carried on by the experts on dietetics, it
has been found that the average man using much muscular energy in work
or play, will require food sufficient to supply 4000 calories of energy
daily; the average woman using much muscular energy, will require 2700
calories; the average man doing little or no work 2700 calories; the
average woman or girl doing little or no work, will require 2100
calories.

Many of our patients are engaged daily at some work, and they lead a
fairly active life; their food requirements, together with the employees
of the hospital, can safely be calculated from the standard dietary
tables.

Those amongst the hospital patients whose mental and physical condition
is such that they require special attention and care, the food for them
is prepared and served under the direct supervision of Dietitians
specially trained for this work, and the amounts and kinds of food used
is in accordance with each patient’s individual needs as ascertained by
observation from day to day.

 In selecting foods for St. Elizabeths
 Hospital we aim to have meats, milk, eggs,
 cheese, sufficient to furnish                 20% of the energy needed.
 Cereal foods                     〃            30%           〃
 Vegetables and fruits            〃            20%           〃
 Fats                             〃            20%           〃
 Sugars, sirups                   〃            10%           〃

A diet made up of foods in this proportion will be sufficiently bulky,
and will furnish the right proportion of protein, fats, carbohydrates,
mineral matter, and vitamines.

As the report of the daily average per capita consumption of foods used
will show we use slightly more than the amounts considered sufficient
according to the standard dietary tables, because of the mental
condition of many of our patients there is apt to be a considerable
amount of food unavoidably wasted; also approximately three-fourths of
the population are male adults, and for this reason they require more
food than would be needed for an evenly mixed population.

From the investigations carried on in the office of experimental
stations, the conclusion has been drawn that the total amount of protein
needed every day is estimated to be 100 grams; one-half or 50 grams is
taken in the form of animal foods, the remainder is taken from the
cereals and vegetable foods.

It is well to encourage the use of cereal foods, especially where
economy is to be considered, and they should be used as freely as can be
without making the diet one-sided.

The use of cereals and vegetables increase the wholesomeness of the
diet, by providing the minerals, and the bulk necessary for the normal
digestion of the more concentrated food materials, and makes the diet
more varied and attractive.

In the use of the cereal foods, bread should have the first
consideration; the best bread that can be obtained should be provided;
bread that is well flavored, light, of good texture, and well baked.

It is also well to remember that large quantities of cereal foods may
not seem attractive if served alone; they may be made very appetizing if
combined with small amounts of the more highly flavored or seasoned
foods. A well seasoned soup may lead to the eating of a large quantity
of bread. A little savory meat or fish, or a small quantity of cheese,
may be used to flavor a fairly large dish of rice or macaroni.”


MISS FLORENCE D. HANKS of the U.S. Naval Hospital at Annapolis: She stated
that cooperation is the big thing, that without it the dietitian is
helpless. She said she has received the most hearty cooperation from the
Chief Nurse and Commanding Officer, and stated further that in different
hospitals liquid, soft and regular diets are different, and that it must
be immediately understood just what the doctors mean.


MISS GENEVIEVE FIELD, Head Dietitian of the Walter Reed General Hospital:

At Walter Reed there are all kinds of patients to deal with. They have
at least one dietitian present at every meal, and the patients feel free
to bring comment or criticism to them at any time. In the wards the
nurse is directly responsible for the service of food. If any food is
not just as it should be the nurse is expected to telephone to the
kitchen and report it, and it is immediately corrected. The nurse also
knows just what is appetizing to certain patients and may request
certain foods for them. One big problem is the patient who has been in
the hospital for a long time and needs special attention, and it is
these patients that the dietitians try the hardest to please. The menus
are sent daily to the ward, and the nurse makes out her diet request
list. She stated also that for the regular diets 1 pt. of milk and 1 egg
are allowed per day; for light diets 1 qt. of milk and 1 egg; for soft
diets 1½-qt. milk and 2 eggs; and for liquid diets 1½ qt. milk and 4–6
eggs.


CAPT. EARL P. GREEN, Mess Officer at Walter Reed: Stated he had been three
years at the Walter Reed and that during that time many problems have
come up. He stated that food and service are the two principle things
about feeding people, but the greatest difficulty is service. It is very
important to get the people serving the food confident that it is all
right. He said a nurse could take the best food to a patient and if she
thought it was not good the patient would not eat it. Good food can be
bought with money, but service cannot. He said he used to get his
complaints from the Post and Star, but this has been eliminated by
requiring the nurse to report anything which she thinks is wrong in the
diet, and that no complaint is too small to investigate. He believed the
mess department could hide nothing, but should be fair and above board.


GEN. SAWYER: “Recently the White House and my office have been bombarded
with what seems to us to be a propaganda against the reduction of the
ration cost in one of the hospitals of the Public Health Service. This
brings to my mind two thoughts: first, in the matter of administration
of the affairs of your hospital be sure that you do not take too many
people into your confidence in considering any changes you have in mind
to make. The fewer people that do the talking and the more that do the
acting the better you are off. Also, I would like to express the
feelings of Mrs. Harding, who has given a great deal of attention to the
matter of the world war veteran and the matter of his feeding. This is
what we would like these veterans to have—a generous diet of wholesome
food, well-prepared and neatly served.”


MR. L. C. SPANGLER, Associate Medical Purveyor of the public Health Service
presented the subject “Hospital Supplies”, reading as follows:

“The term Hospital Supplies may be construed in its broadest sense to
mean everything used in a hospital. A fully equipped modern hospital in
its various departments will use approximately 5000 different articles.

In the selection, purchase, inspection, storage, and distribution of
such a wide variety of supplies in the quantities used by the government
lies an opportunity to effect the saving of large sums. Careless or
inefficient handling of any branch of this work may result in heavy
losses. As it is obviously impracticable to purchase all articles for
which individual officers have a preference it becomes necessary to have
a standard list of supplies. This list is revised from time to time
eliminating such items as can be replaced with more serviceable
articles. Through frequent revisions all new medicines, instruments,
etc., of proved worth find a place on the list.

By referring to the standard list requisitioning officers can ascertain
the articles kept in stock at supply depots. Requisitions for articles
not appearing on this list should be reduced to a minimum and when such
requisitions are submitted they should be accompanied by a detailed
explanation as to the necessity for the supplies requested.

Standard specifications are in course of preparation for all supplies
which are purchased in large quantities. Such specifications enable the
Supply Section to obtain wider competition from manufacturers and
insures the delivery of a uniform and satisfactory product.

Commodities purchased in relatively small quantities can be obtained
more advantageously when manufacturers stock articles are specified, as
lower prices will be received and earlier deliveries secured.

The careful test and inspection of all supplies purchased either during
their manufacture or after delivery has been made is an important
function of the Supply Section. The inspection of supplies shipped
direct to hospitals by contractors devolves upon the receiving officer
who is furnished with either specifications or samples to enable him to
protect the interests of the government.

Satisfactory distribution of hospital supplies is extremely difficult
unless suitable warehouses are available which should be centrally
located at points having good shipping facilities, preferably both rail
and water. To attempt to use buildings for a supply depot which have not
been constructed for that specific purpose delays the work and
appreciably increases the cost of administration.

Approximately 25 per cent of the supplies now being issued from Public
Health Service Supply Depots were received from surplus Army stores.
These supplies will be issued on approved requisitions until the stock
is exhausted and no further surplus is obtainable. Every effort should
be made by service officers to use these materials and avoid the
purchase of supplies as far as possible, as with few exceptions such
supplies are in good condition. Such items as rubber goods, suture
materials and others of a perishable nature received from Army surplus
are occasionally found defective due to the fact that they were
purchased several years ago. Attempts have persistently been made to
eliminate such deteriorated articles from stock by examination at the
Supply Depots before shipment is made. This process has been successful
in preventing the issuance of inferior goods except in a few instances
in which the material forwarded was in original unbroken packages.

In the interest of economy substitutions of articles received from Army
surplus will continue to be made for special items requisitioned for
unless some compelling reason requires a purchase be made. The necessity
for the continuance of this practice will be understood when it is
considered that sufficient funds have not always been available to lay
in stocks of standard supplies to permit us to intelligently anticipate
and arrange for our future requirements, or even at times, such as
during the last quarter, to enable us to make purchases for actual and
urgent needs of the Service, a condition of very serious concern to the
efficiency and proper functioning of the work of purchase and supply.

The proper care and economical use of hospital supplies should be
insisted upon by officers in charge of hospitals and the officer who
permits loss through excessive breakage, negligence of theft fails in
the performance of one of his most important duties. To delegate this
duty to a subordinate and fail to require its strict enforcement does
not relieve the officer in charge of his responsibility.

It may be interesting to you to know the procedure through which a
requisition passes after being dispatched by a station.

As soon as it is received in the Purveying Service it is numbered,
record is made of it and notice of receipt forwarded to the station
where it originated with the statement that the receipted requisition
bears a certain number to which reference should be made if inquiry is
later necessary concerning items appearing thereon.

The second step is to the approving officer. Here it is carefully
scanned, its contents noted and it is found to include articles of a
non-standard or unusual character the requisition is forwarded to that
section of the Marine Hospital Division interested in supplies of the
class involved, such as Laboratory and X-ray, Physiotherapy, etc., for
recommendation as to furnishing, after which it is returned to the
approving officer who approves it without change or with amendments
deleting certain items entirely or reducing the quantities
requisitioned, in each case notifying the station whence the requisition
emanated of action taken. In some instances he may request, as you are
fully aware, further information relative to the necessity for certain
materials.

After approval the requisition is returned to the Purveying Service. If
the supplies desired are in stock, the Supply Depots are instructed to
forward them to the station. Information of this action is sent them at
the same time by mailing a carbon copy of shipping order. If not in
stock, but covered by the General Schedule of Supplies, articles are
purchased under the contracts contained in that schedule.

Circular proposals are then prepared for the remaining items which are
not carried in stock at the Supply Depots or for whose supply contract
has not been placed by the General Supply Committee. Bids are requested
from as many firms as are able to supply articles and after a period of
from 5 to 10 days award is made to the contractor agreeing to furnish
the most suitable article at the lowest price.

Before, however, any article can be purchased, unless specifically
exempted, inquiry must be made through the Office of the Chief
Coordinator, General Supply, as to whether or not the articles desired
by the station can be secured from the surplus stocks of any Government
Department. Action is this regard is taken prior to issuance of the
circular proposal. If the Chief Coordinator states that it is possible
to secure the supplies from surplus of a particular department, we must
then communicate with the department mentioned to inquire if the
articles desired are at that time available. A statement regarding their
condition, price and location is also requested. Upon receipt of this
information order is placed with the particular department.

For the procuring of certain items of which there is no supply in stock
or which are not usually stocked, authority is given the station to
obtain proposals locally either because the quantity is insignificant,
the value small, not justifying the cost of transportation, or because
the station can more advantageously obtain the particular item
requisitioned.

Of course this routine regarding requisitions does not apply to
emergency requests. They are always cleared without delay and every
effort made to furnish the supplies called for as expeditiously as
possible.

It is not a part of the functions of the Purveying Service to approve or
disapprove requisitions for hospital supplies. This duty is performed by
an officer who represents the Marine Hospital Division and who works in
the office of the Medical Purveyor that the prompt handling of
requisitions may not be delayed. It is greatly in your favor if you have
in the eyes of the approving officer a reputation for practicing economy
in the use of supplies. Many of you have not met this approving officer,
but you are all old friends of his. He has made you acquaintance through
handling the requisitions prepared under your direction and he has
formed a very accurate idea of your ability to foresee your needs. He
knows whether your requisitions are closely scrutinised before you
approve them, or whether your chief aim in life is to have the contents
of the Supply Depot shipped to your station before the other fellow gets
it.”


LIEUT. JOEL T. BOONE, U. S. NAVY: presented the next subject—“The Social
Service Worker”, as follows:

“Mr. Chairman, members of the Federal Board of Hospitalization, and
fellow guests—

The subject given to me to present is worthy of more expert and more
specialized elucidation than I an able to furnish with meager knowledge
of the functions of the Social Service Worker. We are interested to know
just what position the Social Service Worker should advantageously
occupy in our sincere efforts to provide the very best care and the very
best care and the very best treatment for those unfortunate individuals
who have been disabled in the service of our country or who have
suffered disabilities as a result of or traceable to that service during
the World War.

My knowledge of the Social Service Worker for the most part is limited
to his or her duties associated with Naval institutions. For almost
three years I have represented at National Headquarters of the American
Red Cross the Surgeon General of the Navy, who is the Navy Department’s
representative on the National Executive Committee. My official position
has been one of liaison but, in the organization of the Rod Cross, I am
the Director of the Bureau of Naval Affairs. In that position it has
been my privilege to assist in the adoption of a Naval-Red Cross program
for the carrying out of one of the purposes of the Red Cross
Congressional Charter, which obligates the Red Cross to act, “in natters
of voluntary relief, and in accord with the military and naval
authorities as a medium of communication between the people of the
United States of America and their Army and Navy.”

In my investigations as to the sphere of the Social Service Worker, I
have found two schools of thought or two groups interpreting the meaning
of the Social Service Worker differently. One group limits the
definition to that personnel which deals with purely personal and
community problems of individuals, and also to those who are trained
medical social service workers; while the second group, sees no
limitation to the field of operation by a highly specialized worker in
dealing with an individual’s welfare. The first group separates the
recreational, amusement, entertainment and athletic directors from the
strictly medical social service workers; while again the second group
consider the amusement personnel as properly placed under the category
of social service workers.

We are not particularly interested here in this academic discussion but
we should be mindful of it in giving consideration to the organization
and administration of our hospitals. There is a limit to all things so
the social service worker is limited in his or her field of activity. We
seem to be living in an age of specialization. We need sanity in the
practice of our professions irrespective of their nature; and what is
just as essential, we need good practical common horse sense and not too
much theory.

I believe the Commanding Officer can be rated a skilled social service
worker more competent to deal with the problems of his patient than any
other individual, if he is a keen observer of human nature, if he has
the interest of the patient at heart, if he searches for, what we call,
the soul of the man and not merely observe his flesh and blood, if he is
determined to correct the mental restlessness as well as the physical
agony, if he considers his patient individually and not as a case, and
if he impresses on his patient that no one is as much interested in him
as his Commanding Officer. No one in an institution should be able to
take the Commanding Officer’s place in the sympathetic understanding of
the patient. Of those in the military and naval service it has been
said, that the uniform stands like a closed door between officer and
patient. There should be no reason for this. If it exists, the officer
is responsible.

You will appreciate why I make the foregoing remarks. The Commanding
Officer cannot perform all the duties incident to the operation of a
hospital and the care and treatment of a large number of patients, but,
while he must have various types of personnel to care for the patient,
he cannot delegate his responsibility for the patient’s welfare.

In the organization of our hospitals there is a proper place for social
service the detail operation of which must be left to personnel which
devotes its entire time to matters of a social nature, and to matters
touching the personal, family and community problems of the patient.
Obviously it would be most desirable to have all classes of personnel
working in our governmental hospitals to be paid governmental employees.
We are working toward the millennium but we are far distant from it,
hence, we must avail ourselves of what we find at hand. The United
States is populated with a kindly, sympathetic and generous people,
which fact makes it possible for the unfortunate hospitalized to enjoy
the generosity of our citizenry, much of our social programs in
hospitals is made possible by the great membership and charitable
organizations of our country. Through these organizations the American
people can and do desire to assist constituted governmental authorities
to provide for the welfare of the war disabled as well as the regular
service man. As I have stated in the first part of my remarks, the
Congress has legalized the assistance the American Red Cross can render
the Army and Navy. When the veteran is hospitalized in Naval
institutions he is given every consideration and treated as a naval
patient. We cannot and have no desire to make any distinction between
him who is serving his country today, and him who went to its defense
yesterday. The truly patriotic would not have it otherwise. The service
man of today has been actuated by just as high patriotic motives to
serve his flag as the man who stood willing to sacrifice his all in the
days when our beloved land was outwardly threatened by a visible enemy.

To those of us who are intensely interested in every phase of the
veteran problem and who do not look upon the veteran as merely a medical
or surgical case, the testimony given and the tribute paid to welfare
endeavors and all forms of social service by Doctor White yesterday
morning, was most gratifying. Those of us of the medical profession have
the highest regard for the keen insight of a patient’s mental condition,
possessed by Doctor White.

Social service should have a definite place in hospital organization.
Social service should be the agent of the Commanding Officer for dealing
with; (a) the relationships of the hospital to other groups in the
community; (b) the relation of the patients to their families and their
community; and (c) in the relation of those matters which affect the
social conditions which are involved.

Of course everything in the Social Service Department as in any other
department of the hospital must be under the absolute control of the
Commanding Officer. It has a relation to the administration of the
hospital, and to the patients’ treatment. In its relation to the
hospital the Social Service Department may:

 (a) Provide entertainment.

 (b) Regulate visiting under the Commanding Officer’s direction.

 (c) Receive proper donations previously authorized by the Commanding
       Officer.

 (d) Stimulate in the adjacent community resources which can be
       beneficial to the patients.

In the Navy the funds for our entertainment program are primarily
provided from allotment made by the Morale Division of the Navy
Department and from ships shore or canteen profits. The Red Cross
supplements our endeavors and assigns at certain hospitals other
personnel than Home Service or Social Service Workers, to assist in
recreational measures.

The Social Service Department’s relation to the patient’s treatment:

 (a) Securing social histories and other significant data for use of
       tuberculosis specialists and psychiatrists.

 (b) Securing reports on home conditions for help of physicians in
       deciding whether or not to discharge a patient to his home.

 (c) Correspondence with home communities to adjust home situations,
       thereby making it possible for patients to remain in hospitals.
       This sometimes involves financial aid to families.

 (d) Arranging through local communities for men who return home to have
       proper care and assistance in adjusting him to civilian life.

Then there is the After Care of the patient and one the Social Service
Department should be competent to handle:

 (a) Helping to connect men approved for vocational training to get in
       contact with the proper government officials later. With a
       Veteran Bureau’s representative in the hospital, this should be
       much simplified.

 (b) Following up patients who leave the hospital A.W.O.L. or against
       advice, to see if they return or if leaving against advice that
       they are placed under proper supervision in the home community.

Lastly there is the Information service which this Department may
provide:

 (a) Communicating with family doctors and others to assist in securing
       affidavits necessary to substantiate government claims.

 (b) Information to families regarding patients’ personal and family
       affairs when advised to do so by the Commanding Officer.

 (c) Furnishing information to patients regarding government
       legislation.

 (d) Furnishing information regarding government insurance.

The Social Service Department of the hospital irrespective of the source
of supply of the personnel must be considered as an integral part of the
hospital, subject to the inspections, rules and regulations of the
hospital.

The Red Cross at present provides the personnel for social service
endeavors and I cannot conceive how any other agency could undertake to
provide this service without providing the cobweb like organization
spread out over the United States with thousands of Home Service
sections as the Red Cross maintains, prepared to furnish information to
the government officials. Until the government can provide a similar,
and an adequate service, I know of no other civilian organization which
enjoys the semi-official recognition imposed by the Congress and to
which we in the government can turn for assistance, than the American
Red Cross.

The social service problem is one of helping the doctor, the man, the
family, and to represent the community.

We as medical men must remember that treatment, if successfully
instituted, must embrace rehabilitation of the mind to a like degree
that it does the body. A cure cannot be affected by the simple
administration of drugs or a stroke of the scalpel. Something just as
important, and in many instances more so, is the attention to the mental
state of the patient. All the medicine, all the most skilled surgery
will not cure unless careful attention is paid to the mental frame of
mind of the patient. The whole social service effort is one to help
bring back the patient to the world of reality and to maintain morale at
a high level.

We must always be conscious that in caring for patients there is a basic
distinction due to the mental depressions resultant from illness,
helplessness and dependency, and protracted convalescence. Sick men have
distorted judgment, reason illogically, magnify trifles, and acquire a
certain degree of negativeness. Their spirit of discipline is stunted.
They resent correction and restriction. They must be retrained to think
logically and coherently. Each patient must be treated separately,
prescribing for his individualism when he is abed and while still unable
to attempt a return to group action. The morale of the patient is just
as important as the administration of drugs or surgical relief. In fact,
I do not believe it too broad a statement to say more so, for every
patient must be treated from a morale standpoint. While some patients
need medical, others surgical treatment, a great many need neither
medical nor surgical attention, but only mental rehabilitation. The last
class are not necessarily pathological cases nor psychiatric cases, but
a peculiar class demanding careful study and definite prescription
usually of a _recreational_ form.

We must not overdo the social service for the good of the man himself,
his family and his community. The greatest service we can render the
disabled ex-service man is to reinstall in him self-reliance. We must
keep his morale high, for morale is the perpetual ability to come back.”


COL. EDWIN P. WOLFE gave the following discussion on “Hospital Supplies”.

“Mr. Spangler has given us a very complete description of the general
method of procurement, storage and issue of supplies required in the
management of hospitals. It may be permissible, however, to elaborate a
few of the details and to call attention to certain common errors on the
part of hospital personnel using these supplies.

It is a well established principle for the efficient distribution of
supplies that the final “break-up” be made as near the ultimate
destination of the supplies as is practicable. This requires, of course,
a sufficient number of supply depots located in suitable sections of the
country from which the individual hospitals can secure their supplies
with the least practicable delay. The question of size and location as
well as rental cost of warehouses is ofttimes the determining factor in
the number of depots from which supplies are to be distributed. From the
standpoint of economy in operation, fewer depots of larger size are the
more desirable; from the standpoint of prompt distribution, the larger
number, more widely distributed are the more desirable. It requires a
great deal of study of transportation lines and traffic conditions to
decide upon the happy mean between these two.

The average person who uses hospital supplies has very little conception
of the great amount of storage space which is necessary in order to
carry at all times in the warehouses a six months’ stock to the end that
requisitions may be filled immediately upon receipt. As an illustration,
the Medical Department of the Army had in operation within the
territorial limits of the United States on November 1, 1918, ten large
distributing depots, with an aggregate floor space of more than
2,000,000 square feet. This area expressed in square feet is so
staggering as to convey a very inadequate conception of its size. To
those of you who are familiar with the methods of describing land in the
central and western states, it may be made intelligible by saying that
the area exceeds that of a forty acre tract. In fact, it is
approximately 45 acres. If you can conceive of such a tract piled ten
feet high with supplies, allowing, of course, for roadways and aisles
you will get some conception of the mass of material which had been
accumulated for the Army at that date. Then bear in mind that there were
thirty-three camps, each with its large general hospital, having three
warehouses, approximately 25 × 125 feet more or less completely filled
with supplies and you can get an idea of the quantity of supplies
required for current use in those hospitals and for dispensary service
of the camp. As a further illustration of the quantities of supplies
necessary it may be permissible to state that the quantity of gauze of
various meshes, from that required in bandages down to the coarsest
grade used in surgical dressings, not forgetting, of course, the muslin,
that was procured by use between April 6, 1917 and March, 1918, was
sufficient to have provided a strip a yard wide around the earth at the
equator and a bow knot consisting of several hundred miles in addition.
If the yarn which was required in weaving this mass of material had been
all made into one single thread, one end of it might have been hooked on
the limb of some giant tree on earth with the other end dropped into one
of the spots on the sun and still had a few thousand miles to spare. The
number of beds actually available for use in the hospitals in the United
States on January 1, 1919, if placed end to end would have stretched
over a distance in excess of 90 miles. If the mattresses had been placed
side by side and end to end to form a square, they would have covered
sixteen acres.

Proper warehousing is a very necessary part of the supply service. For
efficient warehousing as well as for prompt and satisfactory
distribution of supplies, a standard list of articles to be used is
necessary. These articles should be grouped in the warehouse in
conformity with the class to which they belong,—textiles in one place;
drugs, medicines and reagents in another; hospital furniture in another,
and so on through the entire list of supplies.

Warehouses should be located on railroad spurs so that supplies may be
delivered directly from cars into the warehouse and from the warehouse
directly into the cars. Concentration of storage space is desirable on
account of the shorter distance to move supplies when unloading and
loading. To this end a depot consisting of several stories, one above
another, affords the minimum trackage necessary in handling supplies and
it is desirable that such a building be selected when practicable.

The decision in the early part of the year 1917 to restrict the number
of articles, particularly surgical instruments, which would be
manufactured for the use of the hospital services of the Government and
for civilian use made it possible to provide the essentials for hospital
services with the limited manufacturing facilities which were then
available. Such a list had been in use in the Medical Department of the
Army for many years and doubtless similar lists obtained in the hospital
services of other departments of the Government. This standard list
presupposes specifications for the articles enumerated therein;
specifications again presuppose personnel qualified to determine what
those specifications should be. To write concise and adequate
specifications requires familiarity on the part of the personnel writing
them with the articles described therein and not only with the articles
themselves, but with the process of their manufacture. The prime
essential of the efficient supply service therefore is not limited to
the funds provided by Congress but embraces as of equal importance a
personnel trained in the actual purchase, inspection, storage and issue
of the supplies, secured at the cost of the appropriations which have
generally been so liberally made by Congress. The actual buying of an
article and the placing of the contract therefore, is a comparatively
simple matter, but the question of determining whether the articles
purchased will satisfactorily accomplish the object for which they were
procured is an acquirement which comes only with years of observation
and experience, and then in those persons whose inclinations the more
readily adapt them to the routine necessary to acquire this experience.
Whatever may be the standard of any article which may be selected, the
assurance that the article delivered conforms to the article specified
rests solely upon the qualifications of the person designated to inspect
and accept it.

From years of experience in presenting the needs of the hospital service
of the Army to Congress, I am convinced of the urgent necessity for
economy along all lines of expenditure and activities. Economy does not
necessarily mean the elimination of activities nor the discontinuance of
the use of various articles in order to bring the gross expenditure
within the sums appropriated. It does mean, however, that no greater
quantity of any article, however insignificant, which may be issued to
the user, shall be used for that purpose than is actually necessary to
accomplish the results desired. It means that the services of employees
shall be fully and efficiently used. It means that the articles which
are not consumable in character shall be handled with such care and
regard to their future usefulness as will continue them in efficient
service for the greatest length of time. As an illustration, it is
common practice among many physicians when writing prescriptions for
various ailments to prescribe a four ounce mixture and to dismiss the
patient. The same practice has obtained very largely in the hospital
services of the Government. If, instead of issuing the usual four ounce
mixture a two ounce, or a one ounce mixture had been prescribed, equally
good results would have been obtained, since the patient in many
instances actually takes only a quarter, a third or a half of the four
ounce mixture, recovers from the ailment for which it was prescribed and
throws the medicine away. This is particularly true in military
practice. If the lesser quantity be prescribed and further medication be
found necessary, the patient for whom it is prescribed will return to
the doctor, giving him an opportunity for another and more complete
physical examination and consideration of the remedy, of the result
obtained and of any other more suitable, or have the prescription
refilled if it be necessary. A dozen tablets should be dispensed in
place of customary two or three dozen. In other words, in the hospitals
and dispensary services of the Government the medicines issued should be
in quantities not to exceed the retirements of three days. This will
result not only in the saving of drugs themselves, as well as of
bandages and surgical dressings issued, but will result in material
saving in the cost of the containers in which they are issued. We too
infrequently consider the sum which the aggregate saving of the few
cents here and the few cents there will reach at the end of a year in
the larger hospital services. With supplies abundant and seemingly easy
to secure everyone who uses them is prone to become prodigal in their
use and I cannot emphasize too strongly the need for economy along these
lines. The application of the old saying, “take care of the pennies and
the dollars will take care of themselves” to the every day use of
supplies in hospitals would result in enormous savings at the end of the
year.

I was very much impressed with the remarks of Dr. Lavinder on
specialization of medical practice and the tendency in governmental
institutions to carry it to extremes. This is no where more pronounced
than in the demand for hospital supplies. What our patients need is
plenty of attention and simplicity in equipment and treatment.
Efficiency, yes, but simplicity especially. How often it happens that a
medical officer at a governmental institution becomes imbued with the
idea that he requires certain special apparatus which must be obtained
at considerable cost to the procuring agents to carry out his theories
of treatment. In a few months, or a couple of years at the longest, he
is relieved from those duties, at that hospital and goes elsewhere. The
officer who follows him conceives that an entirely different set of
instruments and equipment is necessary for the treatment of the same
class of patients than those used by the former medical officer. The
instruments and equipment of the former officer are returned to the
store rooms where they take up valuable space and new equipment is
secured by the incoming officer to take their place.

The elimination of these personal peculiarities and requirements will do
much to reduce the enormous expenditure which is everywhere being made
for hospital supplies and equipment.

In closing, permit me again to stress the need for economy in the use of
all supplies required by governmental hospitals, for an earnest effort
to use the equipment provided to its utmost efficiency and an honest
effort to get the most out of all the expendable supplies used in the
treatment of the patients committed to our care. If we are honest in
these efforts we will have no difficulty in convincing both Houses of
Congress of the justness of our requests for funds to carry out the
purpose committed to us.”


COLONEL JAMES A. MATTISON, Chief, Surgeon, N.H.D.V.S.

“Of the various papers which have been read this afternoon on the
medical side, nursing side,              diet and supplies, the two
words which seem to have been the key-note of each of these papers have
been ‘standardization’ and ‘cooperation’. It seems to me that the matter
of standardization on the subject that I am to talk on is one of the
most important factors that we can consider.” He stated that
standardization could be carried not only through the individual
hospital, but through every government agency which does this type of
work. He continued, reading the following article—“Hospital Supplies”.

“Almost every group of hospitals follows a different system in the
business management, especially from the standpoint of procuring,
conserving, and issuing of supplies. It is believed that a decided step
forward for U. S. Veterans’ Hospitals would be a standardization in the
method of procuring, handling, and issuing of all supplies. At the
present time most of our agencies have different laws regulating the
methods by which supplies are to be purchased and handled.

In some branches of the service practically everything has to be
procured on competitive bids. In some, greater leeway is allowed and
certain articles may be purchased by circular letter, while others give
still greater leeway in allowing the purchase of a large quantity of
supplies in open market. There are advantages in all of these methods
and at the same time there are opportunities, at least in some cases of
some of the methods being greatly abused. This, however, depends almost
wholly upon the personnel responsible for the transactions.

The property officer or employee, whether he is represented by the same
person as the purchasing officer or not, is inseparably connected with
the subject of supplies, and the weaknesses connected with hospital
supplies, provided such an officer is not too greatly handicapped,
depends to a very large extent upon this individual.

The per capita cost of supplies in general is dependent not so much upon
the quantity actually used as upon the waste which takes place, and the
waste depends wholly upon the personnel handling the supplies. It is
therefore, highly important that the personnel in charge of the supplies
must of necessity be thoroughly trained and conversant with the needs
and requirements of the service and at the same time have authority to
question requisitions and demands which are in excess of apparent needs.
This is a fact which I am sure we all recognize.

It is not the policy of the Government in any branches of the service to
furnish inferior quality of supplies. However, the experience of
Government hospitals in general is, that it is quite difficult in many
cases to get the grade of goods delivered that is specified, regardless
of what method is followed in making purchases. This is particularly
true with certain firms who regard U. S. Government agencies as
legitimate prey and have no scruples in unloading undesirable goods or
goods of an inferior quality, provided they are able to get away with
it. I daresay that every branch of the service has to contend with this
condition and it is believed that here again there should be some means
by which other branches of the service may be apprised of information
regarding unreliable firms which has been obtained by them through
actual experience.”


MR. M. SANGER, of St. Elizabeths’ Hospital, gave a further discussion of
“Hospital Supplies”, as follows:

“Mr. Spangler, in a presentation of the question of Hospital Supplies,
has covered in a general way the method of deciding the class of
supplies required, how to procure these supplies, how to decide upon the
quantities needed, and the general scope of standardizing supplies so as
to serve the best interests of the Government, to supply the needs of
the patients, and to procure and conserve the supplies in the most
economic and efficient. manner.

In reference to the supplies themselves, as has been stated, the first
thing is to decide what is needed. The second, as to the best method by
which these supplies may be purchased. Third, the amount of warehouse
space available for storing these supplies. Fourth, as to the best grade
of supplies to secure for the particular purpose for which they may be
required. Fifth, considering warehouse space and the non-perishable
class of supplies, what are the most economic quantities in which they
may be purchased.

There are one or two matters pertaining to the question of supplies,
however, that it seems he has not touched upon, and which I will discuss
for a few minutes. The first is in relation to those which may be
considered the non-expendibles, or more specifically those supplies
which are necessary in connection with machines of various classes;
whether it be automobiles, refrigerating machines, boilers, large tools,
or what not. As soon as a machine of this sort is secured, an entry
should be made showing date of order, date of receipt, cost, name of
make, from whom purchased, and any other information of a similar
nature. This information will be needed in order to purchase repair
parts, and when needed, as in case of a breakdown, it will be needed in
a hurry. Parts may have to be purchased by telegraph. The same
information would be needed in case of inventory, or, if a cost system
were in effect, to show depreciation, wear and tear, or give other
information in order to secure accurate cost figures.

The second item which I would speak of is the manner or method in which
you keep record of your general supplies. To a great extent, your
success or failure will depend upon the extent to which you are able to
keep up a continuity of certain supplies. For illustration, in running a
power plant one must at all times have an ample supply of fuels, oils,
packings, and repair parts. If you are furnishing food, you must at all
times have an ample supply of certain articles of diet. Your dietitian
prepares your menu and lists certain articles. These articles are
required for certain periods. Failure to have these items of supplies
when required upsets the menus. Substitutes must be utilized, which
ofttimes bring duplication of items on succeeding days or meals. This
will often lead to complaints on the part of the patient or student, who
desires a change and who believes his rights are being interfered with.

I would suggest, in order to minimize such occurrences, that a form of
perpetual inventory be installed, with labels in the form of cards or
records attached to each item. On such records, there should be marked
the minimum mount of each item that should be carried before a new
requisition is to be placed for replenishing the supply on hand. The
amount of the minimum of each item will have to be decided upon data
based upon experience covering, (first) quantities used, and (second)
time required for a new supply to be received after the order has been
placed, (third) whether supplies are to be obtained direct from the
contractor or if purchase must be made on the open market, whether
supplies come from the vicinity of the place where required or must be
shipped from a distance.

These things, though they seem small in themselves, as your experience
will doubtless demonstrate, are of such importance that I cannot place
too much weight upon them; and I think that a very early and close study
of these questions will assist you to a material extent in meeting the
problems that will confront you, and enable you to overcome many of your
difficulties.”


MISS RUTH EMERSON, of the American Red Cross, taking Mr. Pearson’s place on
the program, stated that it was because the Surgeon General of the
Public Health Service turned to the Red Cross that they came into being
in this particular connection.

She stated that certain fundamental principles had been written down
between the Public Health Service and the Red Cross, which had been
abided by, and that it had been a great problem which was taken up with
the Commanding Officer to keep out the things that were undesirable and
to bring to each hospital the best things for that hospital, not only
for the patients but for the personnel. She stated further that on the
information side the Red Cross had been a great aid in bringing to the
patients knowledge about various government regulations, but that now as
more and more attempts are made by the various departments to get this
information to the man the need for the Red Cross in this regard becomes
less. Another important function of the social service worker is to find
out the home conditions to which a man with tuberculosis is going when
discharged from the hospital.


CAPT. BLACKWOOD: stated that as the hour was late he moved that the
discussion of this important subject be postponed until tomorrow
morning.

The motion was carried and the meeting adjourned at 4:45 P.M.




            _Fifth Session_      Thursday, January 19, 1922.


GEN. SAWYER: “I would like to ask if either of our committees are ready to
report or whether they have any inquiries to make”. He asked Captain
Blackwood for a report.


CAPT. BLACKWOOD reported that the Committee on Forms met yesterday noon and
felt they had a task that was going to take months. As they had no
copies of the forms in use two of the members of the committee were to
get them by noon today.


GEN. SAWYER: urged that the matter be pushed in order that some little
understanding at least might be had before the end of the meetings, that
perhaps some suggestions could be made that could be carried out after
the meetings adjourned. “I am requested to state for the Committee on
Resolutions that there is no special report that they have to make now.”
He introduced Admiral Stitt, to preside.


ADMIRAL STITT: “The first paper is “Discussion of Disciplinary Regulations
of Veterans’ Bureau as they affect the beneficiaries and hospitals,”
which someone will read for Colonel Patterson, who is still ill.”


MAJOR R. W. BLISS, U. S. Veterans’ Bureau, took up “Discussion of
Disciplinary Regulations of Veterans’ Bureau as they affect the
beneficiaries and hospitals”, as follows:

“In a discussion of U. S. Veterans’ Bureau General Orders 27, dated
September 9, 1921 and 27–A dated January 14, 1922, covering the
Disciplinary regulations governing beneficiaries of the Veterans’ Bureau
who are patients in hospital, it is assumed that even before September
1921, all present recognized the advisability and necessity of some
lawful method by which the small lawless element, often present in
hospitals, as it is in any other community might be effectively dealt
with.

It is further assumed that the provisions of the September General Order
#27 are generally well known to this audience.

Therefore, this present paper will be limited to a brief statement of
fact of the numbers of patients discharged under this order, and to a
statement of the essential differences in the September G. O. #27 and
the G. O. 27–A, issued yesterday, leaving any comment to the general
discussion.

I have here a chart showing the name, location and type of every
Government hospital receiving Veterans’ Bureau patients, and giving the
total number of patients in each, and the total number of patients
discharged from each one, under the provisions of General Order #27,
between the dates of the issuance of this order, on September 9, 1921
and January 14, 1922.

This represents 67 Public Health Service Hospitals, 14 Naval Hospitals,
9 hospitals connected with the National Homes for Disabled Volunteer
Soldiers, 6 Army hospitals and St. Elizabeths’ Hospital, under the
Interior Department, a total of 97 Government hospitals.

The total number of patients, to which I shall refer hereafter, mean
Veterans’ Bureau Patients.

Between the dates above mentioned there have been in and admitted to
these 97 hospitals, 44,318 patients. Of this number, 474, or a trifle
over 1%, have been discharged for disciplinary reasons; 732 or 2% have
left against Medical Advice, and 1804 or 4% have been absent without
leave for a period of 7 days or over, and have so been dropped from the
rolls of the hospital. This is a total of 3010 or 7%.

In the 67 Public Health Service hospitals there have been 33,028
patients, of this number 336, or 1% have been discharged for
disciplinary reasons, 520 or 1.5% have left against Medical Advice, and
1233 or 3.5% have been dropped as over 7 days A.W.O.L. This is a total
of 2089 or 6%.

In the 14 Naval hospitals, there have been 2571 patients. Of this
number, 44, or 1.7% have been discharged for disciplinary reasons, 49 or
1.5% have left against Medical Advice, and 44 or 1.7% have been dropped
as AWOL. This is a total of 107 or 4%.

In the 9 soldiers homes there have been 4721 patients. Of this number 56
or 1.2% have been discharged for disciplinary reasons, 111 or 2.3% have
left against Medical Advice, and 437 or 9.2% have been dropped as
A.W.O.L. This is a total of 604 or 12.7%.

In the six Army hospitals, there have been 3076 patients. Of this number
44 or 1.4% have been discharged for disciplinary reasons, 50, or 1.6%
have been discharged against medical advice, and 65 or 2% have been
dropped as AWOL. This is a total of 159 or 5%.

St. Elizabeth’s hospital has had 922 patients and our records show that
none have been discharged for disciplinary reasons, none left against
advice and none have been dropped as A.W.O.L.

In a general way, the large tubercular hospitals show the greatest
number and percentage of discharges under this order. One or two
hospitals show over 30% discharges, these being mostly against advice
and absent without leave.

Since the issuance of the September General Order #27 a great deal of
adverse criticism of it has been received from many sources.

With this in mind and with the knowledge that penalties were prescribed
in the original order which did not conform exactly to the wording of
the Sweet Bill General Order #27 has been rescinded and General Order
#27–A issued in its place.

The essential features and changes in General Order #27–A are as
follows:

  1. There are four classifications:

    (a) Patients leaving institutions against medical advice.

    (b) Patients leaving institutions without permission.

    (c) Patients discharged from institutions for disciplinary reasons.

    (d) Patients disciplined by forfeiture of compensation without
           discharge.

  2. Under Paragraph (a) patients leaving institutions against advice,
     there is a definition of when treatment is completed.

     Patients leaving the hospital against Medical Advice the first time
     receive transportation and expenses to their homes. They may be
     readmitted to hospitals.

  3. Under (b), Patients A. W. O. L.

     Patients AWOL for a period of 7 days may be readmitted to hospital
     but only to the hospital from which they are absent. After 7 days,
     absence, they are dropped from the rolls of the hospital, and
     further hospitalization can be authorized only by the Director.

  4. Under (c) Patients discharged for Disciplinary Reasons, there are
     three limitations

     1. No patient who is mentally irresponsible shall be discharged for
           disciplinary reasons.

     2. No patient shall be discharged for disciplinary reasons, if his
           physical condition is such as to endanger his life by reason of
           such discharge.

     3. No patient shall be discharged for disciplinary reasons, except
           on the recommendations of a Board of Officers approved by the
           Medical Officer in Charge of the institution.

Provision is made for minor punishments.

The Board of Officers above referred to is to be composed of two medical
officers on the staff of the hospital and a representative of the U. S.
Veterans’ Bureau appointed by the District Manager. When it is
impracticable for the District Manager to appoint a representative he
will request the Medical Officer in Charge of the hospital to appoint a
member of his staff to represent the Veterans’ Bureau.

Patients discharged for the first time for disciplinary reasons receive
transportation home. They are not readmitted to hospital except by the
authority of the Director.

On the second or subsequent discharge for disciplinary reasons or for
being AWOL, the board may recommend a forfeiture of compensation up to a
maximum of 75% each month for a period of three months time.

Patients discharged under any of the above classes who are, following
their first discharge, readmitted to hospital and after this 2nd
admission are discharged for completion of treatment revert to their
former status with a clean record.

5. Under (d) patients disciplined by forfeiture of compensation without
discharge. Provision is made whereby patients who have committed an
offense when it is not deemed necessary or advisable to recommend their
discharge because of the nature and gravity of the offense, or because
of the patient’s physical condition, forfeiture of their compensation up
to a maximum of 75% each month for three months may be made effective.

Provision is made for the proper recording of all patients discharged in
all districts, for the making of all forfeitures effective and here
after all admission cards will bear a notation indicating whether or not
the patient has been previously discharged under this order Section II
of General Order 27–A is as follows:

Patients discharged for disciplinary reasons will not be readmitted to
the hospital from which discharged. So far, of the patients discharged
for disciplinary reasons, 71 have been readmitted to hospitals.

The principal complaint received from patients discharged has been that
they knew nothing of General Order #27.”


ADMIRAL STITT: stated that it had been the rule to have all the papers read
before opening the discussions.


SURGEON P. S. RAWLS, U. S. P. H. S. (R): read the next paper, “Relation of
District Managers to Hospitals”, as follows:

“The District Manager and his District Medical Officer need no
introduction to you. You are all familiar with their responsibilities.
They are the representatives of the Veterans’ Bureau with whom you come
in contact most frequently.

The office of District Manager was created by the Director, Colonel
Forbes, when he assumed direct control of District organizations. The
District Manager is charged with the responsibility for all phases of
the work of the Veterans’ Bureau in his district. The Director also
appointed a District Medical Officer who, through the District Manager,
is responsible for all phases of medical work of the District—the
examination, treatment, hospitalization, dispensary, convalescent and
follow-up care—in fact the entire physical rehabilitation of patients of
the Veterans’ Bureau. And only recently the additional responsibility of
the determination and rating of disability has been added.

The medical organization of the District Office has been developed
primarily for the purpose of establishing claimants of the Veterans’
Bureau as patients entitled to treatment, and the furnishing of proper
treatment, under regulations, orders and instructions issued by the
Central Office. The District Manager and his District Medical Officer
are charged execution of these instructions. They are charged with
hospitalization of patients in your hospitals and during such
hospitalization, they must look to you to assume the burden of
responsibility. In order to prevent misunderstanding and to define the
relation of the Veterans’ Bureau and its District Manager to the Service
hospitals and their Commanding Officers, Field Order #23 was issued
which states in Paragraph #2 and #3 as follows:

You will note that one of the duties of the District Manager is to keep
you informed of the general aims and policies of the Bureau. This means
contact—close personal contact, if possible, with the Commanding
Officers of the hospital, working together, keeping informed—the
District Manager with the work and problems of the Commanding Officers
informed of instructions through the official channels of the Service to
which he belongs.

When the District Manager hospitalizes patients in your hospital, he
must, necessarily, have certain reports, as he is still responsible to
the Director for these patients. The reports of physical examination, on
the proper Bureau forms are obviously essential. Important, too, is the
prompt and accurate report of admission to and discharge from hospital
of patients of this Bureau. Mention has been made of the multiplicity of
reports asked for and the Bureau and its District Offices are making
definite effort to relieve you of this burden. With the extensive
decentralization of the work of the Bureau to the District Offices and
the closer cooperation of those offices with your hospitals the request
for reports made upon you in the past will be reduced. I feel confident
that this result is already evident if comparison is made with
conditions of a year ago. During the recent conference in Washington of
District Managers, District Medical Officers and Vocational Officers,
the question of reduction of reports and forms was urged resulting in a
careful revision and some elimination which should indirectly affect
you.

The most direct method of improving this condition will be placing a
representative of the District Manager in your hospital. He will be able
to act with the authority of the District Manager on many matters now
causing difficulty and delay.

I should like to take this opportunity to call your attention to certain
phases of treatment which the Veterans’ Bureau and the District Manager
expect you to give to patients, namely, to disease or disability
developing for which the patient was not admitted to hospital and to
conditions which are not apparently of service origin. In this
connection, I would remind you that the Director is charged with
providing treatment to beneficiaries taking Vocational Training for
disease or disability not due to misconduct, although not related to any
service disability. This is embodied in Regulation #12 recently issued
and from which I quote:—

The relation between the District Manager and the Commanding Officer of
Service hospitals should be one of mutual cooperation. The success of
the hospitalization program of the Bureau depends on this. The
intelligent and sympathetic support of every Commanding Officer is
essential and the Central Office firmly believes that every District
Manager will give you his unqualified support in your work in
hospitalization of patients of the Veterans’ Bureau. The one thing that
I would impress on you above all others and which will do more than all
the instructions that could be issued, is get together with the District
Manager.”


COLONEL H. M. EVANS, of the U.S. Veterans’ Bureau: discussed the subject
“Physiotherapy and Occupational Therapy in Hospitals” as follows:

 Mr. Chairman, Ladies, and Gentlemen:

The subjects of Occupational Therapy and Physiotherapy constitute what
has been designated as the Section of Physical Reconstruction in
hospitals. Early after the United States entered the War the Surgeon
General of the Army realized that it was necessary to utilize all the
agencies that would aid in the recovery of men disabled in the War. He,
therefore, established a Section in the Hospital Division of Physical
Reconstruction, to include Occupational Therapy, curative work-shop
instruction, and Physiotherapy which includes Electrotherapy,
Hydrotherapy, Mechanotherapy, Thermotherapy, massage, and directed
exercise. Col. Frank Billings, of Chicago, was made Chief of the
Section, and the Work was developed until there were 48 hospitals with
more or less perfect equipment in Physiotherapy and Occupational
Therapy, 2000 Occupational Aides and curative work-shop instructors, and
1200 Physiotherapy Aides and Medical Officers. There were as many as
34,000 men engaged in some form of Occupational Therapy in one month,
and 20,000 different men treated by Physiotherapy.

Upon the retirement of Col. Billings I was made Chief of the Section,
and the work continued to develop until 69 per cent. of all hospital
patients were doing some form of work in Occupational Therapy or
Prevocational Training. There were many hospitals that maintained an
average of 5000 Physiotherapy treatments a week for a number of months.
As the men were discharged from Army Hospitals the burden of the Public
Health Hospitals became greater, and many of the individuals who had
been active in the Army work became associated with the Public Health
and established as a part of their hospital program the Section of
Physical Reconstruction, to include Occupational Therapy and
Physiotherapy. This work has developed throughout the past year and a
half. It was not thought within the province of the Public Health to
develop Prevocational Training.

The speaker, having resigned from the Army, accepted a commission in the
Public Health Service and was detailed to the Federal Board for
Vocational Education as Medical Officer in Vocational Training. For a
year and a half in this capacity he assisted in developing 181 centers,
most of which were in connection with hospitals, in which the
Prevocational Training was the major part of the work. Under this
management there were about 800 teachers employed, and about 14,00 men
engaged in some form of work. Unfortunately, the necessity of calling
this Prevocational Training, in order to have it come under the Federal
Board law, gave a wrong impression of the work as done in hospitals.
When the Veterans’ Bureau came into existence, it took over the
activities of the Federal Board and the Bureau of War Risk Insurance and
correlated these with the Public Health Service, the Veterans’ Bureau
having, under the law, power to do anything that was necessary in the
rehabilitation of the ex-service men.

The Centers that had been operated under the Federal Board were divided,
and all those attached to hospitals were put under the Medical Division
and the work was considered as Occupational or Prevocational; all
Centers that were for Section 2 trainees were designated as Vocational
Schools, and on November 17, 1921 a program for Physical Reconstruction
in Veterans’ Bureau Hospitals was approved by the Director, as outlined
in _Exhibit A_.

In accordance with this approved plan, which had previously been
approved by the Federal Board of Hospitalization, it became necessary to
have a procedure; as all other personnel in hospitals were responsible
to the Commanding Officer and controlled from the headquarters in
Washington, it was deemed advisable and consistent to have all Veterans’
Bureau personnel that were detailed to a hospital placed on Central
Office Payroll and directed by Central Office. In accordance with this,
on January 18, 1922, a procedure was approved, to be issued as a General
Order, as shown in _Exhibit B_.

This makes it very plain as to the attitude of the Federal Board of
Hospitalization and the attitude of the Director of the Veterans’ Bureau
toward Physical Reconstruction.

In addition to the agencies described, which are usually a part of
Physical Reconstruction, there have been placed for administrative
purposes the Follow-Up Nurses of the Veterans’ Bureau, which includes
265 graduate nurses, distributed throughout the various districts, and
acting in the capacity of Follow-Up Nurses under the direction of the
Medical Officers, performing duties in accordance with regulations as
outlined in Field Order #18, _Exhibit C_.

During the past month the Follow-up Nurses performed the duties as shown
in _Exhibit D_.

Upon the division of the so-called Training Centers, as outlined, the
number of teachers and the number of trainees which were strictly in
hospitals were reduced, so that the Report for December, 1921, shows a
summary, as given in _Exhibit E_.

The greatest difficulties in the way of proper establishment of physical
reconstruction have been, First, Adequate space for hospitals. Up to the
present time this has been considered an extraneous service and it has
only been possible to secure suitable quarters in a relatively small
number of hospitals; but upon the approval of the Federal Board of
Hospitalization and the Director of the Veterans’ Bureau, it now becomes
an integral part of the hospital program, and little difficulty should
be experienced in the future. Second, It has also been difficult to
secure proper personnel, particularly for Occupational Therapy for
mental cases, and in order to have this work efficiently done it is my
opinion that school of training should be established at St. Elizabeth’s
Hospital, whereby a sufficient number of Occupational Aides, who have
had experience with other types of patients, may have the opportunity to
receive special training in handling mental cases. When you remember
that in the Army there were only 48 special officers in Physiotherapy
and that we now have 100 hospitals, and most of these would need a
special officer for this work and are contemplating establishing a
number of clinics in each district, it is absolutely necessary to make
some provision for training medical officers in Physiotherapy.

We have had authority for some months to employ 100 Physiotherapy Aides
and have utilized every aide that has been made available by Civil
service, and have but 7. If we are to meet the requirements in
Physiotherapy it will be necessary to establish a training center for
Physiotherapy Aides, and it is suggested that the facilities for this
work at Walter Reed Hospital and the various Bureau Clinics, and the
Hydrotherapy department at St. Elizabeth’s be utilized for the training,
and that a regular program be utilized and course of study provided to
meet the requirements of this service.

Another one of the difficulties that is not only applicable to
hospitals, but to all centers of Vocational Training, is the method of
disposing of fabricated articles. The amount of paper work necessary
incident to this and the fact that the money does not revert to the
service but to the general treasury makes it a very unsatisfactory and
cumbersome procedure, and some legislative should be asked for to enable
the Veterans’ Bureau to proceed as the Indian Service proceeds in
disposing of fabricated articles, or articles that are the result of the
work of the trainees. Under the new procedure all personnel of the
veterans’ Bureau detailed to a hospital are directly under the Medical
Officer in Charge. The special work is directed by the Educational
Director, who should be considered as one of the staff of the hospital.
The greatest criticism that has been partially sustained in regard to
Occupational Therapy has been that men who are physically able to do
more purposeful things have been kept making trivial things, First,
because it was relatively easy to amuse them, Second, Because of some of
the articles the patient has derived considerable revenue from the sale
thereof. The whole scheme should have in mind, First, The Therapeutic
value of the activity, Second, The Prevocational Training of the
activity, with the hope that you could shorten the time of
hospitalisation and also shorten the time of Vocational Training by the
amount of Prevocational work done in a hospital.

Prior to the work in Army Hospitals much individual work had been in
Physiotherapy and Occupational Therapy, but this was not correlated. One
man emphasized the static machine, another man built up his institution
upon the basis of Hydrotherapy, another upon the physical exercise, but
it remains for the work in the Army Hospitals to coordinate these
agencies and present a solid front for Physiotherapy. One of the things
that remains yet to be accomplished is a proper coordination between
Physiotherapy and Occupational Therapy. It is waste of energy and money
to have a Physiotherapy Aide spending hours of time in massaging a
stiffened joint when, if her work could be supplemented by properly
directed physical exercise in a shop or upon the farm, the same member
could be so used as to assist in restoration quite as readily as from
massage. It is expressly understood that all the work in Occupational
Therapy should be upon prescription of the Medical Officer in Charge of
the Hospital or his designated agent, and a proper cooperation between
the Medical staff and the staff of the Reconstruction Section will
insure most satisfactory results, and that this cooperation of the work
will be very necessary in order to secure proper efficiency.

In the General Order referred to the ratio of teachers to patients per
teacher must be considered as a general guide only, as it is quite well
known that in mental hospitals the number of men that can be cared for
by a single aide or teacher will be less than in other hospitals, and it
must also be understood that the character of treatment in Physiotherapy
will also modify the number of treatments that may be given by each
individual.

I am particularly grateful for this opportunity to present the matter of
Physical Reconstruction to the men who are caring for the disabled
veterans, and who can do so much to make this phase of the hospital
program a success.


                               EXHIBIT A

                                                      November 17, 1921.

 Assistant Director, Medical Division,
 The Director, U. S. Veterans’ Bureau.
 Physical Reconstruction Section.

1. Modern hospital treatment requires that Physical Reconstruction be
established as a part of the hospital program. It is our duty under the
Sweet Bill to render this service to the beneficiaries of the Bureau
while in hospitals and in dispensaries. Such service includes.

    (a) Occupational therapy and Pre-Vocational Training.

    (b) Physiotherapy, which comprehends directed physical exercise,
    Mechanotherapy, Massage, Electrotherapy, Hydrotherapy, etc.

    (c) Follow-Up Nursing.


_OCCUPATIONAL THERAPY AND PRE-VOCATIONAL TRAINING_

    In order to carry out the work in hospitals of Occupational
    Therapy and pre-vocational training it is necessary to have

                      (a) Personnel.
                      (b) Equipment.
                      (c) Expendable material.
                      (d) Suitable space for work.

    (a) It is estimated that it will require 50 additional trade and
    industrial teachers, 50 additional commercial or academic
    teachers, and 100 occupational aides, making a total of 200,
    salaries ranging from $1600 to $2400.

    (b) As the new hospitals opened will be receiving men from
    smaller hospitals, the equipment that has been used in the small
    hospitals may be transferred to the larger ones. It is not
    possible to make an accurate estimate as to what additional
    material may be needed, as we do not know how much of this can
    be secured from other branches of the Government, but in
    hospitals numbering less than 200 patients the amount to be
    expended for equipment would be relatively small. In the new
    hospitals, however, numbering over 200 patients, where
    pre-vocational training is desired, a reasonable equipment would
    have to be furnished.

    (c) As to expendable materials for Occupational Therapy the past
    experience has shown that it will amount to $2.00 per month per
    man actually at work, and possibly 25 per cent of the entire
    hospital population will be doing some work of this character.

    I would recommend the approval of the plan in operation in the
    Public Health Hospitals for disposing of salable materials made
    in Occupational Therapy or trade work, which is that the patient
    may make two articles, giving one to the Government to be sold,
    and the other retained by himself. The price for which the
    articles to be sold should be established by a Board of
    Appraisal, appointed by the Medical Officer in Charge, or
    Superintendent, the proceeds to be used as a revolving fund for
    purchasing supplies for this work, if it is legal—if not, the
    proceeds to revert to the Treasury of the United States.


_PHYSIOTHERAPY_

    The personnel for this work has been previously authorized to
    the extent of 100 physiotherapy aides and 10 Medical Officers in
    Physiotherapy. It will be necessary, of course, to have suitable
    equipment. This will be recommended by the District Managers and
    approved by the Medical Division before a requisition is filled.

    There is a small expense for expendable material in
    Physiotherapy, which will not amount to more than 50¢ per month
    per man for treatments.


_FOLLOW-UP NURSING_

    The plan for Follow-Up Nursing has been approved and 300 nurses
    have been authorized. These are practically all assigned, and we
    are requesting authority for an additional 50 as they may be
    needed.


_NATIONAL SOLDIERS’ HOMES_

    It is the desire of the Board of Governors of the National
    Soldiers’ Homes that the personnel and equipment for the
    reconstruction work, including Occupational Therapy,
    pre-vocational training, and Physio-Therapy, be furnished by
    this Bureau.


_NAVY_

    It is desired that the personnel, equipment, and material for
    reconstruction service, covering all phases of the work, be
    furnished to the Naval Hospitals and detailed there to work
    under the direction of the Medical Officer in command.


_ARMY_

    It is the desire of the Army Hospitals serving the Veterans’
    Bureau patients that they be permitted to operate the entire
    reconstruction program for these men, and to submit monthly
    statements prorating to the Bureau its proportional part of the
    expense incurred in serving the patients, the entire personnel,
    supplies, and equipment for these hospitals to be furnished by
    the Army, and compensated on the pro rata basis.


_CONTRACT HOSPITALS STATE AND COUNTY INSTITUTIONS_

    The Bureau has been furnishing all personnel and equipment for
    the work in these hospitals, and this work should be established
    in the hospitals where there are 50 or more War Risk patients,
    and continued in the smaller hospitals where it is now
    established until the number available for this work is reduced
    to 20. In all contract hospitals where contracts are to be made
    in the future suitable supplies should be required of the
    hospital for this work as a part of the minimum standard for
    hospital requirements.


_PUBLIC HEALTH HOSPITALS_

    Formerly the Public Health Service furnished all personnel and
    equipment utilized in Physiotherapy. The personnel utilized in
    Occupational Therapy was also furnished by the Public Health
    Service but the workers engaged in Pre-Vocational Training were
    furnished by the Federal Board.

    In view of the consolidation of all three agencies for the care
    of the World War Veterans in the U. S. Veterans’ Bureau, the
    following relation is recommended between the Public Health
    Service and the U. S. Veterans’ Bureau. Physiotherapy Aides, and
    Reconstruction Aides used in Occupational Therapy, will be
    furnished by the Public Health Service and will be paid by them
    from appropriations made from time to time by this Bureau. The
    workers and teachers utilized in Pre-Vocational Training in
    Public Health Hospitals will be furnished and paid by the U. S.
    Veterans’ Bureau. The Aides will work directly under the medical
    officers in direct contact with the patient under the general
    supervision of the Medical Officer in Charge of the hospital.
    The teachers and workers in Pre-Vocational Training will operate
    directly under the Educational Director of the hospital, who in
    turn will be directly responsible to the Commanding Officer or
    Medical Officer in Charge of the Hospital.


_SUPPLIES_

    Supplies and equipment for the work in Physiotherapy and
    Occupational Therapy and Pre-Vocational Training will be
    furnished by the Public Health Service or upon request of the
    Public Health Service by the U. S. Veterans’ Bureau.


_SUITABLE SPACE FOR WORK_

    It is necessary, in order to carry on the work in Occupational
    Therapy and pre-vocational training to have well lighted space,
    properly ventilated and heated, suitable situated, and
    approximately, ten per cent of the bed space in a hospital.
    This, however, does not have to be in a ward, but may be
    provided in a separate building.

3. The general outline of the policy is that to serve the men in
Occupational Therapy and pro-vocational training it will require one
teacher for every 20 men at work, or for every 40 men in a hospital,
exclusive of the administrative force, as it is estimated that only 50
per cent will be available for this work. Experience has taught us that,
where there are 50 beds there will be 20 or more men available for this
work, and that in such small groups trade work should not be undertaken,
but in hospitals of 200 beds or more the work should be organized on the
following lines—Occupational Therapy for ward work and pre-vocational
training, to include academic, commercial, agricultural and trade work,
as the survey of the hospital indicates and as the Medical Officer in
charge may approve.

4. In organizing the work in new hospitals a survey of the needs and
facilities shall be made to the Medical Division for approval before the
work is established. When the hospital population has been so reduced in
any unit that it is deemed impracticable by the Medical Division to
continue this work, it may be closed at their direction.

5. It will be necessary to have specially qualified and experienced
individuals in Central Office to be detailed to the Inspection Section
from the Reconstruction Section to make inspections of the work in the
hospitals, and approval for travel authorization and expenses incurred
by this personnel is requested.

                          Robt. U. Patterson,
                          Assistant Director,
                          Medical Division.

 Approved: _C. R. Forbes_
           Director.


                               EXHIBIT B

              U.S. VETERANS’ BUREAU      January 18, 1922.

                         _GENERAL ORDER NO. 68_

  Subject: ORGANIZATION AND ADMINISTRATION OF THE SECTION OF PHYSICAL
           RECONSTRUCTION, MEDICAL DIVISION, U.S. VETERANS’ BUREAU.

The following General Order is hereby promulgated, effective this date,
for observance by all officials and employees of the U.S. Veterans’
Bureau.

1. The Section of Physical Reconstruction is under the Medical Division,
and includes Occupational Therapy, Pre-Vocational Training, and
Physiotherapy in hospitals and dispensaries, and Follow-Up Nursing
outside of hospitals.

2. The internal management of hospitals of the Army, Navy, Public
Health, National Soldiers’ Homes, St. Elizabeth’s Hospital, and Contract
Hospitals falls under the jurisdiction of the several services
mentioned, or in private and State institutions under the
superintendent.

3. Occupational Therapy, Pre-Vocational Training, and Physiotherapy are
a part of the hospital care and treatment, and fall under the management
of the Medical Officer in charge of each institution, and do not come
under the jurisdiction of the District manager or the District Medical
Officer.

4. Institutions formerly known as Training Centers have been divided
into two groups:

   (a) All centers called Vocational Schools are under the
       Rehabilitation Division.

   (b) All centers in hospitals will be called Reconstruction Centers
       and are under the Medical Division.


_ARMY_

In all Army Hospitals serving the U.S. Veterans’ Bureau beneficiaries
reconstruction work will be established, and personnel, equipment, and
expendable materials for Occupational Therapy, Pre-Vocational Training,
and Physiotherapy will be furnished through the Surgeon General of the
Army and paid for by the U.S. Veterans’ Bureau on a pro rata basis for
such service to its beneficiaries.


_NAVY_

In all Naval Hospitals serving U.S. Veterans’ Bureau Beneficiaries
Physical Reconstruction will be established and the personnel,
equipment, and supplies for Occupational Therapy, Pre-Vocational
Training, and Physiotherapy will be furnished by the U.S. Veterans’
Bureau for its beneficiaries in such hospitals.


_PUBLIC HEALTH SERVICE HOSPITALS_

The Occupational Aides and Physiotherapy Aides in Public Health Service
Hospitals will be furnished by that service. The teachers in
Pre-Vocational Training will be furnished by the Veterans’ Bureau. The
Physiotherapy Aides will be directly under the Medical Officer in Charge
of Physiotherapy, or, if no such officer is assigned, under the ward
surgeons. The Occupational Aides will work directly under the
Reconstruction Officer, if there is one assigned; if not, under the ward
surgeons. Teachers and workers in Pre-Vocational Training will be
directly under the Educational Director. The entire personnel of the
hospital will be under the direction of the Medical Officer in Charge.

Supplies and equipment for Occupational Therapy and Physiotherapy will
be furnished by the Public Health Service. Supplies and equipment for
Pre-Vocational Training will be furnished direct by the Veterans’
Bureau.


_NATIONAL SOLDIERS’ HOMES_

In all National Soldiers’ Homes Reconstruction service will be
established, and personnel, equipment, and supplies for Occupational
Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by
the U.S. Veterans’ Bureau. The Aides in Physiotherapy are to work under
the direction of the Medical Officer (Physiotherapist) assigned, or, if
there is not such an officer, directly under the ward surgeons. The
Occupational Aides and teachers in Pre-Vocational Training will be under
the direction of the Educational Director. The personnel detailed to the
Homes are under the direction of the Medical Officer in Charge.


_ST. ELIZABETH’S HOSPITAL_

Physical Reconstruction has been established as a part of the work in
St. Elizabeth’s Hospital. The personnel, equipment, and supplies for
Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be
furnished by the U. S. Veterans’ Bureau. The Physiotherapy Aides will be
under the direct supervision of the Medical Officer assigned to the
Physiotherapy Section, or, if no such officer is assigned, under the
Medical Officers in charge of the patients being treated. The
Occupational Aides and teachers in Pre-Vocational Training will be
directly under the Educational Director. All personnel will be under the
general direction of the Medical Officer in Charge.


_CONTRACT HOSPITALS_

In all Contract Hospitals, where the number of beneficiaries justifies,
the Reconstruction Service will be established. All Personnel and
equipment will be furnished by the U. S. Veterans’ Bureau. The
Occupational Aides and teachers in Pre-Vocational Training will be
directly under the Educational director. Physiotherapy Aides will be
directly under the ward surgeons. The personnel assigned will be under
the general direction of the Medical Officer in Charge.


_PROPERTY ACCOUNTABILITY_

The Educational Director in a center at a hospital will designate an
employee under his jurisdiction as a Property Custodian, which Property
Custodian will make the same semi-annual reports to Central Office as
are required of District Property Custodians by General Order #52.

The accounting for physiotherapy supplies and equipment will be in
accordance with General Order No. 52.


_SUPPLIES_

Supplies and equipment for Physical Reconstruction in hospitals other
than Army and Public Health Service will be requisitioned from Central
Office. Requisitions must be prepared in accordance with Field Order No.
43.


_SECURING PERSONNEL_

The personnel in the Reconstruction service is obtained through Central
Office from Civil Service register. When the Educational Director at a
hospital desires additional personnel he will make request through the
commanding officer of the hospital to Central Office direct, stating the
qualifications of individual required. Central Office will then make the
most advantageous assignment possible and order the individual to report
for duty at the designated station. In securing personnel for
dispensaries and for follow-up nursing, the request will come from the
officer in charge through the District Medical Officer and District
Manager to Central Office, stating the qualifications of individual
required. The Reconstruction Section will secure the name or names of
individuals and request the District Medical Service Section to secure
the appointment of the same through Personnel Division, and notify the
District Office of the date the same shall go on their payroll and the
amount of salary they shall receive. All personnel in the Reconstruction
service, except the Occupational Aides and Physiotherapy Aides in Public
Health Hospitals and Army Hospitals, will be on Central Office payroll.
This will include teachers and occupational aides.


_TRANSFERS_

Transfers of personnel in hospitals will be made by Central Office upon
the recommendation of the Commanding Officer and the Educational
Director. Transfers of personnel on the District Office payroll in
dispensaries and the follow-up nurses may be made within the District by
the District Manager. If it is an interdistrict transfer, the same must
be made by Central Office. All surplus personnel, either in hospitals,
National Soldiers’ Homes, or in District Office, or in Sub-District
Office, should be reported promptly to Central Office.


_COMMUNICATIONS_

All communications from Central Office to personnel in a hospital will
be routed through the Medical Officer in Charge of hospital. All
communications from personnel in a hospital will be sent through the
Commanding Officer to proper destination. All communications to
personnel in Reconstruction Section outside of hospitals will be sent
through the District Manager to its destination. All communications from
personnel outside of hospitals within a District shall be sent through
the District Manager to its destination.


_SUPERVISION OF OCCUPATIONAL THERAPY AND PRE-VOCATIONAL TRAINING_

There shall be a sufficient number of supervisors of Occupational
Therapy and Pre-Vocational Training employed and placed on Central
Office payroll to properly supervise the work in all districts. Their
duties shall be to supervise the work under the direction of Central
Office, to keep Central Office fully advised as to the condition of the
work and the needs of each reconstruction center they visit, and to
recommend any changes in personnel, giving reasons for recommendations.


_PHYSIOTHERAPY_

There shall be a medical officer skilled in Physiotherapy designated as
Chief of Physiotherapy for each district. He may be a part-time or a
full-time man, as the necessity requires. His duty shall be to supervise
and direct the installation of the equipment in the District and
Sub-District Offices, and, upon request from Central Office, to visit
and report upon the work in any hospital in his district. His line of
communication will be through the District Medical Officer and the
District Manager to Central Office; and Central Office’s line of
communication will be to the District Manager—Attention, Chief of
Physiotherapy.


_FOLLOW-UP NURSING_

Field Order No. 18 covers the entire matter of Follow-Up Nursing.

[Illustration:

  C. R. Forbes.
  Director, U. S. Veterans’ Bureau.
]


                               EXHIBIT C

File No.

              U.S. VETERANS’ BUREAU      October 19, 1921.


                          _FIELD ORDER NO. 18_

  Subject: STATUS AND DUTIES OF NURSES WORKING IN THE PHYSICAL
           RECONSTRUCTION SECTION OF THE MEDICAL DIVISION, U. S.
           VETERANS’ BUREAU.

The following Field Order is hereby promulgated, effective this date,
for observance by all officers and employees in the District Offices of
the United States Veterans’ Bureau:


1. Appointment of Nurses.

All appointments will be made by the U. S. Veterans’ Bureau on the
recommendation of the District Medical Officer with the approval of the
District Manager under the regulations of the U. S. Civil Service
Commission. Preference will be given to nurses who have had at least
three years’ general nursing experience outside of an institution,
particularly to those who have had experience in tuberculosis,
neuropsychiatric and Public Health Welfare nursing.


2. Administration.

Nurses on duty in the districts will be carried on the District
pay-rolls and will be responsible to the Chief Nurse of the District,
who in turn will be responsible to the District Medical Officer under
the District Manager. The work of all nurses in the various districts
not on duty in hospitals will be directly supervised by the District
Medical Officer who will be responsible through the District manager to
the Medical Division; U. S. Veterans’ Bureau (Physical Reconstruction
Section), to whom communications on matters in connection with their
work should be addressed.


3. Chief Nurse.

In each district a Chief Nurse will be appointed by the Central Office
of the U. S. Veterans’ Bureau through the Assistant Director in Charge
of Medical Division upon the recommendation of the District Medical
Officer and with the approval of the District Manager. The duties of the
Chief Nurses in the districts will be to superintend the activities of
the nurses in their respective districts, to visit the local offices
when directed by the District Medical Officer, to inspect the work of
the nurses, to co-ordinate the work of the nurses in the districts,
sub-districts, and local offices and to check up the nurses’ reports. It
will also be the duty of each Chief Nurse, through the District Medical
Officer and the District Manager, to keep the Superintendent of Nurses
in the Physical Reconstruction Section of the Medical Division, U. S.
Veterans’ Bureau, informed of the quality of the work performed by the
individual nurses under her direction. Reports of especially good work,
or unsatisfactory work, should be sent in detail to the Superintendent
of Nurses through the District Medical Officer and the District Manager.
The Chief Nurse in each district will instruct nurses under her charge
as to the proper form for conducting correspondence and of the channels
through which the same will be sent.


4. Duties of Nurses.


                           _General Duties._

(a) To assist Medical Officers of the Districts, whenever there is one
at their station, in the care of beneficiaries who may require medical
supervision and care.

(b) To keep contact with claimants and refer possible claimants to the
proper authorities for the adjustment of their needs.

(c) To conduct medical follow-up work under the immediate direction of
the local or sub-district authority where there is no medical officer on
duty.

(d) At station where there is a social service worker to refer proper
cases to them. If no co-operating social service agency is available the
nurses will perform such social service duties as time will permit in
addition to their regular duties.

(e) Whenever the address of a beneficiary is found to be incorrect,
nurses will report correct addresses to the nearest Bureau Office
immediately.

(f) Nurses, when visiting claimants, will give their residence address
for emergency calls to each claimant under their care and supervision.


                           _Special Duties._

These may be grouped under three heads:

1. For Tuberculosis Claimants:

(a) Ascertain state of health from time to time. Record pulse,
temperature, etc., to detect evidence of tuberculous toxemia. Note gain
or loss of weight; presence of cough. Amount and character of sputum,
etc.

(b) Ascertain their state of morale and that of their families.

(c) Give simple instructions regarding health and appropriate advice
from time to time.

(d) Furnish literature of appropriate character when same is available.

(e) Emphasize the value of hospital care for those who become sick from
other causes or whose pulmonary condition becomes active.

(f) Report promptly to the nearest medical officer beneficiaries whose
condition seems to indicate that hospitalization is necessary.

2. For Neuro-Psychiatric Claimants:

(a) Health instruction and definite advice with regard to home
conditions.

(b) Advice and supervision to prevent intemperance, excessive use of
tobacco, drugs, etc.

(c) Advice regarding habits, whether married or single.

(d) Note general behavior and mental state, such as stream of talk,
mental activity, characteristics of same, such as incoherence,
inattention, distractibility, etc.

(e) Note mood of beneficiaries, such as preoccupations, hallucinations,
illusions, etc.

(f) Endeavor to obtain insight as to how much the patient realizes the
nature of his present condition or of previous illnesses.

(g) Interpret claimant’s condition to his family and instruct them in
the necessity for tolerance of claimant’s peculiarities.

3. For Claimants with General Disabilities.

(a) Make visits to beneficiaries pending hospitalisation, or after being
discharged from hospital, while in training, particularly those said to
be absent from training on account of illness, reporting results of
investigations to the local medical officer. If an emergency arises the
claimant should be sent immediately to a designated physician, if too
ill to report to a physician, a physician in the employ of the Bureau
will be notified of the name and address of the patient and requested
call. A report on each case will be made to the nearest local office,
together with recommendations and a statement of any action that has
been taken. If Claimant’s absence from training was not due to illness
that fact will be communicated to the local Bureau authority.

(b) Report on every case assigned to her and render subsequent reports
on such cases as may be required from time to time; to make supplemental
reports from time to time as may be necessary. Such reports will be made
on Medical E, or other designated form, and will have for their object
the discovery of present results of service disabilities, intercurrent
ailments, or physical conditions which are preventing the physical
rehabilitation of the man. The attention of the District or local
medical officer will be called to any seemingly improper conditions, and
recommendations will be made looking to their correction. Subsequent
reports will show whether or not these conditions have been remedied.
For the purpose of reducing the number of visits that are required the
claimant will be induced to call at the office if practicable.

(c) When calling at the home of a patient the nurse will notice the
sanitary conditions of the home, particular attention being given to
plumbing, adequacy of rooms, air space per capita, light, heat, bathing
facilities, number of flights of stairs necessary to reach quarters,
etc. Information as to how long claimant has lived there and if he has
made frequent changes of residence. Recommendations will be made for
improvement of conditions which appear to be prejudicial to the health
of the men and his _family_ and an earnest endeavor will be made to have
them corrected. In case the _family_ of a beneficiary needs medical
treatment or other attention the social worker or in her absence the Red
Cross or other Co-operating agency will be notified.

(d) Reports on Medical G, or other designated form, will be made on
cases that break down in training, indicating when possible the cause of
the interruption of training, whether the same is actually due to a
reactivation of the original disability, to an intercurrent condition,
or to extrinsic causes connected with training, work, or living
conditions. Medical Form G, or other designated form, will be forwarded
through proper channels to the District Medical Officer or his nearest
representative.

(e) To visit at stated intervals all cases in localities in which there
are not county nurses, and to endeavor to obtain contact occasionally
with county nurses, where such are on duty, with a view of keeping them
informed of conditions for the best interest of the ex-service man.

(f) Field notes on all of the above duties will be conveniently kept on
Assignment Memorandum Form 701, or other form that may be designated
hereafter.

5. It is not the function of the nurses to supervise Vocational
Training. She is not to intimate to the beneficiary any doubt as to
whether he is assigned to the proper course, or whether institutional or
job training is best suited to his needs, but any suggestions she can
give to the Training Officer in regard to the man’s attitude towards his
training, will be helpful in his rehabilitation. Nurses will not call
men away from their work for the purpose of interviewing them, unless by
special arrangement, suggested by the Training Officer.

6. In territory where a nurse and a Social Service worker are both on
duty, the nurse is not to attempt to investigate social conditions or
make recommendations for rectifying them, if unsatisfactory conditions
are found. _Per contra_ the Social Service worker is not to assume the
work of the nurse in investigating conditions affecting the health of
the beneficiaries. Emergency cases will arise where it will be obviously
advantageous to the interests of the beneficiaries for whether a nurse
or a Social Service worker to take immediate action on a matter not
strictly within her province, but when this has to be done the other
should be at once notified of the circumstances.

7. Nurses will not be expected to assist in special nursing except in
training centers, or in temporary emergencies when it is impossible to
hospitalize claimants, or where there is no person available to give
instruction in home nursing.

                                       C. R. FORBES,
                                       Director, U. S. Veterans’ Bureau.


                               EXHIBIT D

                      NURSES’ CONSOLIDATED REPORT
                                  for
                            NOVEMBER, 1921.


                               _SUMMARY_

 Superintendent of Nurses                            1
 Neuropsychiatric Chief Nurse                        1
 Chief Nurses                                       14
 Follow-up Nurses                                  246
        TOTAL NUMBER NURSES ON DUTY                ———
        November 30,—1921—                             262

 ───────────────────────────────────────────────────────────────────────

 No. Cases treated at Dispensaries & Relief                   610
   Stat’ns
 No. Visited at Homes                                        6907
 No. Needing Medical Care                                   12938
 No. Medical E’s made out                                   15279
 No. Medical O’s made out                                     339
 No. Needing Social Adjustment                               1316
                                                           ——————
        TOTAL MEDICAL ACTIVITIES                                  37,389

 No. Neuropsychiatric Cases under supervision                      7,329

 Total No. Interviews—(Home, Placement)                           45,487
                       (School, Office)

 No. Appointments approved during November, 1921                      27

 No. Reported for duty (Oaths rec’d Central Office                    20
   to date)

 No. Resignations submitted                                            5

 No. Declinations Appointment                                          1

        TOTAL NO. CLAIMANTS UNDER SUPERVISION
        NOVEMBER 30, 1921—                                        63,397

                                                 (MRS.) K. C. HOUGH,
                                               SUPERINTENDENT OF NURSES.


                               EXHIBIT E

                        RECONSTRUCTION TRAINING

                          SUMMARY BY DISTRICTS

                            January 1, 1922.

 ───────────────────────────────────────────────────────────────────────
                                          Assigned  Enrolled  Percentage
  Dist.    Number of    Number  War Risk     to        in     of Avail.
          Institutions of Staff Patients   Classes   Classes   Patients
                                                               Enrolled
 ───────────────────────────────────────────────────────────────────────
        1            7       30      1443       652       429         66

        2           11       50      2282       926       782         84

        3            7       16       819       344       257         75

        4            9       61      2538      1228       846         68

        5            8       66      3846      2053      1394         68

        6            4       18      1185       563       452         80

        7           19       49      2309       916       753         82

        8           15       52      1631       914       711         78

        9            5       12       303       260       239         92

       10           11       33      1432       707       521         74

       11            2       19      1577       617       341         35

       12           15       55      2646      1117       725         65

       13            3        9       649       172       138         81

       14            1       13       942       442       300         70
 ───────────────────────────────────────────────────────────────────────
    Grand          117      483     23602     10911      7888         72
   Total:


ADMIRAL STITT: reminded the men that at the meeting yesterday afternoon a
motion was made to discuss the paper on the “The Social Service Worker”
this morning, and there were about 25 minutes for the discussion of each
of the four subjects—the social service worker, disciplinary
regulations, relation of district managers, and physiotherapy and
occupational therapy in hospitals.


CAPT. BLACKWOOD: said it was his opinion that the social service worker has
done more to aid the Commanding Officer and to follow up the work on the
ex-service man, as well as the service man, than anything else he knew
of that has been introduced into the hospitals. The social service work
in the Navy is all done by the Red Cross, one of the most wonderful
organizations in the United States for doing good.


SURGEON CHRONQUEST emphasized the point that diversion and recreation should
be distinguished from the social service, with which it is so often
linked.


SURGEON LASCHE: stated that at first he was sceptical about the introduction
of people under extraneous control into the hospital, but that he
incorporated the Red Cross into the official organization of the
hospital and made the director a member of the staff. He believed in
keeping a fairly close supervision over the activities until he knew the
individual, and made a rule that the social worker should send a carbon
of every letter written about the patients to the officer in charge. It
was found that at the beginning there was no possible reason for about
30% of the letters written, but only one-half of one percent of the
letters produced harmful results. He said he was inclined to think that
owing to the fact that the Red Cross has the benefit of a nation-wide
organization that for the present it is very much better to utilize
their services than to establish government employees to do the same
work.


COL. BRATTON: said that experience had shown him that the Red Cross is a
great aid in carrying on relation to the outside world. He told of the
situation in Atlanta. When the hospital was established he found it
would be necessary to satisfy the people of Atlanta that the wounded
boys were being properly taken care of, and was fortunate to secure the
services of a first-class man from the Red Cross. The result was that
the people became very interested in the work and sent committees with
food, also provided pictures two or three times a week and all kinds of
entertainment.


SURGEON PAYNE stated that one of the greatest difficulties he had
experienced had been in sidetracking the people who, though kindly
disposed, brought food and all kinds of entertainment which were
injurious to the patients. He said he did not believe in any kind of
athletics in a hospital, unless under the Physiotherapy Department,
neither did he believe in dances in a hospital. He said people would
bring in all kinds of food and the patients would eat it before going to
mess, and then of course would complain of the hospital food furnished.
The greatest benefit from the Red Cross had been the coordination of
those activities.


COL. BRATTON asked that some of the men who served in General Hospital #6
speak on this subject.


SURGEON WILLHITE: stated he had served under Colonel Bratton, and agreed
heartily with all he had said. He stated also that in his work in the
hospital in Philadelphia the Red Cross had done the finest kind of
social service work, coordinating all the agencies that Dr. Payne spoke
of as so detrimental to him, and he believed had been a very great
benefit rather than a hindrance.

Dr. Dedman took up the work of the Red Cross in taking care of relatives
of patients who come to the hospital. Often these people spend all their
money for railroad fare, and have none left when they reach the
hospital, and the hospital has to take care of them. He said he had
arranged that four or five rooms be fixed up for such people as this and
believed some definite authority should be had from the Veterans’ Bureau
to house these people and furnish their meals. He stated that some boys
will ask for things and others will not. He referred to an instance in
which a patient had told a lady that he needed a shirt, and two days
later when she brought him one she gave it to him before the whole ward
and the boy was ridiculed for a long time afterward. He had had trouble
in getting the work done through the social welfare workers in the
hospital, as the public wants the individual glory of handing something
to the boys themselves. The Red Cross has also been a great aid in
investigating home conditions of the patients, especially of tubercular
patients who want to go home to die. Also, in the case of a man who asks
for a long furlough because his mother or sister is dying, the Red Cross
will investigate and get an immediate report, and many times it will be
found that the mother or sister is not sick at all.


SURGEON PAYNE: stated that he did not want to be misunderstood, that he did
not mean to take credit away from the Red Cross.


LIEUT. BOONE: stated that the discussions had gone afield, that real social
service work is summed up in four or five heads—securing social
histories and other data for the use of tuberculosis specialists and
psychiatrists, securing reports on home conditions for help of
physicians in deciding whether or not to discharge a patient to his
home, corresponding with home communities to adjust home situations,
thereby making it possible for patients to remain in hospitals, and
arranging through local communities for men who return home to have
proper care and assistance in adjusting themselves to civilian life. He
believed a great deal of this entertainment work should be separated
from social service.


ADMIRAL STITT stated that the question had been considered by the Federal
Board of Hospitalization, and it had been recognized that only the Red
Cross has this tremendous machinery and it was considered that the Red
Cross is the proper agency and organization to take care of that sort of
thing. The Red Cross should coordinate and control these outside
agencies. He announced that the next discussion would be on
“Disciplinary Regulations”.


DR. KLAUTZ took up first that in tubercular institutions the rules must
always be stricter than in the general government hospital. He
emphasized the fact that tuberculosis in a civilian is the same as in an
ex-service man, that the same methods of procedure must be applied in
treatment, and that the patient must recognize the importance of
discipline in the tuberculosis hospital.


SURGEON DEDMAN stated he had taken part in the compilation of General Order
#27, and that he found one flaw in it now. This was the clause about
giving a man his transportation. He believed that a man would soon get
restless and if he could get his transportation home against medical
advice many of these men would get some wonderful home trips. He said
this would make it one of the hardest things on earth to keep sick men
in bed. He said the only way for this to be done would be to deduct the
transportation from the man’s compensation. He stated that General Order
27 had put Commanding Officers where they could sleep at night, that
before there was simply turmoil and strife, like the boy in France whose
wife, every time she wrote to him, nagged him, and he of course was
never anxious to get her letters. Finally he wrote to her “Dear
Maggie—Received your last letter. For God’s sake don’t write me any
more. Let me fight this war in peace!.”


DR.LLOYD: referring to Dr. Dedman’s complaint, stated that in the case of a
man discharged for disciplinary reasons the man would not have the means
to get home, and the community would have to take care of him, that it
was a choice between two evils. In the case of a man who goes home
against medical advice, if his transportation were not paid he would
just do something and get fired for disciplinary reasons. He asked for
some further discussions on the matter of patients being sent back to a
hospital when they ought not to be.


SURGEON MILLER: referring to General Order 27, stated that in his hospital
the patients were willing to pay their own transportation, and would go
whether it was paid or not.


ADMIRAL STITT: asked that those who wished to present resolutions be writing
them.


DR. GUTHRIE: requested that the medical officers who have complaints in
regard to General Order 27 and do not have time to express then write
them out and he would be very glad to have them sent to him.


SURGEON WHITE (Speedway Hospital): asked whether, if a patient stays away
over night A.W.O.L., paragraphs 3 or 4 on Page 3 of General Order 27–A
would apply.


ADMIRAL STITT asked that Dr. Lloyd answer that question.


DR. LLOYD: suggested that if patient stays away less than 24 hours mild
disciplinary action might be applied, if longer than 24 hours he should
be disciplined, that these matters were covered in the paragraphs
referred to.


ADMIRAL STITT: “The next discussions will be on “The Relation of District
Managers to Hospitals.””


DR. WILLIAMS: emphasized the point that when a man comes to the hospital he
should be treated for everything that is wrong with him.


SURGEON BROWNE: wished to report a plan in operation in Boston. Every two
weeks a luncheon conference is held, at which are present the Commanding
Officers of the hospitals, the head of the American Legion in the State,
head of the New England Red Cross, and the Commissioner of State Aid and
Pensions. In this way it was possible to straighten out all difficulties
and there is now practically no friction between these departments.


CAPT. ELLIOTT: spoke on the contact with the District Manager here in
Washington, that it was very easy to reach him by telephone and obtain
advice which facilitates the discharge and treatment of patients very
much. The relation of the Naval Hospital with the District Manager has
been one of greatest cooperation, that the Veterans’ Bureau had even
gone so far as to lend a typist and stenographer to help in the great
amount of clerical work necessary in making out papers for Veterans’
Bureau patients.

Another man spoke of the multiplicity of paper work necessary in
connection with the new form adopted by the Veterans’ Bureau in place of
1934–B, that it was impossible to manifold this form and it necessitated
just twice as much work as before. He suggested that the Committee on
Forms consider the feasibility of adopting forms that can be manifolded
and thereby make economical saving.


SURGEON YOUNG: stated that in regard to the relation of the District Manager
he would like to know whether the representative of the Veterans’ Bureau
to be in the hospital is to be there as a man directly connected with
the personnel of the District Manager’s office, or whether he is to be
there as a representative of the Veterans’ Bureau itself.


DR. RAWLS gave the information that the educational director would be a
representative of the District Manager, on the staff of the Commanding
Officer of the hospital, who would deal with the District Office in
matters pertaining to the District and to the hospitalization of the
patient. He stated that it might be that in dealing with certain other
phases he would have a direct channel to the Bureau, but this had not
been definitely decided.


GENERAL SAWYER: stated that the subject of hospitalization most now be
viewed as a much broader field than ever before, that after discussing
the subject of an educational department and social service work with
people in contact with it it was decided to be absolutely necessary to
enlarge the personnel of these hospitals so as to take in these various
new things which were coming up for consideration. He emphasized the
fact that the end result is the important thing, but that in
consideration of all of these subjects it should be understood that
these Red Cross representatives and all other employees will be subject
to the Commanding Officer. He said he was satisfied that most of the
complaint made was by individuals who come into the hospital and do not
come in contact with the Commanding Officer. The whole idea of the
social service relation is that these men shall be made more resourceful
and more capable of earning a living for themselves.


COL. EVANS: took up the number of personnel required, and stated that it had
been approved that the average requirements would be—one teacher or one
occupational therapist for each twenty individuals actually engaged, and
one physiotherapy aide for each twenty treatments per day. He stated
that one might not take care of over five patients, but the basis of
estimation was one for twenty, and that the average would be one to
sixteen if the educational director and his clerical help are included.


SURGEON SPRAGUE: spoke on the value of occupational therapy. He told how
after the introduction of occupational therapy in his hospital in New
York boys who had been very troublesome before became deeply interested
in the work and the wards became as quiet as any other wards. He wished
to express himself as most heartily in favor of occupational therapy.

Another discussion on this subject followed. It was stated that there is
no question as to the direct therapeutic value of occupational therapy.
The disciplinary value is its greatest value. Very often, too, there
will be found a boy who has real talent.


SURGEON PAYNE: stated that in his opinion a simpler method of reporting
should be adopted, that the system of bookkeeping is perfectly idiotic
and that nobody knows just what is meant. He said there was a great deal
of sentiment against the Government having any interest in what the man
makes, and that in many cases the men buy their own material. He cited
the case of a man in his hospital who makes all kinds of toys out of tin
cans and has worked up quite a trade. Public sentiment is all on that
man’s side.


COL. BRATTON: with regard to paying transportation for men discharged for
disciplinary reasons, made the following motion, which was carried;


                                _MOTION_

    That the Director of the Veterans’ Bureau be requested to secure
    legislation so that the expenses of the patient’s transportation to
    his bona fide home, when he has been discharged for disciplinary
    reasons, be deducted from his compensation, when compensation is
    being given, or may be given thereafter.


DR. KLAUTZ: said it was his opinion that it was better to put a man right on
the train and send him home.


CAPT. BLACKWOOD: “In view of the remarks made at this meeting yesterday in
regard to the nurses, and in view of the fact that Congress is
contemplating the question of pay for the services, I would like to
present this resolution:”


                              _RESOLUTION_

    Be it resolved that it is the sense of this meeting that the pay of
    the nurses of all branches of the Government service is far below
    what it should be and therefore is a detriment to the entrance to or
    continuance in those services of the better type of nurses, and that
    it be urged upon Congress by the Federal Board of Hospitalization
    that legislation be enacted to remedy this condition.

This resolution was adopted.


DR. KLAUTZ: offered the following resolution, which was also adopted:


                              _RESOLUTION_

    That a standard procedure be adopted for the treatment, medical
    supervision and control of tuberculous patients in all Government
    hospitals for ex-service men, including uniformity in matters of
    furlough, application of occupational therapy and pre-vocational
    training, as far as it may be possible, without sacrificing
    individualization of treatment.


                  The meeting adjourned at 12:25 P. M.




            _Sixth Session_      Thursday, January 19, 1922.


  Present: Members of the Federal Board of Hospitalization and about one
           hundred Conferees.


GENERAL SAWYER: In arranging the program of this afternoon, we wish you to
consider it as open for discussion for bringing to the attention of the
Conference any subject which you may have in mind.

We have divided the work in this way. In order that we might have some
leading thought from which to start and upon which to base our
discussions, I would remind you that in the n.p, and tubercular case,
the Government has its greatest liability.

I would remind you also that particularly in the n.p. case the medical
man has his greatest responsibility.

We have learned by comparison month by month since taking over this work
that the general medical case has already become a quite rapidly
decreasing case in numbers. We find, however, that the mental case and
the tubercular subject are both increasing in number. We realize that in
the general medical case ultimately we must get to a place where we
shall have finished largely with that character of case.

But with the n.p. case we know that so long as we have a remnant of the
World War Army in existence, we have these neuro-psychiatric cases under
our observation.

I would like to charge you, while I have this opportunity, with this
particular responsibility on your part, and I would like to tell you how
I think you can do greater justice to the soldier and how you can
certainly help your Government best in considering this subject.

For myself, after a very close personal contact of ten years in the
specialty of treating mental and nervous diseases, I am satisfied that
in 99% of all of these cases,—perhaps that is a little strong,—I should
say in 90 per cent of these cases you will find, where the case is
genuine, that you have some physical cause at the bottom of the mental
trouble.

Therefore I wish to suggest that in the consideration of this case, that
you never allow one of them to pass you excepting you give him the most
careful examination; that you go over him in the most thorough way; that
you look into his case, so far as his history is concerned, taking into
consideration the decade in which he is living; go over it with every
laboratory refinement of diagnostic assistance that you can possibly
give and see if you cannot find somewhere some physical trouble that is
behind the mental symptoms.

For myself, I am convinced that there is no case, excepting those that
have gone on to the degenerate class of diseases, which usually appear
after fifty, but has some physical derangement the overcoming of which
may help very materially in the curing of the case.

So I would like to emphasize this thought: that you have not exhausted
the service that you can render, you have not relieved yourselves of the
responsibility, you have not acted as loyal doctors of modern times
should have acted, excepting that you take the greatest care in the
preliminary examination of these patients.

And then I would like to emphasize also that your preliminary
examination, by comparison with frequently recurring examinations, so
long as they are under your observation, will help you very materially.

I wish you to know that I am impressed with this idea. This is what I
believe:

That many of these cases that come to you will be better off outside of
institutions than in them, and I want you all, all of you, to help us to
try and correct this impression that is now existing, that the
Government does not give this class of cases proper attention.

If the Government is not giving them proper attention, it is not because
of their disposition to do so, but it is because they have not had time
enough to develop resources by which they can handle these cases well.

I would feel that I have not performed my function here as a doctor if I
did not say to you to be thus careful in your diagnosis and then help to
work out a plan whereby, if this subject cannot be made well, he can at
least be made more self-dependent. Use all of your influence to help to
cite where these men can find niches into which they can go and make it
possible through the influence you can bring to bear upon the people who
are associated and connected with them that they are better when they
really are established in their homes. There is no case in the world
that is more unfairly treated than the neuro-psychiatric case. We all
know that by many experiences and observations. So let us give
particular and special attention to this subject.

They say to us we have no specialists in this line. I am not so sure but
we are better off for that. This is what I do believe: that every man
who has broad experience of a general practice of medicine is competent
and capable of quickly developing himself to conduct these cases along
carefully.

You have no greater field, men, either for yourselves, for the patient,
or for your Government, than in this field.

Now as to the tubercular case. The error we find in the matter of the
tubercular case is this: We find a great many cases are diagnosed
tubercular when really they are not,—a very bad impression, as you can
imagine, to give to any subject. So let us be very sure, let us leave no
influence, or power, or activity unused that will help us to define the
exact attitude of these cases.

We know, as was related here yesterday, that many of the so-called cases
of shell shock are really due to other causes. This is my own
observation of those cases, we had a number immediately after the war,
at the Institution with which I am connected, and we found a most
invariably these men were the subject of the toxemias of fatigue, and by
relieving the toxemic conditions, whether it be uremic infection, or
what not, these cases soon got well and their mental symptoms soon
subsided. So be sure that you be perfectly fair with these men, and you
are never fair with them until you have exhausted every resource in
discovering whether or not, as the basis of their mental or nervous
disturbance, there may not be some physical condition.

The meeting is now in charge of Dr. White.


DR. WHITE: I hope there will be free discussion of this matter. There are a
good many men who have had charge of neuro-psychiatric hospitals, and I
hope you will feel free to get up and briefly set forth such vital
problems as you may have in mind. In order that we may cover as many
problems as possible, I will, with your permission, let you know when
the five minutes is up, so we can cover the ground as fully as possible.


DR. KOLB: In relation to the examinations made of these neuro-psychiatric
cases which were sent to us, I want to outline the procedure we use at
Waukesha in arriving at correct diagnosis and methods of treatment. The
patient is given to one special doctor. This doctor is supposed to make
the first preliminary examination, which included a complete physical,
neurological and psychiatric examination, and do all the work in
connection with these patients while in hospital. In making this
examination we have on our staff a number of very competent attending
specialists in order that we can obviate the mistake General Sawyer has
mentioned of assuming that these men are simply neurotics and passing
over important physical conditions. By this method we have caught a
number of cases which have been passed over as cases of neurasthenia.
For instance, I have in mind a case diagnosed neurasthenia which was
treated six months ago, which was a case of brain tumor.

After we have made the first preliminary examination the man is
carefully observed in hospital, not only by his own officer but by the
clinical director, and notes are made from time to time. Examinations
are also made by the dentist, x-ray examinations and various laboratory
examinations, including serological and base metabolism. In the end,
after all the data is assembled and written up, he is brought to the
staff and there his case is thoroughly discussed by all the members of
the staff; a diagnosis is arrived at, methods of treatment discussed and
afterwards put into effect.

Now as to the organic conditions with which our neurotics suffer. It is
true a large proportion of them do have organic disorders in connection
with their neuroses. We find that most of them do have functional
disorders originating purely in their mind, or because of some
constitutional nervous defect and that the real fundamental condition
from which they are suffering is not an organic condition but is nervous
or mental and must be approached along lines of psycho-therapy.

Now I will not go into the subject of psycho-therapy. We pay special
attention to mental questions but we do not neglect the physical by any
means. Every physical disorder which is found is corrected, if
correction is possible. We have complete physio-therapy and occupational
therapy and all other facilities for treating nervous cases. We are
careful never to stress too much on the physical treatment we give these
patients, because by so doing we suggest to them conditions they really
do not have and by that means prolong their functional disorders.

Regarding occupational therapy. We all know that this is a very
important method of treatment. It should always, as Colonel Evans said,
be directed treatment and should not be given in a hap-hazard way. All
of our occupational therapy treatment has been given a definite
prescription. For eighteen months we have had a bright young medical
officer interested in this subject, whom we have made reconstruction
officer and who observes the effect of treatment and changes the
prescriptions of the other physicians when he finds the treatment given
does not have the desired effect.

With reference to reconstruction aides, every week our reconstruction
officer gives them a talk on some phase either of occupational therapy
or physio-therapy or of mental disorders. We cover any subject in which
the neuro-psychiatrist should be interested. This officer has devised a
system of observation which the aides are supposed to make on patients
and which they do make on each patient who takes occupational therapy
and which is looked over by our reconstruction officer and the officer
in special charge of the case. We are getting up data and statistics
which we think will be of interest to the general profession when it is
finally published,


DR. TREADWAY: I think that the Public Health Service has had a very grave
and serious problem affecting the N.P. Veterans of the World War. We
have included in that term, besides the mental and nervous cases, the
neuro-surgical cases as well.

There are a number of problems which still confront us, and one of these
is the question of personnel. I am sorry that Dr. Kolb did not say
something about the training school he had started in connection with
his hospital. We sent some young officers over to learn technique and
methods of handling the psycho-neurotics. We have also sent some
officers to the Public Health Service clinic at the Psychopathic
Institute in Boston and we hope that some of our other hospitals will
start a similar school. The question of personnel is an exceedingly
grave one. A great many young men want to become surgeons.

They are not interested in mental or nervous cases. They want to go into
general medicine. Last year we sent two officers to the Southern
University and to the Northern and Western universities to meet the
graduating classes and the internes, and from that we have been
recruiting some younger men who are manifesting considerable interest.
We hope to get additional personnel by interesting the young graduate.

Another problem is the question of creating, in connection with General
hospitals, wards where patients of this sort may receive at the
beginning of their treatment, their preliminary examination, where they
may be evacuated home with compensation or without compensation, or
evacuated to a prolonged treatment hospital for further care.

It has sometimes been difficult to get enough men, trained personnel, to
man these wards.

We have believed all along that the proper method of treating the
pyscho-neurotic, so-called, is in out-patient clinic and we have
attempted to develop out-patient clinics with the old dispensaries
maintained by the Public Health Service; but the question of personnel
again entered into it, and we were unable to develop as many
out-patients clinics as we should like. We think, however, that the
mild, mental case, as General Sawyer has said, is far better off in the
outside world than he is in an institution. If such cases go to a
hospital, it tends to have their symptoms crystallized and they believe
they are sicker than they really are. In other words, they seek out some
minor physical disability as a peg on which to hang what they think is a
grave disorder.

The question of compensation for these cases is an important one which
must be worked out. The man who believes he is seriously ill when he has
but a minor defect, if he has compensation and has a weak will, will not
make a strenuous effort to get back on his feet. The question of maximum
compensation for these cases many times interferes with rehabilitation.

We believe that this is a new method of handling mental patients and it
may serve as a copy to other States to prevent this enormous building
program which every State has had to go through and which has not met
the needs of the insane.

Compensation for epileptics and their examination is a very important
question and has been a serious problem to us.

We find among neuroses not infrequently mild convulsions. We don’t know
a great deal about these convulsions; some are epileptic and some are
not. The true epileptic, however, has great difficulty in making a go in
the outside world. The number of convulsions per month is not an
indication of his disability, entirely, because the passage of the
Employees Compensation Act in the several States, has interfered with
the employment of men with an epileptic past.

It is as hard for the man who has a seizure once a month to get a
position as the one with four, so the question of treating epileptics is
one largely of social service and compensation.

The hospitalization of epileptics has not been a success in the hands of
the Public Health Service. One of the Western States that built a large
colony for epileptics some years ago has now turned it into an
institution for feeble-minded.

The question of vocational training is also a big problem in connection
with this type of disability. A man, for example, whom I saw a few weeks
ago, had been a jewelry polisher in Boston. Before the war he had to get
up every morning early and go to his work. He gave most of his earnings
to his family. He was suddenly taken out of that situation by the draft
and put into a situation where it was simple for him. All he had to do
was to get up and move around when some one told him to. He was
furnished with his clothing; he was furnished with his food. When he got
over on the other side he painted a rosy picture about how things were
at home. When he got back home it was not like what he imagined it was.
He had to get up and go back to his old job. It was hard for him to make
the effort. He quit his job. He goes to the Vocational people (he had a
seventh-grade education). He wants to become a civil-engineer. Obviously
he cannot. He tries another occupation, etc. Now the attempt of that man
to better his condition is a laudable one, but very often that desire to
get away from a difficult situation is a part of his mental disorder. He
must be made to understand and meet that problem frankly and not be
seeking round-about paths without very much continuity of purpose.
Vocational training in connection with epileptics has not been very
successful. Dr. Ellison who has had charge of a hospital for epileptics
can give us some valuable information on the problems of the epileptics.

I think that Dr. Wilbur, who has had charge of a large station at
Chicago, can give us some valuable information about preliminary
examinations, the social service aspect of these cases, the need of
social service and the handling of the psychoneurotic in out-patient
clinics. Dr. Wilbur and Dr. Chronquest can tell us about the problem
affecting the insane. Mr. Chairman, I suggest that you call on them.

Dr. ELLISON: I want to say the program as outlined in the afternoon
session is one of vital interest to me, because I have been in charge of
one of the most problematic Government Institutions in the country, that
is, an epileptic hospital in East Norfolk. The administrative program in
hospital of this kind, taking into consideration the application of
general orders, hospital regulations and internal regulations as within
the hospital, is entirely different from any other class of hospital
under Federal control.

The very fact that you attempt to apply certain regulations in a
hospital of this kind where the morale is naturally at a low ebb, due to
the mental phases under which these men are suffering, sometimes results
in disaster and the breaking down of the morale you have in the
hospital.

I would like to go on record in stating it is my belief that voluntary
hospitalization of the epileptic is anything but desirable.

From the standpoint of rehabilitation of the epileptic, I must take into
consideration the particular type of epileptic we have in the hospital.
As Dr. Treadway stated, the majority of these man have not reached
probably the school grade of seven years. There has been an attempt on
the part of the rehabilitation department to make lawyers, doctors,
diplomats out of these epileptics. It is absurd and cannot be done.
These men are social and economic lepers, so far as their rehabilitation
is concerned. The communities do not want them. Their families do not
want them and the responsibility for their care rests upon the
Government. Then what is to be the solution of the disposition of these
men? I can see but probably two solutions to the question. Voluntary
hospitalisation is out of the question. I believe that that part of the
Bureau concerned with the compensation of these men, from an economical
standpoint, must take into consideration the question of the grouping of
these epileptics. There is a class which can live at home. There is
another class, not definitely formidable, which does need custodial
care. Then there is the psychiatric epileptic who needs psychopathic
institutional care. In arriving at the disposition of these men you must
take into consideration those three groups.

Then there is another group, there is a mixed group of epileptics. In
many instances we have noted, after a long period of observation, that a
man may react to some situation, starting out in a hysterical seizure
and wind up in a definite epileptic attack. That has been true in quite
a number of cases and I should like to urge upon the Bureau District
officers and those concerned, this one thing:

In referring cases to East Norfolk, I think a very careful examination
should be made of these men to determine as nearly as possible that they
are epileptics.

At East Norfolk there is a situation existing which I have endeavored to
correct; that is hospitalizing psycho-neurotics,—neuropsychiatry cases
which are not definitely epileptic, which are made worse by contact with
the epileptic patient. These men are being made worse every day. Some of
them simulate very closely the epileptic; many have learned to bite
their tongues as the epileptic does. They should not be hospitalized;
about 25% of the cases are not epileptic. I think that should be taken
into consideration and a careful survey made of these patients before
they are transferred to East Norfolk.

As to these cases, very much the same program is carried out as Dr.
Kolb’s. Complete preliminary physical and neurological examinations are
made and patients are placed under observation of one man, who observes
them and makes notes from time to time. As for the treatment of these
men, there is little to be done in a way. I think it resolves itself
into occupation mostly. I think the occupational measure as applied to
the epileptic is the only solution. I think they should be kept busy
every moment, for many reasons. They are naturally fault finding and if
they have something to do it will lessen the time they have to think of
these things. It will promote interest in their surroundings. It will
lessen the liability of deterioration but as the thing now stands that
cannot be done, under the present method of hospitalization. The
solution covering that is, I believe, for the Government to formulate,
properly taking into consideration these districts, and build an
epileptic colony, under proper supervision, and I believe from an
economic standpoint, it could be made almost self-supporting.

In regard to the medical treatment, we have been instituting at East
Norfolk a very careful treatment,—careful observation—to determine the
real value of luminol in the treatment of epilepsy and we have found
that it has been beneficial in many ways; that it lessens the severity
of the shock, prolongs the intervals between shocks and in many
instances effects complete cessation; the patient becomes more alert,
more active, more interested in his surroundings. This treatment must be
continued day after day. If there is a cessation, or lack of it, or a
failure or inability on our part to obtain luminol, these men
immediately react to the lack of it. I should say we have had at least
four deaths at East Norfolk due absolutely to the lack of luminol.


DR. WILBUR: At Chicago we developed a diagnostic clinic at the Marine
Hospital and had two departments: in-patient and out-patient
departments. We had a capacity for in-patients of about 150. The
out-patient department was unlimited and developed to approximately 160
to 175 patients at one time. The in-patient department is divided into
five groups for the investigation of cases;

1. Cases which would be immediately transferred to some other hospital
as soon as arrangements could be made;

2. Certain disorders taken up under direction of an officer particularly
interested in such disorders and investigated as fully as possible;

3. Hyper-thyroidism, following operations, where the pulse is still
high. When such cases were sent to us, an attempt was made to stabilize
the patient and bring him down to a nearly normal basis so that he could
go out and take Federal Board training.

4. Psycho-neurotics.

5. Epileptic and hysterical cases.

I might say that out of every fifteen cases sent in with diagnosis of
epilepsy, about twelve or thirteen of them proved, after careful
observation for a period of from two to three months, to be hysterical.
That was about our ratio on cases sent in.

Our procedure was much like Dr. Kolb’s at Waukesha. The man was given
complete physical, neurological, examination first. We had a special
consultant who visited the hospital about once a week. After a man had
his examination, he was checked as needing further examination in eye,
ear, nose and throat, or x-ray,—whatever was indicated in the case, and
that was tabulated on the chart and checked against his examination. At
the end of that time each ward surgeon prepared a summary of the case
and a decision was made as to whether the patient needed a short term of
treatment in our own hospital,—we had there occupational therapy and
other methods of treatment,—and then be discharged and sent back to his
home.

In connection with the in-patient hospital work, we had a committee at
the district supervisor’s office made up of one representative at the
Bureau of War Risk Insurance, one from the Federal Board, the
neuro-psychiatric contact officer and one representative from the Public
Health Service. We tried to place the men in some definite schedule,—the
Federal Board, if possible, after he was discharged from the hospital,
and we would bring our problem cases to this meeting, where they would
be taken up and such arrangements made for their further treatment as
necessary. The contact man visited the station once or twice a week to
familiarize himself with the problems of each man.

The out-patient department was naturally on a different schedule; that
is, certain hours of the day were set aside and definite offices
assigned to the out-patient department; they kept track of their own
patients, who reported in at intervals of two or three times a week,
every two or three weeks, according to the needs of the case. If the man
needed some special treatment, he came into the hospital for that
treatment and at the same time he saw this ward surgeon and talked the
case over with him. Just as soon as that patient was ready for
vocational training, he was put into touch with our contact officer and
a schedule was made out for him.

In regard to the vocational training for epileptics, a great many cases
during the year I was at Chicago, came up to that board for
consideration. We tried the epileptic at various occupations; kept him
away from machinery so as no injury would come to him, and we succeeded
in rehabilitating only two epileptics out of the whole group. These two
were given positions in factories that were owned or governed by some
relative or friend who had taken an interest in then, disregarding the
compensation laws and disregarding the inability of the men to work when
they would have a seizure. In two instances only have we succeeded in
putting men into training where it proved a success.


DR. MCLAKE: I represent the National Sanitorium in Marion, Indiana. Presume
all of you have heard more or less about it. It was organized about a
year ago; opened on the first of January as a sanitorium. During the
past year we have cared for about 1500 patients. The present Census is
800.

Now this institution was opened under a provision that it was to be used
for the hospitalization of reasonably curable cases. In other words, it
was not to be an asylum. It was not a place for merely domiciliary
residence or custodial care. The needs of hospitalization, however, this
year, have been such that we have taken all sorts of cases. As this has
been a matter of discussion for many hospitals and in many districts, I
want to take half a minute to show you that during the past year and at
the present time, I am hospitalizing at Marion nearly every variety of
n.p. case which we have.

Up to the present time we have had no special accommodation whatsoever
for n.p.-t.b. patients. Our institution is built on the cottage plan and
in the preliminary survey and construction no provision was mode for
t.b. patients. However, at the present time I have one ward which is
filled with eleven of these cases. I may say in this connection that we
are expecting to build a t.b.-n.p. unit of eighty beds and will start
construction in about five or six months, which will be gratifying to
you men who have these combined cases and would like to unload them and
as soon as we can take these cases off your hands we will be glad to do
so.

In that connection I want to emphasize one thing: that in your general
hospitals and in your t.b. hospitals you get many cases toward the end
of this t.b. condition, which present n.p. symptoms. Now I know from
experience at Fort Bayard and in other t.b. sanitoriums, especially at
Fort Bayard, where I was associated several years with Colonel Burke,
that these patients become exceedingly troublesome and exceedingly
annoying. However, if you are perfectly frank with yourself and
perfectly frank with the n.p. man, you will admit that these cases are
not primarily n.p. cases, but cases of terminal toxemia. I don’t believe
myself that these cases should be hospitalized as n.p. I believe in your
t.b. hospitals you should set aside a ward or two or three wards where
you can take care of your terminal toxemias whose symptoms are
principally mental; they should not be unloaded on the n.p. hospitals
which are built and equipped for reasonably curable cases of n.p.
disease.

As to what General Sawyer said about many of these n.p. cases living
outside. I want to most heartily indorse that attitude, and I will say
in that connection that during the past year I have turned out between
two and three hundred men because I firmly believe in that view. My
method for turning out these n.p. cases is as follows:

After a final conference on a man after preliminary observation, if we
feel that he has come to the point where he should be given a chance, we
give that man a thirty-day parole. If he has a guardian, his guardian
must report every ten days. If he has not a guardian he is placed in
communication with the Veterans’ Bureau officer, or a Red Cross worker
in the District, in which he is paroled.

In other words, during the first thirty days I get three reports as to
his condition. If after thirty days he is still doing well, I grant an
extension of thirty days. During the second thirty days he reports in
twice. If he is still doing well at the end of sixty days, the parole is
extended to ninety. I believe in the majority of our cases that if a man
makes good for ninety days, it is reasonable to suppose that he is going
to make sufficient adjustment to stay outside of the institution. If, as
I said, his report at the end of ninety days is a good one, he is then
discharged from the Institution, with the privilege, of course, of
returning. Now of all the men I have sent out under that scheme this
year, I have had less than eight per cent of returns, and I consider
that in the first year a fairly good average.

I want to commend that scheme to every man who has charge of an n.p.
hospital and after this conference adjourns, I would like to correspond
with you on that subject. I would like to compare notes because I
believe it is worthy of attention.

There is one other thing brought up in a previous meeting and that was
the question of our constitutional psychopath, and drug addict and the
building of special hospitals for these men. I personally am not in
favor of such a scheme and I will tell you why. I have a considerable
number of these men. I believe that every complete n.p. hospital should
have a department with definite numbers assigned from the staff who are
particularly clever in handling this line of case. I think that they
should be handled in your regular n.p. hospital as a separate unit.

Now there is just one thing in connection with that statement I wish to
emphasize. There are a certain number of these men who do eventually
make an adjustment. For the sake of that percentage alone we should not
place the stigma upon them of being sent to practically a penal
institution, and that is what it means if you set aside a place and
brand it as a place for those of criminal tendencies and drug addicts.
We tried that in New York and you all know from the papers what it
resulted in.

There has been another plea. Dr. Treadway spoke of the shortage of
personnel. It is acute everywhere in every department. Then on top of
that comes the plea from the general hospital men, from the t.b.
hospital men, for neuro-psychiatrists to be assigned to his staff. That
is a physical impossibility. There are not enough n.p. men to go around
and I have a solution of that which I have put up to numerous men and
that is just this. Along with what General Sawyer said today about every
one’s being a well-rounded out man, every man who has charge of a
hospital, every man who is on the staff of a hospital taking care of
ex-service men ought to go down and buy a copy of White’s Outlines and
study it for the next six months. If you will do that you don’t need
specialists on your staff. You can make a near enough diagnosis so you
will be reasonably certain in 95% of your cases as to whether they ought
to be sent to an n.p. hospital or not.


DR. FULLER: I an particularly interested in the question of personnel. The
shortage of neuro-psychiatric trained personnel and physicians is a real
and very acute problem. We have any number of vacancies for such men in
the Public Health Service at the present time. I dare say the same
conditions exist in the Army and Navy. I believe that the only way of
solving the problem that Dr. McLake spoke of is for the Commending
Officers of those hospitals who have one psychiatrist on their
staff,—and practically all the large hospitals have one on their
staff,—to insist that these psychiatrists interest other members of the
staff. The fact that Dr. Treadway brought out, that most young men are
not interested in psychiatry is due to the fact they do not know
anything about it. I was one of the men who visited the schools last
year. I was suddenly confronted by statements made by the deans or their
assistants: “Oh, neuro-psychiatry, I don’t expect you will get much
enthusiasm from any of the schools on that subject, because that is a
post-graduate subject and we don’t make any attempt to teach it during
the under-graduate years.” Any number of young men who will state a
preference for general medicine can be interested in this subject about
which they know nothing. The solution, therefore, depends upon the
commanding officers of these hospitals and upon the psychiatrists on
their staffs; depends upon their willingness to detail one or more young
men to the psychiatrists, who are interested in the subject. I don’t
believe that the problem is going to be solved in any other way because
there are not enough men outside who are willing to come into the
Government service, who are interested.


DR. MILLER: We have a specialist at Oteen who lectures to our entire medical
staff Tuesday and Friday of each week. They are very much interested in
it and we think it is a very great benefit to the institution and the
patients.


COL. EVANS: What are you going to do with the group the doctor describes
that ought to be in a colony? What are you going to do with the mentally
deficient who will never be able to carry on? There is no appropriation
available for that group. If the Soldiers’ Homes are not properly
supplied with means or some other special effort made, every community
will have these individuals as a reproach upon them, and it occurs to me
there is no group of men that would be as able as this group to have the
propaganda go forward that there is a problem to be solved in these
cases.


DR. WHITE: I had this in mind about some of these difficult problems, some
of these border-line cases I didn’t have a chance to speak of the other
morning. I suggested there in just a word that in connection with these
disciplinary measured such as have recently been promulgated in this
order we got this morning, No. 27–A, probably we shall have to come to
some form of disciplinary treatment with a considerable group of these
border-line cases, and the plea I wanted to make was that discipline
should not be used as discipline per se, but that we should seek for all
of the possibilities that are incorporated in disciplinary measures
which can be brought to bear upon the patient for his welfare; In other
words, if we can make out of discipline a therapeutic tool.

Now we are dealing for the most part, in these border-line cases and in
the delinquent group, with types of individuals that are more or less
defective. Almost all of them are defective in some sort of way, not
necessarily intellectually defective but frequently on the affective
side; but there undoubtedly has to be some kind of disciplinary pressure
brought to bear.

I have in mind a fellow who is a high-grade defective, who has passed
through a praecox attack, who has come back to comparative normality. He
is a reasonably useful citizen around the institution but he can’t get
on outside the institution and he has periods of not getting on well in
the institution, because every once in a while he will go out and get
drunk. Now what are you going to do with that sort of fellow? Such an
individual does not always stand discipline very well. A doctor came to
me and talked to me about him the other day and wanted to know what
should we do with this fellow. I said, “Shut him up; take his privileges
away from him and watch him very carefully, because I don’t believe he
will stand shutting up very well. When you have made the maximum
impression upon him from that discipline, let him cut.” You have
constantly to shift between severity and almost lack of discipline with
these people to keep them at their level, and you have to realize all
the time it is a matter of very fine adjustment and that after all you
can very easily do them a great deal of harm. Therefore I am always more
or less disturbed by the constant effort that is being made in bodies
like this to standardize all kinds of rules and regulations, because I
realize that in this class of cases particularly there are individual
problems and they must be left for the individual judgment of the
physician who has charge of them.

I have, for example, a clerk in the office, a man who is probably sixty
odd years of age. When he is sober he is as efficient a clerk as we have
in our office, but he persistently gets drunk and stays drunk for days
at a time. Now the easiest thing on earth is to discharge that man. What
is going to become of him? He can’t take care of himself. He has a
family dependent upon him. That would mean to pauperize him and make him
a public charge. I developed some time ago a method of dealing with him.
I penalized him every time he got drunk by taking away a certain amount
of his pay. It was hard punishment. He does not get much pay. The result
was I pushed him to the limit, because it cost him too much to drink.
The result was he had longer periods of sobriety than he ever had
before, but he did break down once in a while, and when he did we had to
forgive him.

Now we have to deal with that sort of problem among our employees and
patients, and we are put to it constantly to devise out of our ingenuity
how best to meet it; and one of the agencies at our command is the
disciplinary measure, which, if wisely enforced, can be used to push the
patient to the highest possibility of his adjustment.

Then, in that connection, as to our friends, the morons and epileptics.
I am fond of saying that practically everybody, no matter how defective
he may be, has a certain capacity for usefulness. There is almost nobody
who is, under proper arrangements, a total loss socially. A Moron, of
six or seven years of age, may be ten per cent efficient. He may be ten
per cent efficient under one set at social conditions, maybe fifteen per
cent efficient under another set. He may be total loss under other sets
of conditions.

Now a lot of these people, like the young fellow I spoke of a while ago,
are very useful citizens in the hospital community. They would be a
total liability outside that community. We have always had these people
in the community and we always shall have them probably. It is perhaps a
worth-while endeavor to try to get the community, through these various
social agencies, to appreciate them for certain values. One of the
medical officers of the Army was discussing with me, a while ago, this
problem in the South, in the cotton mill districts, where there is a
large number of mentally deficient people. They do not do much of
anything, except perhaps, drink whiskey, breed and make trouble. They go
into the mills and either get injured or discharged. A lot of that
material is really capable of utilization. The mental defectives, as a
whole, are fairly good natured and tractable. There were lots of mental
defectives in the Army, enlisted men, who carried on and made good
soldiers. Some young fellows went into the Army from the School of
Feeble Minded, in Massachusetts, and had excellent records. The
Superintendent there kept track of his feeble-minded boys in the Army,
and they made excellent records because they belong to that type of
individual which has a very strong leaning upon persons in authority and
will follow his officer like a Newfoundland dog his master, will obey
orders to the letter and they make most valuable persons. So this
officer suggested to me that these feeble-minded groups running around
might be assembled into industrial units. They could be worked in
factories. In order to avoid the possibility of exploiting that type of
labor they could be employed under proper social conditions and placed
under the eye of a neuro-psychiatrist; and where there was an immense
shortage of labor, perhaps factory owners would be pleased to get these
men.

In other words there is a lot of this defective material which exists in
our society today which has absolutely lost motion, which could be put
to a great deal of use if we were wise enough to do it, if public
sentiment would support us and assist. It is easy to talk of that here.
It is another thing to get public sentiment to help us. There is no
longer hospitals organization than this in the world and perhaps the
hundred hospitals represented here might do something to bring about
that public sentiment. So I am disposed to look at people not from a
strictly diagnostic point of view to look at them from the social point
of view as to the possibility of their becoming useful to a certain
degree as social units and the possibility of society metabolizing them.

Just one more word. There has been an enormous amount said the last few
years on heredity, and there is a great deal of feeling that there is a
great deal due to heredity. The study is very interesting,
scientifically very important, but the only attitude we should assume is
to practically throw out of consideration the whole question of
inheritance. If you are going to say this fellow has got a certain
disease, and you are going to conclude it is inherited, that is a
fatalistic diagnosis and the tendency of the diagnosis is to hamstring
any effort that may be made in his behalf. The only way we can find out
the percentage of salvageable material is to endeavor to make the
adjustment. If we put them down as hereditary, our inclination will be
to throw them out of the possibility of consideration. We should rather
stress the possibilities to the utmost and find some solution or partial
solution of a great many of these problems.


DR. CHRONQUEST (U.S.P.H.S.): So much has been said that I shall not go on
with the problem. I would mention the Compensation side. I have been
wondering for some time, especially among the neuroses, if by our
present system of compensation we are not tending to make crystallized
neuroses. I do not pretend to answer the question. Take, for example, a
chap who has been in the service, who has done good work, whose social
scale has not been high, whose life prior to service has been, as you
might say, from hand to mouth. He has come out of the service with a
definite, known disability acquired by service. By being hospitalized he
has been compensated justly by the Government; he has received the
treatment to which he is entitled; but during the days of his treatment
he has found that he is able to get along more easily under these
conditions than he did prior to service, and decides that one of the
best ways he can make a living is by Compensation. I do not say that
that is true with all, but it is with some of the cases.

I have wondered whether or not our present system of compensation to
that type of individual was the best, or whether the system of Canada or
England would be better. In other words, they do not put a premium on a
man to go to a hospital. If I am correct, a man gets less money when he
goes into a hospital than when he is out. It is my meagre opinion that
in that type of neurosis, he would tend to fight harder as an individual
to put himself back into a financial, gainful pursuit; and with the
advantages the Government offers him now, especially through
rehabilitation, I feel he could be put on a much better adjustment than
he was before.

Another point which has recently come to the attention of us locally is
the question of guardianship; and I am going to ask Dr. Guthrie if it is
a known fact that two men in the same hospital, with the same
disease—that one will draw his compensation without a guardian, the
other is required to have one.


DR. GUTHRIE: It was our understanding that a man who is a psychotic by
reason of service should at least have a guardian. If that is not true,
I suggest to the Hospital Committee that it is a point for
consideration, as it puts the man in the field between the devil and the
deep, blue sea.


DR. W. A. WHITE: I think the man who has a guardian has one usually because
his people have applied for such. I believe the Bureau never
relinquishes the right to control of the funds, and is not obliged to
pay the funds to the guardian. Legally the patient can be paid if he is
competent.


DR. CHRONQUEST: In looking over histories of cases that come to West Roxbury
and information received, I believe that a point that would be of help
to the service as a whole is the getting of accurate histories. We find
patients being transferred to N.P. hospitals, who have a diagnosis which
is not correct according to the past histories taken, due to the fact
that careful search has not been made in gathering the facts of the
men’s disabilities. At times it may be the fault of the examining
physician. It may be the fault of the social service department. Again,
it may be the fault of the individual, or of the family itself in trying
to protect the patient in question. I believe that those errors, which
are seen every once in a while, should be overcome; and I feel that all
of us, whether Neuro-psychiatrists or not, who have anything to do with
either neuroses or psychoses, should be extremely careful of the
histories and get them complete, detailed and accurate.


COLONEL MATTISON: (acting for General Geo. Wood) The Tuberculosis Section
has to deal with a group of patients,—the largest group that the
Veterans’ Bureau has to handle. I am sure that we have many men here who
are interested in this subject, and I hope we shall have a very free
discussion of the subject. We shall begin by having each subject opened,
and then the program will be given to general discussion. We shall ask
Dr. Stites to open the session on “The Segregation of Cases”.


SURGEON T. H. A. STITES (R) U.S.P.H.S.: This question of segregation of
Tubercular cases is one that has been vexing all of us for a long while.
To understand it at all we have got to review the history of T.B.,—from
the ancient times when T.B. was looked upon as a sort of visitation from
Heaven, and looked upon as a disgrace to the family, on down to the
period when Koch, with his great discovery, found the disease to be
infectious. During that time there came on an organized propaganda for
the control of T.B. upon the ground that any infectious disease is a
preventable disease. This propaganda, as is true of all propaganda, ran
to an extreme. It was so hard for those interested in proving that T.B.
was an infectious disease to impress it upon the public and to compel
them to accept the proposition of its infectiousness, that we went to
the extreme of leading everybody to the idea that it was a virulent
infection; that it was as contagious possibly as some of the acute
infections like scarlatina.

There were those who believed that every case should be sent to a T.B.
hospital, absolutely isolated from his family and the world in general.
Then the pendulum began to swing back, and we came to a sensible
conclusion,—that while T.B. is an infectious disease, it is only
slightly so to the adult; and if virulent at all, it is so only among
children and the adolescent. This being so, we had to change from the
separate and isolated hospital for T.B. It has been accepted that every
general hospital should receive its quota of T.B. patients, T.B. being
one of the most common forms of illness, and that in sending out
patients to a strictly T.B. hospital; they should be sent only after the
presence of the disease has been fully well proven.

The control of T.B. is after all the big problem before all of us in
T.B. work today. I have often heard it said that any benefit that comes
to the individual is necessarily more or less incidental, and that the
big object we are laboring for is the control of the disease and the
care of the general public health. Be that as it may, the problem that
faces us in the care of the veteran of the World War is the actual care
of the sick.

The question of prevention of T. B. must be dealt with, first, upon
educational grounds,—to educate the public and the individual to the
point where we can more or less limit the spread of the infection;
secondly, and perhaps more important,—by a campaign for the improved
living conditions of our people in general, especially in childhood.

As a matter of fact, when you get right down to it, T.B. is a social
disease; it is a social problem even more than it is a medical problem.
We know that when the good Lord made us, he put into us a certain amount
of quality which, for lack of a better term, we have called natural
resistance. If we can keep that natural resistance at a high
point,—build it up,—the infection, though it may strike us, will not
produce the clinical disease, T.B.

In the second place, we come to the actual treatment of the sick. This,
too, is largely a hygienic measure. Since time immemorial, those
interested in T.B. have been searching, have been praying for a specific
cure. Every now and then somebody bobs up with a story of how he is
going to cure T.B. overnight by this or that injection, treatment, etc.
In each of these cases there is a grain of fundamental truth. We have
got to put these things together; and when we get down to the final
conclusion we can not get away from the fact that the treatment of T.B.
is the building up, the bringing back to normal, and in fact if you can,
the reaction to the point beyond the normal, of that quality I spoke of,
natural resistance.

In order to accomplish this, I believe one of the most important points
lies in the word, morale; and to encourage your morale, it is wise to
get your classes classified, and to get your T.B. patients working
together in classes in sufficiently large numbers so that you get that
inspiration that comes from what my friend used to speak of as “the
psychology of the crowd.” The thing the soldiers know as the touch of
the elbow; there is a certain magic in it. It is easier to get farther
when you know that somebody besides yourself is going through the same
thing. I think we men in charge of hospitals feel that. That is one of
the inspirations that comes to me from meeting with such a crowd of my
fellows here. Away off there in the swamps of Louisiana there comes a
sort of feeling, “We are here alone; it is hopeless”. When we are all
here together exchanging experiences, there comes the inspiration, “We
are not alone”.

In your general hospitals you have T.B. beds; have them in sections by
themselves,—not because you are afraid of the spreading of the disease,
not because the T.B. patient is an outcast,—but because you can do more
successful work for the patient, not by segregation, but by classes.

In your T.B. sections, have your sub-divisions; have your places to
which you are going to send your ambulatory cases, your far advanced,
etc. Keep them far apart. Use the class system, but be sure that your
personnel is sufficient, so as not to get away from the personal touch.

Perhaps a little outline of the organization of at least two of the
hospitals with which I am familiar will illustrate my point.

The first essential thing when a patient enters a hospital is a complete
examination. Do not let that examination be routine because it is a T.B.
patient. Do not be satisfied with punching the man in the chest and
sticking your ear to his heart. Have somebody who understands
neurological conditions, test his nerve reactions; have someone to test
his mental reactions, as well as the surgical and general medical. Have
your examination ward in which this can be done.

Next is your general medical and, possibly, observation ward. I don’t
care how you try to keep observation cases out of T.B. hospitals,—they
are going to get in. If a patient, after being in a month, is found to
be a T.B. case, he is apt to say, “I caught it here”. Put him where you
can answer, “You did not get it here. You have not been in sufficiently
close contact with the disease to catch it.”

Have your surgical ward; and then your strictly T.B. section.

Have first your infirmary or hospital.

The T.B. man needs special treatment, nursing care and dietetic care.
One of the chief things to give to a T.B. infirmary is good dietetic
care;—place the food before your patient in an appetizing manner; too
much will disgust him.

Then have your ambulant section and sub-divide it into the section in
which there is clinical activity of the disease, and into the section in
which the clinical condition of the disease is quiescent. By doing this
you can give your people graduated exercises, whatever diets they may
need, periods of rest, and occupational therapy; and you can do it in an
organized, scientific way, and get away from the everlasting complaint,
“You let the fellow in the next bed do it; why won’t you let me do it?”

You have got to study the psychology of your patient. It may be a little
out of the line of segregation of cases. We have heard the talk here of
cases, of hospital management, and all that; but be sure in dealing with
the ex-service man, or any other case, that you do not treat him merely
as a case; that you do not segregate the medical officer in charge. I
find there in the South that one of my life-savers is the fact that my
office door is open to any patient. When I first got to be understood
there was a line-up. I gave an hour every day. Now, since the patients
know that everyone can come to me, I have possibly three or four in a
day. And I don’t do it either by reversing the decisions of my ward
surgeon and my executive officer; I back them up.

                  *       *       *       *       *


DR. KLAUTZ (N.H.D.V.S., Johnson City, Tenn.):

The subject of occupation in connection with T.B., is not only an
extremely important one but an extremely difficult one to administer,
particularly in the large government institution, and especially in
connection with the psychology of the ex-service man, which has been
referred to a number of times. He is apt to misunderstand and to be
resentful toward any application of work; and yet at the same time, if
we are going to measure the results of the sanitarium treatment of T.B.
by the functional restoration to activity and usefulness, we still find
that it results in a great many failures. That has been one of the
complaints on the part of T.B. workers not only in government but in
civil institutions as well.

We still find relapses occurring after the patient has been discharged
from the sanitarium or T.B. hospital. Men go into training, and in a
short time undergo another course of treatment, and so on. The reason
for that is that they have not been given the necessary physical
rehabilitation while still in the sanitarium, while under institutional
protection and medical supervision.

The question of occupation is so broad that it is impossible to take it
up extensively here today. We can point out one or two of the basic
principles in connection with its application in the treatment of T.B.
One very important feature brought out this morning is the
psychotherapeutic object,—the point of view of relaxation or recreation,
that is, giving the man something to occupy his mind and improve his
morale, helping him to forget his home anxieties and anxiety about
compensation.

The second point, or 2 A, deals with muscular reconstruction,—conversion
of recently acquired adipose tissue into working force by rebuilding
flabby muscular tissue which has resulted from the long period of rest.

2 A is the acquiring of a tolerance for T.B, toxins. This is important.
We do know that in the recently toxic stage, exercise or work does
produce a reaction which is shown by a rise in pulse rate. We know that
if exercise is begun in small doses and gradually increased, the time
will come when the patient can be made to take a fairly large amount of
exercise continuing over a fairly long period of time, without
manifesting the symptoms of reaction. Formerly we gave Tuberculin in
gradual doses until we reached the point where the man could take an
injection which surely would have killed him at the beginning of the
course. The main point is if a man leaves the sanitarium before he
reaches this toxin tolerance, he is more likely to break down. This is
the reason for the man’s frequently returning to the sanitarium for
treatment.

The third point deals with applying occupation as a means of training or
retraining the man for some new occupation or modification of his former
occupation; and here is where a great deal of judgment and study of the
individual case becomes necessary. It is very difficult to find out just
what is the best kind of work for the man from a physical and mental
point of view; but the important thing is to have the man try it out and
test it, and begin this physical reconstruction and rehabilitation if we
are to get permanent results from sanitarium treatment. I don’t believe
we have solved the problem completely, and I believe other agencies will
have to be called in.

In this connection the question of dispensary work and social and
nursing follow-up work is going to be extremely important. The man who
leaves an institution ought to be followed up very carefully, and effort
should be made to bring him back to some medical unit for re-examination
at least every two months in order to see if there is any relapse of the
former activity.


SENIOR SURGEON R. H. STANLEY, USPHS (R): It is always interesting of course,
to be told what we ought to do and how to do it, but it seems to me it
would be a great deal more interesting to take the little time we have
this afternoon and discuss some of our real problems, and I mean by that
problems that we as commanding officers of the hospitals have to contend
with every day. I know and you know there are thousands of little things
come up upon which we would like to have advice. There are many problems
I might be able to solve readily; there are others you would be able to
solve. I believe it would be worth more to tell how to get rid of some
of these problems.

I believe that the success of running a hospital rests entirely upon the
confidence that your patients have in you. If you are sincere they know
it, and when they know that they will do anything for you. If you are
not sincere they are going to know it mighty quick and you are going to
have trouble. If you tell the men you are with them, that you are going
to be 50–50 with them, if you call them in and talk to them as you would
to a son, and if you let them see you are not doing it because of a
matter of necessity, you can get by without writing petitions into
Washington.

I found the other day a petition had gone to Washington from my
hospital. It was necessary to discharge two men for drinking. It was
their first offense. They came to me and said, “You have not treated us
fair because it is our first offense.” Just before I left my station I
received a letter which was addressed to these men by Colonel Forbes. In
that letter he said “I have received your petition signed by 27 patients
and asking that the hospital be investigated on account of a few
patients being discharged for drinking. I wish to state for your benefit
that I have given the matter consideration and I am standing right
behind the medical officer in charge.” Leaving out the names, I had
copies made of those letters and placed one of them on the bulletin
board of the hospital.

When I went out to Whipple Barracks there had been some little
disturbance there among the men. They were dissatisfied in various ways
and it seemed like a big problem how to handle these men. When I once
had their confidence I handled them.

I have found this in my experience, that I have never been able to have
a satisfied personnel unless I give them the best I can. So long as you
feed them well you will not have much trouble, because that will keep up
the morale better than any other one thing I know. If you will feed
them, be honest with them, be fair, you will have very little trouble in
running the hospital.


SURGEON J. F. WALLACE, USPHS (R): The subject of entertainment probably
would cover the subject of recreation at hospitals. It is rather hard
for me to describe what recreation should be given at a tuberculous
hospital because it depends on the location of the hospital. At the
hospital at Fort Stanton where I am located we do not have any
entertainment. If any social workers come down there I will be glad to
entertain them, because we have only three visitors a year down there.
That is one of the things in which I would compare our institution with
some of these other institutions.

For many years I have been connected with a large sanitorium where we
had strict discipline and little entertainment. The patients were
satisfied. Our average stay of patients is six months. In looking over
your sanitoriums you don’t find many patients staying six months.

When I was in the Army I was in one of the largest t.b. sanitoriums of
the country. They sent back hundreds of men to this hospital and people
came out and entertained them. They were entertained every night by the
Red Cross with moving pictures, they were entertained in the afternoons
by a local organization; they were entertained to death. These men
afterwards got out and were not satisfied unless they were placed in an
institution which was a social center. After I went out I was Chief of
the Eleventh t. b. district of Denver. I noticed that the men who were
treated at Fort Lyon were a better class to handle because they were not
so much entertained. Once in a while I would talk to some of these men
and ask them if they wanted to get well, as I could tell them a place to
go and frequently I used to send them to Fort Stanton where they could
not be entertained and they could get well.

If you have ever lived in an isolated place, you can appreciate it. My
wife and I had pioneered this sanitorium together for quite a while.
Once in a while we used to go to Denver and we could enjoy any show they
had in Denver, even the 10–cent and 20–cent ones. I have heard men
criticize entertainments at Fitzsimmons; they would swear and walk out
while Madame Schumann-Heinck was singing, because they were
dissatisfied; they were saturated with entertainment. I am against
entertainment for tuberculous patients only in a very mild degree. We
have one picture show a week and they enjoy that picture show. We have
only Sunday School Sunday morning. The minister will bring in a few
amateur singers and the boys think they are wonderful; they are
wonderful; and they will all sing.

I have some fifty War Risk patients at my Sanitorium. I have known them
for three years. I know them all by name. They were kicked out from
Sanitorium to Sanitorium. They came down to Stanton. I went there on the
first of July and no man has asked for his transfer or discharge. I
suppose there is less turn-over of t.b. patients at any place than at
Fort Stanton, where there is no entertainment. These men can go
anywhere. We have a 30,000 or 40,000 acre farm. We try to get these men
interested in the different things in the Sanitorium. On Christmas we
let the men arrange the Christmas trees. They amuse themselves down
there. The men trap quite a number of wild animals, bob cats, etc. and
they are interested in the place we have, which is close to nature. You
would be surprised how little amusement you need for entertainment if
you get away from it. You have got to control these men and direct them
every minute in the day. You have got to give them a task. Have their
hours for rest; their hours for exercise. It is up to you who are
running Sanitoriums to entertain your men. You might lecture to them;
that is entertainment; but don’t have them twice a week or three times a
week. Once in a great while the men are interested in the study of their
disease. Don’t speak to them in scientific terms, let them understand
the disease. They say in the curing of tuberculosis it depends more upon
what a man has from his neck up than what he has from the neck down.
Impress upon them that they have got to live a careful life. Keep people
out who want to entertain them. Your men will be just as well and better
satisfied with little entertainment if you keep them busy all day long.


DR. SMITH, U.S.P.H.S.: I wanted to discuss this afternoon a matter which is
of great concern to all branches of the service, and that is Order 59 as
applied to transfers from hospital to hospital. Order 59 is going to be
watched rather carefully by the Veterans’ Bureau. Order 59 lists
hospitals and gives a certain number of hospitals to each district. A
district manager in New York may take a tuberculous patient and send him
to a local hospital or he may send him away to a certain designated
hospital to which he has blanket authority to send him, Oteen or
Fitzsimmons; but according to Order 59, once they send a man to a local
hospital, the district manager may not remove the man from that hospital
and send the man to Fitzsimmons Hospital in Denver. In other words, it
is worth watching to see whether Order 59 will not rather tempt the
district managers to make a snap diagnosis on the ground and send away
to the hospital to which he has blanket authorization to make transfers,
on the one hand, a man whose disease is so far advanced, that it might
be unwise to send him; or, on the other hand, men with questionable
diagnosis. It will be worth watching. I am sure the Veterans’ Bureau
will desire information on the subject as to whether you who are out in
the tuberculous hospitals will receive classes of patients who are
unsuitable in the usual sense of the word for transfer.

Here is another thing we shall all need to watch and concerning which
the Veterans’ Bureau will I know desire information. Will the practice
of sending patients to the local general hospitals result in a piling up
of patients who need to be transferred and whose transfers will be
delayed. We all know that a transfer is indicated not only for the
purpose of providing a climatic change and we all know that in certain
sections of the country there are provided beds for tuberculous patients
and it is necessary to keep these beds filled.

According to the present practice and strict interpretation of order 59,
if the medical officer in charge of the Naval Hospital in New York has a
tuberculous patient and wants to effect his discharge to Fitzsimmons, he
first asks the district manager for permission to transfer the patient.
The district manager in turn asks the Director of the Veterans’ Bureau;
the Director of the Veterans’ Bureau advises the district manager, who
in turn advises the officer in charge of the Navy Hospital. Now it will
be necessary to watch and see whether this effects an undesirable delay
in making the transfers. The Veterans’ Bureau will desire to be informed
if such is the case.

There is another thing. A patient under treatment at Fort Bayard, New
Mexico, and fit for discharge cannot, according to a strict
interpretation of Order 59 be discharged without invoking the same
authorities who sent him there. In other words, he must take it up with
the district manager, who then advises the man in charge of the
hospital.

Order 59 is magnificent in this, if it works out: that no man will be
transferred from one hospital to another except upon the recommendation
of the medical officer in charge, and you who have had experience in
this matter will know what that means. It means that it is not the man
with the longest and strongest pull who will be transferred but the man
whose transfer is recommended by the officer in charge of the hospital.
We are prepared to assist in every possible way in carrying out that
order but it is necessary for us to watch the effect from the field and
get advices from all hospitals concerned, as to whether this order will
not need modification.


SURGEON F. H. MCKEON, USPHS: Some have stated that they were in ignorance of
the existence of G. O. 27. At Hospital # 64, upon the receipt of that
order we immediately had about one hundred copies made and the entire
hospital personnel was supplied therewith. After that every man upon
admission was furnished with a copy, together with a copy of the rules
of the hospital, for which he signed a receipt. I offer that as a
suggestion.

On Tuesday the statement was made here that a man who is able to take
five or six hours prevocational training at a hospital has no place in a
hospital and should be in training. I think that statement should be
qualified somewhat. It may easily happen that a man who can safely take
five or six hours prevocational training in a hospital would soon break
down under vocational training, for the reason that while he is in
hospital his entire life is supervised; he must take a rest hour; he
must turn in at a given time at night; he is assured of three or
possibly more proper meals a day. Those conditions do not obtain when
that man becomes a trainee and I sincerely hope that the follow-up
nursing system which the Veterans’ Bureau is putting into effect now
will result in a more careful supervision of the trainee’s life, so that
when it is found he is living not wisely but too well he may be given
proper advice and be returned to the hospital before the breakdown
occurs.

This afternoon the subject of hospitalizing the tuberculous veteran in
n. p. hospitals was discussed. I rather think it a somewhat sweeping
assertion to say that every tuberculous individual with mental symptoms
should be hospitalized in a t. b. sanitorium. We will all grant that men
with signs and symptoms of an active tuberculosis disease should be
hospitalized in an institution for the treatment of tuberculous. But to
my mind that does not hold where the disability is clearly a mental
disorder; that man is ambulant. The other man gives no trouble whatever
because he is bed-ridden. I have no doubt that every t. b. hospital
commander here today has had such cases. Your ambulant case, with few if
any indications of active tuberculosis but who notwithstanding is
tubercular, when he develops mental symptoms is not only a source of
annoyance in the tuberculosis hospital but is destructive of morale. His
place is clearly in a hospital for the treatment of mental cases.


DR. M. C. GUTHRIE, U. S. VETERANS’ BUREAU: This matter affects us
administratively from a different angle. Many of the general hospitals
have wards for the cure of tuberculosis. We presume that the turn-over
must be fairly rapid. When men have accumulated in sufficient number and
their disposition is determined as to whether they should go to a
tuberculous institution, and they refuse to go, shall we turn them out
or shall we let them stay?


SURGEON L. M. WILBUR, USPHS: If the transfer is suggested in the interest of
the physical welfare of the patient and he refuses to accept that
transfer, he is interfering with treatment. The regulations provide for
that.


SENIOR SURGEON T. R. PAYNE, USPHS: I don’t agree with some of the t. b. men.
I think a man can make a fight if he is dissatisfied and does not want
to go and I think you will do harm in transferring him. If a man is
home-sick and will not improve, I think he will do very much better to
stay just where he is and you ought not force that man to go somewhere
where he will not be satisfied. A sanatorium is a school to teach men
how to live. In a general hospital you will have trouble in enforcing a
rest hour because there are a great many other men in the institution
who are not compelled to do so. The pass privilege is another thing.
Some patients have but one pass a week and other patients get passes
frequently. It serves to dissatisfy the t. b. men as they felt they were
not on an equal footing. That is the only objection I can see.


SENIOR SURGEON J. E. DEDMAN, USPHS (R): There are several things that occur
to me. In the first place there is the question of food. Of course that
is the vital thing in every hospital. In our hospital, as I said before,
we have a large number of negroes and what you give to the white boys in
the north is not satisfactory to the colored patient. I think it is an
important thing to try to give the men what they want in the way of
food.

When I went to Greenville it was the custom to give the men breakfast at
about seven o’clock; luncheon at 10:30; noon meal at 12 o’clock; at noon
the men were not hungry and were generally dissatisfied with the food;
at 3 o’clock, after the rest hour, they would have another nourishment;
supper was served at five o’clock and as a rule they did not care much
for that. Then we would send over to the wards large quantities of milk
and eggs and bread and butter. They did not need any base balls. They
played ball with apples.

It occurred to me that that was a bad system. We omitted the morning
nourishment and the afternoon nourishment and I substituted an evening
cafeteria luncheon thinking that it was a long gap from the supper at
five o’clock to breakfast at 7. We thereby saved a great deal of money
and since we did that we find the patients think the food is fine. We
also find that they sleep better by taking this light luncheon just
before they retire. I mention that for what it is worth.

The rest hour is important in tuberculosis. That is why hospitalization
is so essential, because men will not take proper rest. We have a
morning rest from 9 to 10, afternoon rest from 1 to 3 and evening rest
from 6 to 6:45. The last period is not universal, and we wonder how you
can get an accurate record of a man’s condition when you do not get his
evening temperature. We find that it has been a great help to us. When I
instituted this rest period from 6 to 6:45 I told the men it was for
their good and although they objected at first, it appealed to their
reason, after they were told why it was done, and we have had no
trouble.

Another thing we have inaugurated along this line. I talked with Dr.
Smith last spring. He agreed to send to our hospital a school for
chiefs. I think this was a most helpful thing, because we had chiefs of
medical staffs come to us and take a course that would tend to make for
uniformity in administrative medical work in our tuberculous hospitals.
I have talked since that time with several of the men who came down to
take that course and I believe every one of them expressed the opinion
that it was very helpful to him to have an opportunity to exchange ideas
and to have the same methods for carrying of medical staff work which
required tact and executive ability.

There is one thing I could not pass by because it is of such great
importance to the Federal Employees Compensation Commission. We have
sometimes employees engaged along various lines, and shortly after I
arrived at the station I found one or two who said they had
tuberculosis. I think it is most essential to see that not only one man
but a board of medical officers examine every employee when he comes
into a tuberculous hospital to make sure that he does not show activity
in tuberculosis so that later he will not have a claim against the
Federal Employees Compensation Commission by saying that he was working
in a tuberculosis hospital and contracted tuberculosis while in the
hospital.

There are many things I would like to speak of. I was very much
impressed with what the doctor said about entertainment. I believe it
helps the morale and is the most wonderful thing in the world. We can
spend sleepless nights building up morale in a hospital and one man can
disturb the entire morale.

In closing I want to say, after all is said and done, the big thing with
us is the backing we get from the heads of our department and from the
Surgeon General. I have known times I felt like throwing up the sponge.
All of us have gone through these moments. The main and only thing that
keeps us up is the encouragement we get from the heads of the department
and I want to take this opportunity to express my appreciation.


GEN. SAWYER: This meeting was called for the week of the 20th, with the
understanding of the Budget Director, General Dawes, that on tomorrow
the Chiefs of the various Departments of the Government were to hold
their semi-annual session and we thought that you would enjoy that
occasion. It has been found impossible in the compilation of the facts
and figures necessary to hold that meeting tomorrow. Therefore it
becomes necessary for us to change our program and I am happy to
announce to you that I feel sure you will have quite as interesting a
program as you would have otherwise, for tomorrow we will have as the
first speaker of the morning, Congressman Madden, the head of the
Appropriations Committee. If you have not heard him I am sure you will
be very much interested both in what he has to say and in the way he
says it. We are then to have as the next speaker of the morning, General
Dawes. General Dawes is remaining over tomorrow that he may have the
pleasure of meeting you personally, and I predict that you will agree,
after you have heard General Dawes, that if you have had no other excuse
or no other compensation in coming to this meeting, you will have it in
hearing General Dawes. For the balance of the program of tomorrow
forenoon, it comes to my mind that possibly it would be most interesting
to you all if we were to take up some of the questions that come to your
mind that have not been presented in this program. This was suggested to
me by one of the gentlemen here who I noticed does not talk much but who
evidently thinks a lot, that it would be to the interest of a good many
if they might bring up some subject that they are particularly
interested in. So we are going to have in the morning a question box,
and if any of you have questions in which you are particularly
interested and will present them at the desk of the Secretary, we shall
try to have them taken up for discussion at this round-table hour
tomorrow forenoon.

President Harding will not be here in the morning. When I spoke to
President Harding to come over and address this meeting, he said to me,
“General, you know Mrs. Harding and I are to receive this body tomorrow
evening.” I am sure that you are going to have in that reception, in the
personal contact with the President and Mrs. Harding, a joy such as you
have not contemplated.




            _Seventh Session_      Friday, January 20, 1922.


GENERAL SAWYER: Fellows of the conference, as I told you yesterday we had
expected this morning to be here with the Chiefs of the Bureaus. I
explained to you why that program was changed. I told you also that you
would not be disappointed in today’s program, and now I am going to
prove it.

America produces many things. It is wonderful in agriculture, in
industry, in commerce, but one of the greatest products of America is
its men, and, strange as it may seem if you will stop to study it from
that aspect, you will find that each State of the Union has its record
for producing certain kinds of men. For instance, from Wyoming we get
our stock men; from Iowa, our farmers; from Indiana, our authors,
particularly our fiction writers; from Ohio, of course, we get our
presidents; from Illinois, a thousand miles from Wall Street, we get the
greatest of financiers. It is true that Illinois has produced more
financiers than any other State, and men who have been at the head of
the greatest banking institutions of the United States have come from
this great corn-raising, middle-western State.

I should like to remind you, before I introduce this speaker, that this
Federal Board of Hospitalization represented last year an expenditure,
in all of their various lines of work, of $750,000,000.00. We have in
our employ this morning something like 42,000 individuals, for which it
is costing us something like $42,000,000. Today we are providing 132,000
meals for the people in the government hospitals and the employees that
are necessary to take care of them. Tonight, if this northern blizzard
continues, it will require 132,000 blankets to cover them; and in the
most economical way in which we can provide for the needs of these sick
men it will cost us—it does cost us—in round numbers, a hundred thousand
dollars each day, with institutions operated as economically as they can
be.

I only relate this that all of you may know and may carry this message
to the country—that Uncle Sam is certainly not stingy; that Uncle Sam is
really putting forth every energy he possibly can to carry out the idea
of the best treatment of the World War Veteran.

This is my story in brief.

I have pleasure now in introducing to you Congressman Madden, Chairman
of the Appropriations Committee of the House.


CONGRESSMAN MADDEN:—

“Mr. Chairman, ladies and gentlemen:

The most sacred obligation we have today imposed upon the Government is
the proper care of the men who came back from the War less physically
fit than they were when they went away. Provision is being made for
their care to the extent that it is possible to make it. I think it may
be safe to say that no country in all the world has been so generous in
its care of its wounded soldiers, as America.

Hospitalization is one thing that we must provide, and we must provide
every necessary comfort for those who gave to the country in its hour of
direct need. We must not be foolish, however, in what we do. We must
have a care as weal of other things as of the men themselves. I think
the American people would be willing to make any sacrifice for the
comfort of the men who served the nation either in the late war or any
other war; and the best evidence of their willingness to do that and of
the willingness of the Congress to cooperate is the fact that we are
spending out of the public treasury for the allotments, allowances,
hospitalization, vocational training, insurance, and other things for
the comfort of these men, 489 million dollars a year; and it is growing
and, as far as I can see, it will continue to grow.

Now we may be doing some things in connection with this expenditure that
are not for the best interests of the men, and I sometimes have doubt as
to whether we are wise or unwise. I sometimes have doubt as to whether
we are managing this expenditure as it ought to be managed,—whether we
are giving the proper care to the moral situation surrounding the
hospitals where these men are being treated. We have evidence before my
committee in the record testified to by those in charge of hospitals in
which these men are being cared for, to show the most demoralizing
situation as the result of the extravagance and expenditure of money by
the men being hospitalized at the expense of the Government.

I have a suggestion to make in this connection. I have no desire
whatsoever to take away from any man anything that ought to be given to
him in the way of service or care by the Government. On the contrary, no
man will go as far as I will to see that proper care and proper
attention is given to every man that served the nation; but I believe
that in the payments we make to these men who are being hospitalized, we
ought to have some control over where that money goes, while they are in
the hospital. (APPLAUSE).

I would suggest two thoughts, either the thought that while they are in
the hospital they must deposit their money with those in charge, and be
allowed to expend only a limited sum, and thereby prevent the assemblage
in the neighborhood of the institution which the Government of the
United States is maintaining for the care of its patriotic men, from
becoming the nest of demoralization or prostitution. You can’t make it
too strong. The facts disclose the situation. Now, we have an obligation
greater than the obligation to care for the man, and that is to see that
while we are caring for them we do not destroy them. (APPLAUSE). We have
got to have the courage to adopt a plan.

Up to the present moment most men connected with the government service
have been afraid to express an opinion in connection with the ex-service
men, lest somebody might become offended at his attitude. (APPLAUSE) Now
I am not one of these men. I believe the time has come when the man in
public office has got to have the courage of his convictions; there is
nobody in the world that people hate so much as the man in high public
place who has not the courage of his convictions. The man in high public
place has got to have sufficient courage to protect the rank and file of
those who are being protected by the Government from the folly of their
own deeds; and that applies as well to the Legion and all other
organizations connected with the ex-service men, as well as anybody
else, for it can.

Now we have a two-fold obligation,—I may say three-fold. We have the
obligation to the men, to give them proper care. We have the obligation
to the Treasury to see that that care is not conducted at an outrageous
expense; and we have the obligation to the Nation to see that the moral
standpoint of the communities in which these men are being cared for, is
not degraded as a result of our attempt to help the men; and the only
way you can stop that is to prevent the men while in the care of the
Government, from having unlimited right to spend the money allotted to
them out of the Treasury of the United States. It would be far better
for them, far better for the community, for the nation, far better for
the future of all if we could arbitrarily take the money away from them
while they are in our control; place it on deposit, and see that it is
applied for some useful purpose for their families after they leave our
care. We can do it. We have the power. Have we the courage? I think we
have, and if you will join me, we will do it! (APPLAUSE)

I think the men themselves will be happier. Their organizations will be
more pleased. You will have some grumbling, but you will have it anyhow.
Far better to have the grumbling when the men are sober than otherwise.
Far better to have the grumbling when men are likely to be contented
than when they are discontented; and I don’t know of any individual more
happy than he who knows that when we get through with the treatment we
are giving him he can look forward to having a bank account somewhere.

You know we are liable to destroy the usefulness of this man. The
citizenship of the future may depend upon our actions, and we must be
careful. The obligation is ours today; it must be somebody else’s
tomorrow; but the transfer of obligation from one man to another ought
not to make any difference. Any man afraid of the obligation to do this
work ought to be transferred, because he is not fit for his job. Public
office is just an opportunity to serve; that is all. The man who is in
public office, who trims his sails to meet every passing wind is not fit
for the job. He must have courage, integrity, purpose in life; and the
man who cannot do the things that are dictated by conscience and right
in a great public office ought not to be returned to it. The man that
cannot feel the consciousness of his own rectitude, but rather the
political bee buzzing, is not fit for a public office; and the men who
are in the great service in which you men are employed have obligations,
wonderful obligations, wonderful opportunities.

We depend upon you for the outline of the plan that we must follow in
our treatment of this great army of patriotic men that have come back,
eyeless, legless, armless, and sick in many other ways; but we must also
depend upon you to cooperate with us in an effort to prevent the looting
of the public Treasury and the reduction of the moral standpoint of the
nation.

You need not be afraid to suggest. We should like to have your
suggestions. We invite them; we welcome then. You need not be afraid to
criticize; we are glad to have that. But we want you not only to
remember that money is a factor as well as a help, but we want you to
learn how to spend money. Most doctors do not know how, especially Army
doctors. I have discovered that. I don’t blame them. Their minds run
along other lines, but somebody has to watch this side of the case.

Now one thing we ought to remember is that the estimates for the
expenses of the Government of the United States for the fiscal year,
1923, sent to the Congress amount to 167 million dollars more than we
have got; and since these estimates came, 50, 60, 70 million dollars
more have come, adding that much more to that which we have not got. I
just want to say to you, gentlemen, right here that it does not make any
difference how many estimates come, there won’t be a bit appropriated
beyond the revenue, and I don’t care from whom the estimates come.

Our job is to represent the tax-payers. Somebody must visualize the
nation. You men visualize the thing before you; you see the local
picture. We see more than that; we see the whole picture; and our job is
not only to see that the rights of those under our care are protected
and preserved, but that the rights of the people who are not under our
care and under whose care we are, are protected. We represent the
tax-payers of the nation. They have been mighty patriotic; they have
been liberal; they have not grumbled; they have paid the price; they
have paid it with courage; and they have shown their patriotism. They
have shown their unselfish devotion to liberty. They are willing to meet
any expense that may be imposed for the proper care of those who fell
before the bullets of the enemy; but they want and will insist upon
proper supervision of the expenditures.

They have a right to that. They have a right to relief from the burdens
of taxation to the extent that we can help to give them that relief; and
it is your job and mine and that of every other man in the government
service,—whether he be a dollar-a-year man or whether he be given fifty
thousand dollars a year for the privilege of service,—to do everything
in his power to make the people of America feel that they are not
misrepresented in anything we may do.

The expenses of the Government for 1919 were nineteen billions; for
1920, seven billion, five hundred; for 1921, six billion, five hundred;
for 1922, four billion, thirty-four millions; but a billion, eight
hundred and forty-five millions of that are in three fixed charges,
i.e., nine hundred and seventy-five million dollars a year for interest
on the public debt, which did not exist before the war; three hundred
and eighty-one million dollars a year for the sinking-fund, which did
not exist before the war; four hundred and eighty-nine million dollars a
year for the care of the men that you are here to represent, for their
hospitalization, allotments, allowances, insurance, and so on; so that
we have that fixed charge in these three items that never existed
before. Our Government in the future is bound to cost twice what it ever
cost before, and so we have everybody in the United States watching
every dollar of expenditure.

We have seven million tax-payers now that pay out of their
incomes,—seven million people watching what we do. Before the war we did
not have any of these people. They did not care what you did; how much
money you spent, or where you got it. They did not have to pay it; it
was not being paid directly. Now it is paid direct, and the more
tax-payers you have got paying into the Treasury, the more account you
have got to have of what you do with the government funds.

I am just here today to say to you, gentlemen, that I know you can help
a lot both in effecting economy of expenditure and in creating a better
condition, from the moral standpoint, in all of the surroundings where
our men are being treated and cared for. You can cooperate by suggesting
to our Committee on Appropriations how we can best meet the situation
that will prevent extravagant waste of money by the men who are being
cared for, while they are in the institutions, and how we can preserve
the funds for them and their families; also, how we can preserve the
moral standards of the institutions.

Why, the statements that come to me are appalling about the low moral
standards around some of these institutions. I heard a good deal about
the Army camps during the war, but it was not any worse than now. It is
for you men to say what we shall do to prevent it, and we want you to
cooperate fairly, loyally, actively, unitedly and promptly, because we
must at any hazard and at any cost prevent any condition that will bring
stench to the institution that we are trying to preserve.

We must not under any circumstances allow the fund that is being used to
preserve the health to the limit and build up the men who served us
during the war, to be used for any purpose that will create scandal in
the nation; and it is bound to create scandal if we do not watch out for
the moral standard in every community.

Now, pave the way. Show us how we can tie the fund up, and help us to
help the people of the nation to preserve the men who are the wards of
the nation. We must not demoralize them; we must not make them
mendicants; we must not encourage them to leave their normal, legitimate
employment to become wards of the nation; but we must encourage these
men in every way that we can to become so useful that they will be able
to help themselves and be willing to do it, and not depend upon the
nation.

If I have been able to express a thought at all here that will be of any
value in the long run, I shall feel well repaid for having come. I know
of no more patriotic men than those who confront me, and no more
patriotic women than those who devoted themselves to the service of the
nation during the war. There are no more patriotic men and women than
these anywhere. They made the sacrifice during the darkest hours. Many
of you men could go out and, as far as dollars go, be much better off;
but you prefer to do a service to the nation.

Now, couple with your medical service the two suggestions that I made.
Let me repeat them,—the up-building of the moral standard, and the
maintenance of an economic expenditure of the funds that may be placed
under your charge.

Thank You.”


GENERAL SAWYER: “Fellows, as an expression of your appreciation of the
presence of Congressman Madden this morning, I would ask you to rise to
your feet, that he may know we believe in him and are for him.”

The assembly responded by standing up.


GENERAL SAWYER: I would lose a great opportunity if I did not take advantage
of this particular moment to say to you that I should like—being a
doctor myself—that we relieve ourselves of the charge of not being
business men. Certainly in the administration of year affairs you have
the greatest opportunity that can come to men now to demonstrate that
you have some business sense as well as professional sense, and to me it
is a great pleasure to have this program this morning because it gives
us a new idea of what it means to think in the language of dollars and
cents.

This administration has great ambitions to develop within the Government
a business organization. The President of the United States believes
that the machinery conducting the affairs of the Government of the
United States is about as complete, is about as capable as any machinery
that could possibly be devised, providing it has a perfect system of
organization and business operation of these affairs.

The experiences of the past have shown that we have gone on in our
governmental affairs without due regard to where we were to get out. We
have depended upon deficiency bills to help us in our extravagance or
our over-expenditures. The time has come when that policy is a matter of
the past.

Realizing that it was only possible to carry on the affairs of our
Government along business lines, the President sought what he
regards—and I know this personally because I have heard him express it
many times—one of the biggest and best and most potent business men of
the United States of America to take charge of the direction of the
budget; and I now have great pleasure in introducing to you, follows, my
dearest, closest friend, General Charles G. Dawes, of Chicago, Illinois.

“Mr. Chairman and Members of the Conference:

The trouble with most of the Government meetings is that they do not
assume the nature of a business meeting. We have something that is
entirely different from the atmosphere which surrounds the meeting of
any private business organization.

In my work down here for this year, I look upon the Government simply as
a business organization and unless I get formality out of my mind, I do
not get close to the people with whom I do business. So this morning I
just simply want to explain—because when you can give the reasons for
the imposition of discipline and rules of action, you make these rules
of action doubly effective.

I want to explain, and grasp this opportunity to explain something of
the working of the machinery which has been set in motion by the
President, creating by Executive Order for the first time, a machine for
the imposition of an Executive plan, and a pressure upon Governmental
business. In other words, the President, for the first time, has assumed
his responsibility as business head of the organization. He has
established certain agencies for the imposition of executive policies
and I wanted to explain something about them.

This meeting, itself, is the result of the creation of one of these
coordinating agencies by Executive Order. And what is involved in this
meeting?

Suppose a private corporation was spending, apart from the interest it
paid on its debts, about one-fourth of all its expenditures along one
certain line of activity. That is what this Government is doing through
the Boards represented here,—Army, Navy, Veterans’ Bureau, etc.
Supposing that business had run along for a hundred years and somebody
would come in and say to the head of the business, “How much money are
you spending on this particular activity?”

“Well, so much, one-fourth of all we spend.”

“Have you ever had a meeting of the heads of the agencies for the
expenditure?”

“No.”

“Well, how do you know you are not duplicating facilities? How do you
know there is any coordination between the establishments you are
building in the securing of supplies, in the hiring of men?”

“We don’t know. We never have had, in this business organization, even a
meeting to discuss the question of proper expenditure of money upon the
standpoint of one corporation as distinguished from five separate
departments of a corporation.”

Now what a ridiculous situation that is and yet that is what has
pertained from the beginning of Government. We have forty-one
independent governmental departments and establishments and each of them
has been going on its own way and the result has been chaos in business,
absolute chaos. It is a remarkable thing that here for the first time in
the history of the Government you have got together the elements to
determine the proper administration of this most important matter of the
care of the sick and the disabled among the veterans of the war. For the
first time it is possible, by this juxtaposition, to properly consider
policies to prevent duplication, to devise ways and means and it is a
comment upon the terrible conditions under which the business of this
Government has been transacted, and that is the first instance where you
could get them all together to discuss a coordinated policy. That has
been so with everything. The meeting never would have gotten together,
you never could have gotten together physically in connection with this
thing unless you had been ordered together by the use of the Executive
power of the President of the United States. Now don’t get that out of
your head,—that underneath this reorganization of government, which is
not to be effected, but which has been effected in this routine
business, there is the idea of force, and if the idea of force was not
there we would not have gotten anywhere in connection with the securing
of these results, which small as they are, represent an immense advance
upon the old situation. I speak now from the standpoint of the
accomplishment of these coordinating boards,—not as predicting something
that is going to be done, but of the result of that which has been done
during the last six months through coordinating agencies such as your
Federal Board, established by the President of the United States through
the use of his authority and running the routine business of the
Government for the first time upon a business basis.

I make this distinction (for Mr. Burke, for instance) as some
misapprehension may be had in connection with this matter of policy. The
Budget Bureau, is not concerned with policy save that of economy and
efficiency. We are concerned with the routine expenditure of money, of
proper conduct of routine business. It is our business to see that when
money is appropriated by Congress along a certain line or policy with
which we have nothing to do, that that money is spent as economically
and as judiciously and carefully as possible in order to secure the
greatest results along the line of the policy imposed by Congress.

If Congress as a matter of policy should pass a law to put garbage on
the White House steps, it becomes our duty, regrettable as it might be,
to advise Congress and the Executive as to how the largest amount of
garbage may be most expeditiously and economically spread on the White
House steps. And that is why we are safe in demanding what is absolutely
necessary, in every business, in routine matters,—a centralized
authority. There is no democracy in a properly organized business so far
as routine business is concerned. It is a monarchy, and if the sense of
responsibility on the part of the agent to the man at the head of the
corporation, who is responsible for the policy, is lost, the business
goes to pieces, and, if a private business, you go into the hands of the
sheriff.

The trouble is that in the past the Presidents of the United States have
not done their full duty and assumed the control of the routine business
organization of Government. The result is, as is always the case, with a
private or public organization, that when the money is spent by parties
interested alone in spending the money, the plan of the unit over which
the spending head presides takes precedence over the plan of the
organization as a whole.

Now that has been exactly the situation in the United States up to this
time, and in dollars and cents, to say nothing of the matter of the use
of facilities, there has been a waste that is incalculable in the past.

Now, for instance, take this. All this is preliminary but it is very
important. Let me talk about human nature in connection with this matter
of taking order,—this matter of jealousy of prerogative. I sometimes
think we ought all to take a course of study in human nature. I
sometimes think that while in the A. E. F. charged by the
Commander-in-Chief with this same job of coordinating separated
services, the independent services of the Army in connection with the
unified business plan of the A. E. F., and afterwards in trying to
couple up the allies in the same line of endeavor, I had a better chance
than most people to see in its full majesty,—if you choose to look at it
that way—that desire for absolute independence,—that willingness to
subordinate practically everything on earth to hold power which is
characteristic of human nature.

When you have to approach independent power, to induce voluntary
surrender, I have found you might as well give it up in advance. There
is nothing a man holds to like this right to exercise power, and the
best illustration of that is shown by the fact that the greatest war of
all ages was fought for four years without a central command. Napoleon’s
44th maxim in war was that nothing is more important in war than a
unified command, under one chief. Everybody knew it, but it was not
until the unnecessary loss of hundreds of thousands of lives and
billions of dollars worth of material that Great Britain bent its pride
and accepted that plain, common-sense provision of unified command of
the allies under Foch. Not until the fourth year of the war when the
allied cause faced annihilation was such a plain, common-sense provision
as that for central command possible to be made for the allies, and the
certainty of annihilation alone made it possible.

Now do you think it is any different in connection with the independent
jurisdiction of these Government Departments, from the independent
services of the Army?

They talked in the past about Interdepartmental Boards, to correct this
old chaos, when they had no Executive leadership. An effort was made
from time to time by Interdepartmental Boards, acting as a committee
without relinquishment of the independent authority represented to
undertake some of these reforms, the necessity of which everybody saw.
Nothing was ever done to amount to anything. Why? They would meet
together and talk and outline the situation and necessity for action
until some question came up where somebody was going to lose control of
something or a part of his jurisdiction by some coordinated action for
the benefit of the whole Government. Then immediately the whole thing
died out and nothing was accomplished practically by any
Interdepartmental Board, where anything vital had to be given up by one
of the independent members of it, whose jurisdiction and power would be
cut down in the interest of the common plan of the Government.

When the President of the United States assumed this central control of
routine business, he did what any man would do in connection with a
private corporation; he called together in conference the business
administration,—everybody connected with the business of the Government
as head of department or independent establishment—Cabinet Officers
correspond to Vice Presidents in a business corporation. Of necessity
they had allowed this disgraceful system of chaos and extravagance to go
on. It was not their fault any more than it is the fault of you
gentlemen, who have been running along independent lines, because you
were not joined together in a system operating under a central
authority. We all were properly subject to the indictment of loose
business methods because the President of the United States had not
imposed a unified plan and system over us nor had he created the
machinery by which this plan would be carried into effect, as he has
since done.

In connection with surplus supplies, every department formerly was
selling its supplies in the open-market, and other departments were
buying the same kind of supplies in open market. In a number of cases
speculators would come and buy our public sales material from one
department to sell it to another department at two or three times the
price. Real estate was being leased in cities right along from private
owners, when the Government had vacant property to rent. This was the
custom also in connection with motor transport. If any Department wanted
something moved and did not have motor transport, it would go out and
hire motor transportation. There was no machinery by which the empty
motor trucks and idle men of the other departments could be used.

When goods were to be shipped, everybody would route them as they
pleased. There was no unified central authority which could deal with
the services as a whole as regards the classification of freight and the
whole transportation question.

The same thing existed in the making of contracts.

The same thing existed in Government purchasing. There was competition
between the Departments, the Departments themselves not being
coordinated. In the Treasury Department alone we found 18 separate
points of purchasing activity. Everything was run in Government business
as if it was composed of 41 separate corporations. How were things
changed for the better? It is all simple enough. It all depended on the
President because he alone had the authority to impose the methods of
coordinating and controlling this great general business, just as he is
coordinating these great activities here today through this Board,
presided over by his appointee, General Sawyer, a co-ordinator.

The plan which the President adopted was simple enough,—just what would
be done in any business organization—without asking for any additional
legislation for additional employees, but by simply taking from the body
of the employees, officials of the United States, those men especially
qualified by knowledge and experience to act as his agents, and then
creating the machinery through which they could transmit his policy and
plan of unified business to the general organization.

It is the simplest thing in the world, and the only possible objection I
have ever heard was urged the other day where it was said that the
detail of Army and Navy Officers for this central work by the President
might not result in giving him the benefit of absolute impartiality of
judgment because of their former connection with the War and Navy
departments. That nonsense!

For instance, in my bank,—supposing I wanted to take a man from the
Discount Department, from the Foreign Exchange Department, or the Real
Estate Department,—what folly to say that I would be justly afraid that
he would not be my loyal and faithful agent in the imposition of a plan
for the interest of the institution as a whole because of his former
connection with those departments of the bank. What folly to say that
the President of the United States with all his power over personnel can
not receive from men detailed for co-ordinating work the same loyalty as
he would receive from men appointed from the outside to come into this
complex machine. And I say now that the plan must stand or fall upon
that proposition. Regarding Colonel Smither, the Chief Coordinator, or
Commander Stanley, or any of these men who have been connected with the
Army or Navy,—so far as this work is concerned, as agents for the
President of the United States, they are as independent as if they had
never been in the Army or Navy. If anybody thinks they are not, let us
give him an example. We have not found anything but cooperation from the
heads of these departments and the heads of these services because their
personal interests lie parallel now with the unified plan of the
government since the President of the United States to whom they are
responsible, is behind that plan.

If the President becomes indifferent,—if he loses his eyes, and ears and
fingers in matters of routine business in the shape of the Chief
Coordinators of the Boards,—if he lets them drift, immediately there
will come the effort from you and everybody else to pull to pieces this
coordinating machinery which alone is able to impose a unified plan upon
the governmental business.

Now why is it necessary for you to accept, without mental reservation,
the necessity of the existence of this coordinating board under which
you act and the authority of the Chief Coordinator of that board as
representing the President? Let me say in connection with this that the
rights of the independent departments and establishments are jealously
regarded under these executive orders.

What I want to impress upon the minds of all is the necessity of these
co-ordinating boards to enable you to do your work properly.

Take it in ships. In coordinating shipping transportation, you have got
to have Mr. Weeks, Mr. Denby and Mr. Lasker in contact in connection
with a decision involving the economical use of ships. How can anybody
get them together without the authority of the President? Suppose I was
expected to call them together without the authority of the President. I
would go to Mr. Weeks for example and wait until the Senators were
through seeing him, and then perhaps because of his personal friendship
persuade him to go over with me to see Mr. Denby. When we had seen Denby
how could we get the two together with Lasker? You could not get
anywhere in this co-ordinating work without a delegated authority from
the President to compel contact between high officials.

In connection with this great work of yours in which you spent last year
three-fourths of a billion dollars, you cannot have it run right without
the existence of this co-ordinating Board,—without that authority to
make a bird’s-eye view of the whole situation,—without that authority to
say why this building, for example, is unnecessary, because there exists
a superfluity of this sort of building in another department. What’s the
use of endeavoring to catalogue those activities in which there is
duplication, in which you have got to have the bird’s-eye view, and
would never get proper action taken, unless you have in existence this
Board created by the authority of the President!

In connection with the rights of your department, for instance, there is
preserved for you at all times in connection with the coordinating order
of the Federal Board of Hospitalization, a right of appeal to the
President of the United States. If this Coordinating Board interferes to
such an extent with the plans of your unit that you think the
disadvantage so great that it counterbalances the beneficial effect to
the government as a whole, the right of appeal to the President is with
you. But for the first time in the government, as you know, there will
be presented to the President by the Chief Coordinator the interests of
the government treated from the standpoint of the Coordinating Board, so
that the President of the United States in making his decision on your
matter has the strongest possible statement of the needs of the unit
from you, and the strongest possible statement of the needs of the
government as a whole from the President of the Board. But the final
authority, of course, is in the President of the United States and he
will exercise it. In all of these orders the right of the head of the
independent unit to a proper examination, by the supreme authority, of
his plan is preserved, and it has been so in connection with all of
these coordinating agencies and with the Director of the Budget.

Let me tell you something as to the spirit of cooperation shown. I have
never had a contest before the President with a cabinet officer or head
of a department in connection with a coordinating action. I have never
had one for this reason. Take in connection with the transfer of
ships,—we have independent agencies for the examination of conditions.
We have the right, as agents of the President, of obtaining information
from any bureau chief or head of a department.

We have, through Colonel Smither’s wonderful organization of course, the
means for securing essential knowledge about these things.

Regarding ships,—we asked the Navy the other day for a couple of mine
sweepers for the Coast and Geodetic Survey. They refused. That was
always the case in the old days. Of course, everybody looks out for the
interest of his own department. Well I called over one of the Assistant
Secretaries of the Navy, and gave him a bird’s-eye view of the
situation.

They had 49 mine sweepers; and they were going out of commission. If
they went to the Coast and Geodetic Survey, they would be kept in
commission and would not deteriorate so rapidly. What is more, if they
didn’t go to the Geodetic Survey, the United States would have to ask
for a million dollars to build new ships.

That matter was taken back and proper attention given to it with this
knowledge of the whole situation and the Secretary of the Navy joined in
the request that the ships be transferred.

It was not the Secretary of the Navy who had really been responsible for
the first decision. It was some fellow along down the line, without the
bird’s-eye view, who has been safe for a hundred years from the eye of a
central authority, thinking in terms of the whole government—doing what
he believed his duty, I admit, in directing things for the best
interests of his unit, but who, without the bird’s-eye view would have
thrown the Government into an unnecessary expense of a million dollars.

It then developed when the Coast and Geodetic Survey people went to get
the mine sweepers, that they were in process of repair; that the engines
were disassembled. Now the Coast and Geodetic Survey had no
appropriation available for repairing work and so the Navy said, “We
won’t spend our money on those ships.”

“Why?”

“Because the President of the United States told us to be economical.”

Now supposing there had not been in existence an agency acting under the
President, such as the one here presided over by General Sawyer which
could see what was really involved in that action on the part of the
head of that subordinate unit of the Navy. Because the Navy wanted to
save a repair bill of $10,240.00 the Government would have spent
unnecessarily $1,000,000 for new ships. Do not think that was an unusual
case! It was almost always so in the old days.

Now nobody has been more anxious than the Secretary of the Navy to
cooperate in those matters but he must have information,—and you must
have the information,—to enable one to cooperate. All that was necessary
for me to do was to write to the Secretary of the Navy, that unless
these ships were repaired out of the Navy appropriation at a cost of
$10,240 we would have had to ask for a million dollars appropriation for
new ships. But what if that information had not been given?

The existence of these agencies is necessary to enable this Government
to be run on a business basis. I have given you a simple illustration in
connection with the ships. We transferred thirteen ships with the
acquiescence of the heads of the departments concerned by simply
developing the bird’s-eye view of the situation without ever taking the
matter up with the President, except for the issuance of the Executive
order by agreement.

The patriotic head of a unit really welcomes this system by which he is
given the information which enables him to run the activities of his
particular institution in the interest of the Government as a whole.

I repeat you must have that bird’s-eye view of the necessities of the
Government as a whole, which alone you can secure through the authority
of the President as exercised through the Coordinator of the Board you
have here. It is absolutely necessary that there should be no
withholding of the spirit of cooperation and loyalty to your
Coordinator. There should be no feeling that your independent
jurisdiction is going to be unnecessarily curtailed and interfered with.
There is the right of appeal, and it is just as important to the proper
functioning of the whole governmental business machine that you have
courageous defense of the department unit as you have courageous defense
of the policies of coordination.

There is no proper room for friction; and so far as the Budget Bureau is
concerned and the coordinating agencies headed by Colonel Smithers, we
have had a minimum of friction with the departments. There have been
transferred over $112,000,000 dollars worth of property between these
departments within the last six months. $100,000 per year is being saved
in the comparatively small thing right here in the District of Motor
transportation.

Anybody who stands against the principle of this thing is a man, in the
first place, who is not intelligent. He is a man in the second place who
is not loyal; and he is a man, in the third place, who is in danger, in
view of the accomplishments of this coordinating work. What excuses are
there for anyone not to give his loyal cooperation to the President of
the United States, who, for the first time, has undertaken to be
responsible for a correct system of routine business?

One other thing in connection with the spirit of economy:—the President
of the United States has asked it. He asked it here in the first meeting
of the Govt. business organization last June at which some of you were
present. That request of his has received response. I find over the
country that for the first time in government, economy has become
fashionable, and extravagance dangerous; and all over the country, in
the post office service, the Army service—in all Govt. activities. There
is the spirit of loyal cooperation under the leadership of the President
in the matter of economy.

We know, too, what you have been trying to do in that way in your own
service is resulting in an immense saving to the Government.

What we need are men in authority to help us find out where savings can
be made. We have only scratched the surface, but it is possible now, as
we get the business of the Government in the proper, organized shape, to
determine where the limit of economy is. We do not know yet, because our
reorganization of routine business methods has not gone on long enough.
We have only been in operation four or five months. It will be a year or
two possibly before the extent of economies can be determined.

But in directing the prevention of duplication, etc., in the general
attitude of being desirous to save, as opposed to the old attitude of
being desirous to spend,—all that means that the Government of the
United States can be run more economically than at present provided the
President of the United States gives his attention to the business
organization and he will.”

General Dawes concluded his remarks, and as he walked from the stage
General Ireland made a suggestion that he say something in connection
with coordination within the limits of a department itself. General
Dawes then said:

“General Ireland asks that I speak about a most important matter. We
cannot get general coordination among the departments unless each
department is coordinated within itself. For instance, we found that in
the Treasury Department there were about eighteen separate points of
purchasing activity. No one man was in touch with all these agencies.
The representative of the Treasury department on the coordinating board,
therefore, could not speak for the eighteen agencies. Therefore, each
institution must coordinate within itself in order that its
representative can properly speak for it on the coordinating board, to
say nothing about the desirability of coordination from the standpoint
of the business of that particular department. Therefore, get your units
coordinated.

In connection with this whole matter of hospitalization, the eyes of the
country are on you, who are charged with this great responsibility. No
body of men in Government service has more complexing situations to meet
than you have. You are surrounded by every embarrassment. In these days,
when the pinhead demagogues are flourishing; when the mere politician is
willing to capitalize anything, even a wounded soldier, to catch votes,
you know that you are liable to have your constructive work unjustly
attacked. To get into the lime-light many men will sacrifice right
principles, and it is distressing to see the antics of the puny men in
public life seeking to ingratiate themselves in public favor in
connection with soldier relief. The demagogue has no hesitation in
attacking those things which are right only provided they happen to be
unpopular. His mind, unlike yours, is not on the real good of the
soldier. He is thinking what the newspapers may say about him.

You must be courageous; you must work for the real good of the soldier;
you must work for the real good of the Government; and I will tell you
something. There is no privilege so great, which comes with public life,
as to courageously stand for that which is right, and in so doing take
castigation from demagogues for doing one’s duty. It all comes out right
in the long run.

In the midst of your discouraging embarrassments, when carefully thought
out measures of sane relief for wounded veterans are often attacked by
unscrupulous men, who thereby can advertise for a little time their
insignificant personalities; if you sometimes are tempted to take the
easy way and join the yelping pack of destructive critics, be comforted
in the thought of that everlasting truth that in the long run the man
who fearlessly does right in public place survives, and the man who
weakly takes the wrong way because it is easy receives only ignominy.”


GEN. SAWYER: It seems unnecessary for me to say, still it is only fair to
General Dawes, that he has injected into the affairs of Government the
greatest enthusiasm and the most interest that has been known in
Government affairs in all the history of the Republic.

His idea of coordination, which came to him out of the trying experience
of the war on the other side has certainly served him a wonderful
purpose in the effects that he has brought about in this new plan of
conducting the affairs of the Administration on a business basis, and I
certainly hope that each of you, as you go back to your fields of
activity, will carry with you the idea that you have a most responsible
position. No matter how small your institution, the responsibilities,
the liabilities and the needs are all the same.

It may interest you to know that in the few weeks this present Board has
existed, we have been able to turn over to the various hospitals of the
country in which we have been particularly and necessarily interested,
in a hurry, several million dollars worth of property. Arrangements are
now in operation whereby in caring and preparing for nearly 11,000 new
beds, we have in mind to avail ourselves of the great resources of the
Army and Navy in supplying these needs; and I must say out of fairness
to the heads of those Departments, as represented by the medical
departments, that more hearty cooperation could not be obtained. To give
you an evidence of something of the difference of today and yesterday,
early last summer an appeal came to me to provide some cots for one of
your institutions. It was impossible for me to locate cots that I could
make accessible for the purpose, and one day one of our own
representatives from this Board looking about found 80 car-loads of
these cots at Des Moines, Iowa. Now when we are in need of cots, we know
where to find them and know how to get possession of them; and this is
true of all the things that are really necessary in the conduct of your
affairs.

I am here to say to you without any fear of contradiction that this
Hospitalization Board has already accomplished some very helpful things,
and we have many more things in mind. One thing we do not assume, and
that is authority. We have no idea or desire of being autocratic in our
administration but we have a firm determination that regardless of any
sentiment or any emotion which may be brought to influence the affairs
of this Board, we will go on with what we believe to be the best thing
for the men we are trying to serve.

I believe that the service we should render and that we must render, and
the only service that is worth while to the veteran, is to make him well
if possible, and, if not, to make him as nearly well as he can be and as
resourceful as he can be and put him back into life again with
confidence in himself, with respect to his Government and with ambition
to make America the leading Government of all the governments of the
world.

I am here to say to you that while you are talking to your patients
about the affairs that arise with you each day, do not forget as a part
of your responsibility and your duty that you help to create a spirit
and a determination on the part of the man you are serving to get back
into life again. Discourage in every way you possibly can the idea of
his becoming a barnacle upon this great Ship of State. Encourage him to
believe that the responsibility of the debts that are incurred here now
are debts his children and his grandchildren will have to pay; and so,
while we are talking economy to you, I would impress upon you this one
thought: that economy is only the assurance to yourself that every
hundred cents buys a dollar’s worth. We do not mean by the economy we
are trying to preach here economy that might be regarded as
penuriousness. We want you to have all you need in the best way that it
can be provided for you, but we want you to have concern enough in the
property that is turned over to you to see that it is worth what you pay
for it and that it is used to the best advantage possible.

Yesterday, we decided, I believe, that we would devote an hour this
morning to the answering of some miscellaneous interrogations. Dr.
White, have you received any?


DR. WHITE: No.


SURGEON W. H. SANFORD (R): Having spent the last year and a half in the
Inspection Division, the subject of this excessive amount of money in
the hands of the sick soldier has impressed itself on me more and more
as I inspected the hospitals. It was the cause of great trouble, and is
in my opinion doing more to hinder the patient than any one factor.
Without this $80.00 or $157.50 a month, the vice and crime and drinking
around the institutions could not exist, and therefore I believe that
one of the greatest things that could be accomplished at this Conference
would be for the Committee to promulgate some way of preventing these
men from using that money in the way it is being used today.

I have inspected Ft. Bayard, Ft. Stanton and other large institutions in
the West, and I know these men in charge will agree with me when I say
that the thing that hampers the recovery of the patients is their right
to expend the money the way they want. If they didn’t have it, the
rum-runner and the other vices that come would not be there. I think it
is one of the most important subjects we could settle, and suggest that
it would be well if the Committee would recommend that we give these
men, say, $15.00 a month, and take care of the rest of their money until
they are ready to go back to their homes.


SURGEON J. E. MILLER (R): At our hospital we have a canteen. I suppose most
hospitals have canteens. We have had $3,000 paid into the
hospital—$3,000 a year profit on sales to soldiers. I think such money
could be turned in for the benefit of the soldiers, for entertainments,
Christmas dinners, etc., as that seems the proper place for it.


MR. M. SANGER (St. Elizabeths Hospital): With reference to those funds of
the beneficiaries who are in hospitals, a similar condition

existed for a while with reference to those drawing pensions. That
proposition had to be met. Congress passed a law whereby those people
receiving pensions, who entered soldiers’ homes or hospitals had to pay
that money either to the superintendent of the hospital, the President
of the Soldiers’ Home, or the Governor of the Home, to be cared for the
benefit of the pensioner. Those who had beneficiaries at home received
the benefit of their portion of the pension under supervision of the
Pension Office, the Pension Office having machinery to find out what
beneficiaries had dependents, etc., and what proportion of the pension
should be paid to them.

The only thing in connection with these funds paid to the hospitals
which led to complaint was the money paid to heads of hospitals or
Soldiers’ Homes for deposit in the Treasury, but which was not drawing
interest. This needs corrective legislation. Precedents are at hand.
Moneys paid into the Treasury by beneficiaries or enlisted men of the
Army or Navy are drawing interest. The money from these pensioners
should be drawing interest. These funds, whether from the pensioners or
beneficiaries of the War Risk Bureau should be used as a sinking-fund
possibly to retire the debt of the Government and in that manner to draw
interest. It would help the Government in becoming part of the
sinking-fund; it would help the veteran in that it would permit the
money received to be deposited for his benefit, and would give an
opportunity for regulations to be made to safeguard him; to prevent
these people from coming around the institutions by preventing his
having excessive money to spend. Then when the man is discharged, he
would have an estate with which to begin life and to provide for the
future.

I think this organization should give some consideration to this matter.
I refer to Acts of February 20, 1905 and February 7, 1909, and similar
acts in regard to Soldiers’ Homes. I think the one thing to be
considered is a means of investing these funds for drawing interest.


MAJOR GENERAL M. W. IRELAND: The question of patients having money while in
the hospital is one of the most demoralizing things that can happen. It
has been recognized in the Army for many years.

In the Philippines we had a sympathetic commanding officer and we
received permission to with-hold a certain portion of the funds. Then we
received word from the Secretary of War that it was contrary to law;
that the money was earned by the soldier, and had to be paid to him.

I think you are going to find the same is true of compensation. If you
are going to hold the compensation of the man while he is in the
hospital, you will have to get an Act of Congress. I think, therefore,
that you should consider the amount of compensation the man should get
while in the hospital; consider the proposition of maybe reducing his
compensation while in the hospital, being cared for by the Government.


SENIOR SURGEON J. E. DEDMAN (R): I am glad this subject came up. A year and
a half ago, a committee of T. B. experts came to our hospital and we
discussed that question. I made the statement that many of the men in
our hospitals were getting too much money. It was immediately taken up
by the American Legion, and they said all kinds of unkind things about
me. I said that men who never had any money in their lives single boys,
etc., were getting $80.00 a month and that this was too much money.

I cited the instance of where a lady came into my office, weeping. She
said she had been dependent upon her son; that he had gotten that day a
check for $1200; had bought an automobile for $1500; and had gone $300
in debt.

The greatest set of vultures we have to contend with are the automobile
salesmen. For instance, they come and sell to our boys for $700 cars
which would sell for $400. If the boy has $500, they charge him $750 in
order to get notes and keep him in debt.

I am in favor of getting an Act of Congress to put the man’s money at
interest, so that when he is rehabilitated he will have something to
take care of himself. As it is now the boys are spending their money for
hootch, automobiles, etc., and instead of rehabilitating them we are
ruining them.


MR. M. SANGER, St. Elizabeths’ Hospital: In regard to the question of
General Ireland, the pension regulations include a provision that one
part of the pension shall be devoted to reimbursing the hospital for
part of the care. I think that would serve in a way to admit of those in
hospital getting less while there than when outside.


SENIOR SURGEON G. B. YOUNG, U.S.P.H.S. While on the subject I offer the
suggestion that something might be done along this line in connection
with the disciplinary regulations, which provide that when a man is
discharged for disciplinary reasons his compensation will be withheld
for a certain period. We all know that we sometimes will have to
discharge people for disciplinary reasons, and it may happen that the
offense is of such a character and the man of such a character as to
make you feel that the sentence you have to impose upon him as compared
to that which you have to impose upon a flagrant offender is lacking in
elasticity. It seems to me that it would be well in this connection to
consider whether the regulations could provide for the with-holding of
compensation by the Veterans’ Bureau for a greater period as an
incentive to better conduct, so that the man might be returned to the
hospital with the incentive that if he behaves satisfactorily that this
money which had been withheld would be restored. As it is a man has to
be discharged and he goes out penniless, because he hasn’t anything
coming to him for several months. If he could look forward to a
suspended sentence, I think that would save some of the better element
among these possible unintentional offenders and get them back into a
line of good behavior.


COLONEL JAMES A. MATTISON, N.H.D.V.S. This question which was brought up by
Congressman Madden, General Ireland and others is a very pertinent one.
This method of handling the funds of men of former wars has been in
effect in the National Home service for many years. The matter just
spoken of in regard to handling this money in a disciplinary way has
also been a feature. In regard to the men who have been offenders, who
have been continually guilty of getting drunk, the commanding officer of
each hospital had the authority to with-hold, as a disciplinary measure,
any part or the whole of a man’s pension until such time as he saw fit
to turn the money over to the man or a part of it. Of course the matter
of with-holding pension money in the case of men of former wars is of
much less importance. Formerly, these men were getting $10, $20 and $25
a month, and when Congress passed a pension law providing $30 a month,
they saved money. That does not compare with the pensions our soldiers
of the recent war are receiving, $80, $100 and $150 a month, and, as has
been stated by several men already, it has been and is going to continue
to be one of the greatest factors in preventing these men from being
restored to an active state in life again.

In the matter of the corrupt conditions which have been described as
existing around these hospitals, it is something that cannot be
prevented. Every effort has been made. The civil authorities have been
appealed to and in most cases they have given undivided co-operation.
Personally, I feel that it is an exceedingly important matter.


SURGEON J. B. ANDERSON (R): If I have interpreted the regulations correctly,
we are not permitted to have a canteen around the hospital. If I am in
error, I should like to know it.


LIEUT. COL. W. H. MONCRIEF, U.S.A.: Contrary to the impression given here
yesterday afternoon, revelry does not maintain at Fitzsimmons Hospital.
I think we have a well-ordered institution. The matter of compensation
does give us some concern.

We have four classes of patients,—Army, Navy, beneficiaries of Soldiers’
Homes and of the Veterans’ Bureau. On the day I left, we had a total of
980 patients, 719 of which were Veterans’ Bureau beneficiaries. These
are officers, ex-nurses and ex-enlisted men. I will say that the
behavior of these people during my tour of duty at the hospital compares
favorably with that of any other institution. We have our troubles; if
we didn’t have them, I don’t suppose the institution would need a
commanding officer.

But the question of compensation is one that is not easily adjusted
unless it is adjusted at the source. It is impossible to give you an
idea—unless you have charge of one of these institutions—of how much
trouble the commanding officer is going to have if the responsibility of
withholding this compensation is put on him.

We are near a large city—not too near and not too far—but we are
surrounded by people who want to offer at all times every inducement to
the enlisted men to spend this amount of compensation in the most
advantageous manner. This class ranges from the peddler of tin toys to
the most reliable banking firms in the city of Denver. Those bank
representatives wait on us. Since I have been there, I have had to
pursue the policy of excluding from the reservation all solicitation
whatsoever, my argument being that it was my duty, to protect the T. B.
patients; that if one solicitor were allowed, others must be allowed;
and that I had no time nor inclination to pass upon the merits of the
various propositions offered. I have not had a great deal of trouble;
and since I have been able to get the representative people to
understand this situation—and I take particular pains to inform all my
personnel that reputable firms and others are aware of this
prohibition—it is assumed that anyone soliciting on the reservation is
not reputable.

I think a great deal can be done in regard to taking care of this matter
by the social service work in the hospitals. The good people of Denver
have been very kind in every way.


DR. BUTLER: In view of the fact that economy seems to be the order of the
day, and to have economy the bird’s-eye view has been pointed out to
organizations this morning, I suggest that as a fitting slogan for this
body, the words. “Cultivate a bird’s-eye view” be adopted.


GENERAL SAWYER: I don’t know just what authority you gentlemen have in
regard to the matter of solicitors, but at White Oaks Farm if
interruptions such as these attempted to exist, somebody would get hurt.
I would not tolerate the existence of such affairs. There is no reason
why you should, and if there is any reason why you shouldn’t, this Board
can help you to bring about some regulation or some rule whereby it will
be possible for you to protect yourselves and your people against such
imposition as this. Be assured that this Board is going to provide it;
but I really think that if you will exercise your authority as
commanding officers and not allow these people to intrude upon you, you
will be able to cure a lot of your difficulties at home.


SURGEON J. M. WHEATE (R), U.S.P.H.S.: A year ago we were swarmed with
agents, and I sent out a hospital regulation prohibiting that. It is
easy to issue regulations, but hard to put them into effect, so I have
made it a rule to make my regulations as few as possible. This, however,
I found to be a necessary regulation, and I prohibited agents of all
kinds from access to the hospital.

We have a hundred-acre field, which is approachable in a hundred
different ways, and there is no way of keeping such agents out of the
reservation. I had my Captain of the Watch made a Deputy United States
Marshal. I had my head orderly made a constable for the county. They
helped me to maintain order outside the reservation.

The matter of compensation has been a big problem with all of us. I
recall that about the first time I got “in bad” with my patients was
early in the game. I was waited on by a delegation of patients in my
office one morning, who asked if I were properly quoted in the morning
paper. I had not seen the paper.

A day or two before, a committee of Legion men called at my office (we
had most happy relations with the local Legion heads). One of this
Committee was the editor of a local paper. Among the general things we
discussed was the abuse of compensation. I said I wished we had some law
like Canada, whereby all but one-fourth of the compensation could be
withheld, as I believed that ten dollars a month was enough for a sick
man in the hospital. This was discussed and it sounded reasonable.

The next day, to my surprise, the editor of the local paper printed the
story of my recommendation; and the young chap, thinking I suppose to
give me the credit for the thought, quoted me freely.

The soldiers appointed a committee to wait on me. They wanted to know if
I thought it fair to the United States soldier. They said it was their
money and that they proposed to spend it as they saw fit.

Out of this controversy grow consideration by the Legion; and in course
of time that Legion Post sent a committee man to Washington, who had a
long conference with Mr. Sweet; and indirectly I may be much to be
condemned or praised for introducing into the Sweet Bill the measure of
withholding compensation. Our committee man who went up there stated
that it was a rather new thought to Mr. Sweet and that he waved it aside
at first, but that later he showed interest and finally said he was
going to rewrite his bill, incorporating that idea.

But it did not go nearly as far as I recommended; that is, the adoption
of the Canadian form of withholding all but one-fourth. There is no need
to discuss that. Mr. Sweet said it was illegal; that compensation is a
wage; but he compromised by saying we could fine the men.

Regarding my drastic order, I might add that I do allow the agents of
the banks to come in, and I am proud to say that we do handle much of
our trouble by depositing money either for checking accounts or savings.
I think that about forty per cent of our men are carrying savings
accounts in the local banks.

We have at least 160 N. P. cases in my hospital, although it is
officially a T. B. hospital. As you know, the regulation provides that
if a man is not capable of handling his money, his compensation check
will be sent to the Commanding Officer, who is held responsible for the
money. I put the money in the bank, giving to the man, after conferring
with the Chief of the N. P. Section, such funds as he may need.


SURGEON M. J. WHITE: Early in 1919, when I first opened Palo Alto, I made
recommendation for the amendment of the Act, so that the Compensation of
a patient might be held until he had completely recovered, and I see no
reason why there is a legal bar to it. I think Congress can say that
Compensation is payable when a man has completely recovered and is
discharged from the hospital. We cannot undertake to protect the
patients from sharks. For instance, we give a man a pass; he goes down
town and spends his money. As long as he has money in his pocket, he
will spend it. I think it would be legal for Congress to say that
Compensation will be payable when the man has reached maximum hospital
treatment or when he is properly discharged. Otherwise, if a patient has
accumulated, say, $160, he starts a disturbance and you have to give him
the money.


CAPTAIN F. W. Wieber, U.S.N.:—I am glad to say that we have had very little
trouble with our Veterans’ Bureau patients. We have, however, had
trouble occasionally, but I have always been able to attend to these
matters myself, for I have a good understanding with a U. S. Attorney,
who helps me out.

Regarding money, it would be the best thing if most of the Compensation
to the men could be withheld. They may have dependent families, so no
uniform rule could guide us in our action. I do not think it should be
left to the Commanding Officer, for in the first place, we do not know
how much money the men should receive.

With regard to the matter of smuggling into the reservation, I sent a
request to the Surgeon General to be allowed to put up a fence but I
have never heard from it. I am going to recommend to my successor that
he call attention to that matter again. The reservation at Fort Lyon
covers 1100 acres, and a portion should be enclosed with a fence. There
has been much stealing there, and we have often found the stolen
articles in houses around the reservation. The building of a fence would
be expensive, but it would counter-balance the loss of government
property.

For the benefit of the gentlemen who may succeed at Fort Lyon soon, I
might say that when I was ordered to Fort Lyon I was very much grieved;
I knew it was in a desert, and everybody who had been there gave such a
discouraging report. My sentiment in that matter has changed to such an
extent that if the place had remained in the hands of the Navy, I should
have liked to have remained there. We are a happy family of about
fourteen commissioned officers and we have formed a little community of
ourselves, being independent of the outside world to a large extent. We
have our power house, ice plant, community house, social meetings, and
in fact we are as independent as can be.

During the flood, we were able, for about two weeks to attend to our own
things, and after that we were able to help the outsiders. So, to those
gentlemen I want to say that they need not be disconsolate upon
receiving orders to go to Fort Lyon.

I think it is ideal for the T. B. patients. We have the dry climate,
constant sun-shiny days, cool nights, and everything conducive to the
proper treatment of T. B. Everything is complete, and the people are
greatly benefited by their stay in our vicinity, as can be attested by
the fact that many former Navy People, who had been in the institution,
are now living there and are as strong as any person in the East.

I might say that the people who have had T. B. and who are doing well
out west had better make up their minds to stay our there for fear that
change of conditions might bring about activity again in their cases.

Regarding a uniform system of treatment as suggested, I do not believe
any strict rules should be set. We can have a sort of general system,
but no uniform method as to the hours of rest, food, etc. At Fort Lyon,
rest is now being enforced, and every patient gets two rest periods, i.
e., from 9 to 11 A.M. and from 1 to 3 P.M. Liberty is allowed only once
a week; and overnight, once a month. Those who would be discontented
anywhere have left, and those who have stayed feel they have our
sympathy and support and are doing well.


GENERAL SAWYER asked for resolutions from the Resolutions Committee.


GENERAL IRELAND: “Your committee has gone over the resolutions that have
been presented, and we find all of them in order, with the exception of
one submitted by Colonel Bratton with reference to transportation home.
We would inform you that there will have to be legislation to carry out
that resolution. We have changed the resolution to read as follows:

    ‘That the Director of the U.S. Veterans’ Bureau be requested to
    secure legislation so that the expenses of the patient’s
    transportation to his bona fide home, when he has been discharged
    for disciplinary reasons, be deducted from his compensation, when
    compensation is being given, or may be given thereafter.’

As changed, I recommend that the resolution be adopted by the meeting as
read.”

This _Motion_ was seconded, and carried.


CAPTAIN N. J. BLACKWOOD, U. S. N.:—The Committee on Forms has held two
meetings at which the general subject of this work was discussed and
plans agreed upon. This work is so great that your Committee finds it
impossible to report more than progress at present. The whole matter
must be gone into carefully and thoroughly in order to avoid mistakes
and duplications of the past. The work, to be a success, will require
frequent meetings, careful study and cooperation. Therefore, it seems
wise that all members of the Committee be officers on duty in
Washington, and I recommend that the present chairman, Captain
Blackwood, be relieved, and that his place be filled by Captain M. S.
Elliott, Commanding Officer of the Naval Hospital; also, that all
Commanding Officers here present shall, as soon as possible after
returning to their respective commands, take up the subject of forms and
paper work regarding Veterans’ Bureau patients, and as soon thereafter
as possible submit to the Veterans’ Bureau, Washington, recommendations
and suggestions for the elimination, provision and simplification both
of the forms themselves and their numbers.

Upon receipt of these letters, your Committee will then take up the
whole subject in a more comprehensive way and will, as soon as possible,
submit its recommendations for your consideration and approval.

The _MOTION_ was seconded and carried.

                    Meeting adjourned at 12:30 P. M.




            _Eighth Session_      Friday, January 20, 1922.


Honorable Charles H. Burke presiding.

The roll was called by Dr. W. A. White.


MR. BURKE: “We will proceed with the afternoon program. The first subject is
“Foreign Relations of the U.S. Veterans’ Bureau in care of ex-soldiers
of the former allied countries.” It will be discussed by Dr. F. D.
Hester of the Veterans’ Bureau”.


DR. HESTER: read as follows:

            “FOREIGN RELATIONS OF THE U.S. VETERANS’ BUREAU

                               IN CARE OF

              EX-SOLDIERS OF THE FORMER ALLIED COUNTRIES.

 Mr. Chairman, Ladies and Gentlemen:

As I note that the program upon which I have been placed refers to
foreign relations of the U.S. Veterans’ Bureau in care of ex-soldiers of
the formed-allied countries, with your permission I will add to that,
the care of U.S. ex-service men in foreign countries. The care of U.S.
ex-service men in this country has been discussed from every angle, and
it would seem proper that we should also refer to his care in foreign
countries from a medical standpoint, as well as to the care of the
allied ex-service man in this country.

[Sidenote: THE LAW PROVIDING FOR THE CARE OF U.S. EX-SERVICE MEN IN
           FOREIGN COUNTRIES]

As act of Congress, Public 104, Sixty-sixth Congress, approved December
24, 1919, provides that the Bureau of War Risk Insurance, now the
Veterans’ Bureau, is authorized, to furnish transportation, also
medical, surgical, and hospital services to discharged members of the
military or naval forces of those Governments which have been associated
in war with the United States since April 6, 1917, and come within the
provisions of laws of such Governments similar to the War Risk Insurance
Act, at such rates and under such regulations as the Director of the
Bureau of War Risk Insurance may prescribe, etc.

[Sidenote: AUTHORIZATION FOR SERVICE]

You will note that this provision of the law stipulates at such rates
and under such regulations as the Director of the Bureau of War Risk
Insurance may prescribe. The regulation that has been issued by the
Director of the U.S. Veterans’ Bureau provides that in all cases where
application for treatment is made by ex-members of the military or naval
forces of the allies, such treatment will be furnished only on the
specific authorization of the Director of the U.S. Veterans’ Bureau upon
authority obtained from the Government concerned, to incur the expense
of treatment in each case. When treatment is so authorized, the same
procedure is to be followed as in cases of application made by
ex-members of the Canadian forces, which is as follows:


RECIPROCAL AGREEMENT WITH CANADA:

An agreement entered into between the Canadian and this Government upon
reciprocal lines provides that when an honorably discharged member of
the military or naval forces of the Allies, resident in the United
States or its territorial possessions, requires medical or surgical
treatment for a disability contracted in, due to, or increased by his
military or naval service, he shall apply to the nearest medical
representative of the U.S. Veterans’ Bureau. If such representative is
not available, information regarding the address of the nearest medical
representative of the U.S. Veterans’ Bureau may be secured through any
local representative of the American Red Cross, the American Legion, the
Y.M.C.A., the Salvation Army, the Knights of Columbus, or other
volunteer agency.


METHOD OF PROCEDURE WHEN APPLICATION IS MADE FOR TREATMENT:

When application for treatment is made by an ex-member of the Canadian
forces, the medical representative of the U.S. Veterans’ Bureau to whom
such application is made will communicate with the District Manager in
order to obtain particulars regarding the man’s military or naval status
and medical history, and the District Manager will communicate with the
Bureau (Assistant Director, Medical Division, Attention Foreign
Relations Section), which will obtain from the Government of Canada the
necessary information. If additional information is required, the
District Manager, if speed be necessary, will request such additional
information by telegram. In no case should treatment be undertaken
pending receipt of authority from the U.S. Veterans’ Bureau, unless the
call be one of emergency, and in all emergency cases the medical officer
in the field is authorized to give prompt service.


LETTER OF INSTRUCTIONS:

The articles of agreement with Canada have been supplemented with a
letter of instructions that clearly sets forth just how service is to be
given by representatives of this Bureau to beneficiaries of the Canadian
Government. This letter of instruction is a guide for the
representatives of this Bureau in the field as to proper procedure when
any doubtful situation should arise, and has been sent to the District
Managers in such numbers as to furnish each medical officer with a copy.

It is possible that some of you gentlemen are not in possession of these
instructions; should such be the case, a number of copies are at your
disposal here, and may be obtained from the stenographers’ table.


NUMBER OF CANADIAN EX-SERVICE MEN CARED FOR BY THIS BUREAU:

It may not be out of order to mention at this time that the U.S.
Veterans’ Bureau through its Foreign Relations Section, Medical
Division, has cared for over 9,000 Canadian ex-service men. When I say
Canadian ex-service men, please know that these are not in reality
Canadians, but that 95% of the number are American boys, who, through
their valor and enthusiasm, rushed into the breach in the early stages
of the conflict, having crossed the Canadian border in 1914, 1915, 1916
and 1917. Their Services having been rendered under the English flag in
Canadian organizations, these boys are properly beneficiaries of the
Canadian Government, and are being cared for by that Government through
the U.S. Veterans’ Bureau, Foreign Relations Section, Medical Division,
by cooperation with the Department of Soldiers’ Civil Re-Establishment,
which is an organization of the Canadian Government, similar to the U.
S. Veterans’ Bureau. The personnel of the Department of Soldiers’ Civil
Re-Establishment is something over 6,000, divided into 10 medical units,
or districts. The Foreign Relations Section, Medical Division, of the
Bureau is constantly in receipt of requests for service from allied
ex-service men with whose government this Bureau has no reciprocal
agreement. These cases are promptly referred to the representative of
that government located in Washington with a view of giving service if
the Government under whose flag the man served will authorize the
service.


REPORTS TO BE MADE UPON CANADIAN FORMS 346,399 and 76.:

Your attention is particularly called to the necessity of forwarding to
the Bureau reports required by the Canadian Government regarding the
hospitalization of Canadian ex-service men; and I desire to stress this
point, that, when a medical examination is made of a Canadian ex-service
man, the report of your findings should be furnished on S. C.R. Form 346
(S.C.R. meaning Soldiers’ Civil Re-Establishment), this Form being
similar in requirements to the Bureau Medical Division Form 2545. It is
upon the findings in this report mode upon S.C.R. 346 that the Canadian
Government gives its approval for hospitalization. S.C.R. Form 399 is a
Progress Report, and should be rendered monthly during the man’s stay in
hospital, for the reason that until this report is received no pension
will be paid to the man or to his dependents. When a Canadian
beneficiary is hospitalized his compensation is reduced, but the family
allowance, should he have dependents, is increased. $40 is the maximum
pension payable to a man while in hospital, $10 of which is paid to him
and $30 held in reserve, which is accumulative, and is given to him upon
discharge from hospital. The family allowance is increased according to
the number of his dependents, and is paid to his family direct. S.C.R.
Form. 76 is a discharge report from hospital and should be rendered
promptly in triplicate, as all these reports should be. If you are not
in possession of these Canadian Forms, 346, 399 and 76, they may be
obtained from the District Manager in whose district you are located.


EX-MEMBERS OF THE MILITARY AND NAVAL FORCES OF THE UNITED KINGDOM:

At this time the Veterans’ Bureau has completed agreements whereby
service is being given to British ex-service men, which includes
ex-members of the military and naval forces of the United Kingdom of
Great Britain and Ireland, New Zealand and South Africa, as well as
those of Canada.


RUSSIAN ALLIED EX-SERVICE MEN:

In addition to the above named may be included the Russian allied
ex-service men, an agreement having been entered into with the Russian
Ambassador now located in Washington, whose official status has not
changed since his appointment as a representative of the late Czar. When
medical, surgical, or hospital treatment is requested for a Russian
ex-service man, it must be approved in advance by the Russian
Ambassador, who certifies that any expense incident to this service will
be reimbursed by the Russian Ambassador.


CZECHOSLOVAKIAN EX-SERVICE MEN:

Through an agreement with the Czechoslovakian Minister, this service is
also furnished to the Czechoslovakian allied ex-service men upon request
from the Minister of that country, accompanied by a statement that any
expense incident to service will be reimbursed by his Government.


RECIPROCAL AGREEMENT WITH THE BRITISH GOVERNMENT:

An agreement is pending at this time with the British Government to
provide service for all U.S. ex-service men who may be permanently or
temporarily domiciled in the United Kingdom.


CO-OPERATION OF THE STATE DEPARTMENT IN GIVING SERVICE TO U.S.
EX-SERVICE MEN IN FOREIGN COUNTRIES.:

All medical, surgical, or hospital service that may be required for U.S.
ex-service men now in foreign countries is provided for by this Bureau
through co-operation with representatives abroad of the Department of
State, this Bureau authorizing such service upon receipt of information
that the man is in need of such service, and upon the establishment of
his identity and the fact that the disability for which treatment is
requested was due to or aggravated by his U.S. military service. Any
expense incident to this service is provided for by this Bureau and is
paid for through the State Department by transfer of appropriation. This
procedure has been found very satisfactory, for the reason that it
expedites the service to the man and simplifies the accounting problem
by the prompt payment of any expense that may have been incurred.


MEDICAL EXAMINATIONS IN FOREIGN COUNTRIES MADE BY PHYSICIANS DESIGNATED
BY U.S. CONSUL:

For the past six months a ruling has been in effect that where a Bureau
beneficiary in a foreign country was ordered for examination, he must
appear before a physician designated by the U.S. Consul only, and that
unless a report was received within three months from the date of the
letter directing him to appear, or to furnish satisfactory evidence to
the Bureau as to the cause of his inability to report, his compensation,
if he received such, would be held in suspense pending the report of his
medical examination. The result of this procedure in securing an
examination by competent physicians has been that more satisfactory
reports are received.


CHECKS SENT TO BENEFICIARIES IN FOREIGN COUNTRIES:

The records of the Bureau for the month of December show that at this
time there were 5,977 beneficiaries of the Bureau to whom checks were
sent, totalling in value $489,714. These beneficiaries are resident in
foreign countries located in all parts of the earth, as is shown by the
tabulated statement submitted.


SOME CASES OF INTEREST:

In order that you may have a slight conception of the far-reaching
effect of the strong arm of this Government in giving aid to its
ex-service men wherever located, which means that they are scattered all
over the earth, I believe that it will serve my purpose if I cite a few
cases that may prove of interest to you. I shall with-hold the names of
these men and refer to them by numbers only.


CASE NO. 1:

In this case a member of Congress came to the Veterans’ Bureau and
stated that he had been excursioned around from department to department
in his effort to obtain assistance in coming to the rescue of a boy who
had been discharged from the U.S. military service against medical
advice, suffering from melancholia, and who was sent to his home at the
earnest request of his parents, as it was believed that his return to
normalcy would be more quickly effected in the environment of his home
and under parental care, than in a hospital. The Congressman went on to
relate that after remaining home for about four months, the boy was one
day reported missing. Diligent inquiry and searching parties failed to
locate him, and a river nearby suggested the possibility of an accident
or suicide. We will drop the curtain on this distressing situation, for
we know by the law of the universal heart of the suffering that must
have followed in that afflicted home.


LOCATED IN SYDNEY, AUSTRALIA:

After a lapse of fourteen months a letter was received from Sydney,
Australia, addressed to a small town in a Southern State, signed by the
Christian name of the writer, Henry, we will call him. The letter was a
rambling, disconnected communication, addressed to no one, not even to
the Postmaster, but simply to the town. The Postmaster, being the
self-appointed recipient of the Communication, incidentally mentioned it
to the father of the missing boy. The father did not associate the
letter in any way with his lost son, but that evening upon returning
home, he told his wife of the letter which the Postmaster had mentioned.
I can almost see in your faces now that you have read the sequel to my
story, that the mother’s love quickly put the question: “Did you see
that letter?” and when the father said, “No”, the mother insisted that
the letter must be from her lost boy. A visit to the Postmaster was made
immediately, the letter was produced and identified by the mother as
having been written by her boy. The letter was then two months old. The
Congressman had come to see what could be done as to locating the boy in
far away Australia.

Although the distance between the yearning mother and her lost boy was
over 12,000 miles, I do not think I am exaggerating when I state that
within thirty minutes after learning the facts a cablegram was under the
water, requesting that the Consul General at Sydney cause a thorough
search to be made in the hospitals and other institutions in the city
with a view of finding the boy whose personal description was furnished,
and to hospitalize if necessary and cable results. Within two days a
reply was received, stating that the boy had been found and placed in a
hospital. He has subsequently been returned to the United States, where
he is now being cared for as a beneficiary of this Bureau, and I am glad
to say that he is progressing satisfactorily. Is it strange that the
Congressman and the Bureau should have the gratitude of these parents?


CASE NO. 2.:

A medical officer of the U.S. Army while traveling in Northern Africa
stopped over night at a hotel in Algiers and there learned of the
presence and illness of a U.S. Ex-service man. This young officer was
out of funds and in need of hospitalization. The attention of the
Surgeon General of the Army was called to the case, who in turn advised
the Veterans’ Bureau of the man’s distress. The State Department was
called by telephone and requested to cable the U.S. Consul at Algiers,
directing him to give immediate service to this American boy and report
action taken, with the result that the boy was promptly cared for and
sent by first available transportation to Marseilles, France, where he
was hospitalized.


CASE NO. 3.:

This case is that of a navy man whose disappearance was a mystery to his
family. The first information as to his location was obtained through
the U.S. Veterans’ Bureau, Medical Division, as the result of a telegram
received from the Director Medical Services, Department of Soldiers’
Civil Re-Establishment, Ottawa, Canada, which stated that a man had been
arrested there as a vagrant; that he was apparently a mental case, and
had been in the U.S. Navy. His name was furnished and his identity
established through the Bureau of Medicine and Surgery of the Navy. He
was promptly hospitalized by the Bureau through the co-operation of the
Canadian officials and returned to this country with an attendant, where
he is under treatment at St. Elizabeth’s Hospital.


PURPOSE OF THE BUREAU’S ENDEAVORS:

I might go on to cite many such cases, but my time allotted is
insufficient. My purpose is simply to inform you that it is the wish of
the Director and his associates in the Veterans’ Bureau that it and its
co-operating agencies may give to each case a human touch, reflecting
personal interest and I can think of no better maxim for our guidance
than the title of Charles Reade’s book, “Put Yourself In His Place,”—and
give service as you would have it given unto you.”


MR. BURKE: stated that in the absence of Major Fraser his subject would be
taken up by Mr. Milliken.


MR. J. B. MILLIKEN, of the U. S. Veterans’ Bureau, discussed the subject
“Relation of U. S. Veterans’ Bureau to other existing bureaus in caring
for its beneficiaries”, as follows:

“Ladies, Mr. Chairman, and Gentlemen: The subject of my twenty minutes
talk to you might more appropriately be termed the relation of the U. S.
Veterans’ Bureau to all the Executive Departments of the Government, for
indeed, there is not a Department of this government with which the U.
S. Veterans’ Bureau does not have a vital and immediate contact.

Probably there are three Executive Departments of the Government with
which the Bureau has more contact than with the other Executive
Departments—that of the Treasury Department, the War Department, and the
Navy Department. Inasmuch as the U. S. Public Health Service is a part
of the Treasury Department our contact with this Department of the
government is immediate and vital, and is of more immediate importance
than our contact with the other Executive Departments.

As is appreciated, no hospitals are operated directly by the U. S.
Veterans’ Bureau, and all hospitals with the exception of contract
hospitals are operated by the other independent establishments of the
government, the Public Health Service of course having the lion’s share
in providing facilities, and prior to the Act of August 9, 1921 creating
the U. S. Veterans’ Bureau, the U. S. Public Health Service had charge
of the various fourteen district offices where was stationed at each
district office a Supervisor.

The Secretary of the Treasury’s order of April 19, 1921 transferred the
functions of the District Supervisor’s Office to the then Bureau of War
Risk Insurance, and the Act of August 9, 1921 transferred by law the
activities of these offices to the U. S. Veterans’ Bureau, but left
unhampered the jurisdiction and authority of the U. S. Public Health
Service concerning matters of hospitalization.

Without the work of the facilities afforded by the U. S. Public Health
Service it would indeed be impossible for the U. S. Veterans’ Bureau to
function and discharge its obligations relative to the hospitalization,
medical care, and treatment of disabled ex-service men and women.
Co-ordination of their work has led to the fullest cooperation on the
part of every agency, to the end that the disabled ex-service man is
receiving the best treatment which a grateful government can provide.
You have, of course, before you all the data and information relative to
the extent of the work carried on by the U. S. Public Health Service as
it relates to the beneficiaries of the U. S. Veterans’ Bureau.

The relation of this Bureau to the War and Navy Departments is
fundamental, for the reason that before any person can be accorded the
benefits provided for under the act creating the U. S. Veterans’ Bureau,
a record must be obtained from the War or Navy Department showing the
military or naval record of the person seeking benefits either for
compensation, insurance, vocational training, or medical care and
treatment. Something over 900,000 requests have been made to date on the
War and Navy Departments requesting a transcript of the military or
naval record of the person while in the active service and there has
been no diminution in the number of reports requested daily, in that our
average number of requests each day is about 1,000. The matter of
furnishing adequately the transcript of record of an ex-service man or
woman, showing whether or not they received any medical treatment while
in the active service is indeed a most difficult problem. It must be
remembered cases are now arising where a given individual has been
discharged from the military or naval service for a period of
approximately three years, and that in all probability they did not
receive medical care or treatment while in the service, but their health
has become impaired subsequent to their discharge from the service.
Quite true they might have had some slight attack of influenza while in
the service or some other disability, but did not report for medical
care and treatment.

The most of these individuals believe that the War or the Navy
Department should have had a record of such indisposition on their part,
and that, in turn, it is up to the U. S. Veterans’ Bureau to secure such
a record upon which to predicate the service origin of a given
disability. Certainly not in the history of this government has the
military and naval establishments been called upon to complete and
compile the records of statistics and facts comparable to that resulting
from the late war, and while there have been many mistakes made both on
the part of the U. S. Veterans’ Bureau in requesting the information and
on the part of the War and Navy Departments in submitting information,
the great bulk of work has been performed in a most satisfactory manner,
and great benefits have been accorded to those applying for the same
under the beneficent laws passed by our Congress.

On January 1st, 1922 there had been filed with the U. S. Veterans’
Bureau 81400 claims for compensation. In each and every claim filed it
was necessary to request the War or Navy Department for the military or
naval record of the person applying for compensation benefits, and in
many instances it was necessary to make duplicate requests because of
inadequate identification given or of additional evidence which the
claimant submitted which would make it possible for the War or Navy
Department to make a more exhaustive search of their records. To show
the promptness with which reports have been received from the War and
Navy Departments for no claim is either allowed or disallowed without a
report from the War or Navy Department—out of the 814,000 claims filed,
51% have been allowed, 41% have been disallowed, and 8% are pending
awaiting information either from the War or Navy Departments or from the
claimant himself.

Also to December 15th, 1921, 486,884 former service men had requested
vocational training. It was necessary for the Rehabilitation Division of
the Federal Board for Vocational Education, (now a part of the U. S.
Veterans’ Bureau), to request the military or naval record from the War
or Navy Department, and out of that number 299,000 had been declared
eligible for training; 135,000 had been declared ineligible for
training; and 51,000 cases were pending to determine their rights to
vocational training. These figures also represent a tremendous work
required of the War and Navy Departments in that the records of each man
must be obtained before final disposition was made of the case.

When viewed from the stupendous task, the results accomplished are
indeed commendable.

The great assistance of the War and Navy Departments should also not be
overlooked when it is remembered that at the date of the signing of the
Armistice there were approximately $40,000,000,000 worth of insurance in
force which had been written through the service of the War and Navy
Departments in providing insurance officers to make contact with every
man who was a member of the military or naval forces.

The War and navy Departments have always been of tremendous assistance
in the matter of hospitalization of ex-service men and women. On
December 1st, there were 1,410 beds occupied in Army Hospitals, and
2,032 beds occupied in Naval Hospitals. Certainly then from this resumé
of facts the contact with the War and Navy Departments is most vital.

The contact of the U. S. Veterans’ Bureau with the Post Office
Department is apparent. It need only be mentioned that to date the U.S.
Veterans’ Bureau, representing the consolidated agencies since their
organization have received approximately 90,000,000 incoming pieces of
mail, and have dispatched approximately 105,000,000 pieces of mail, and
the daily average receipt of incoming mail in the Bureau, even under
decentralization, is approximately 41,000 pieces of mail per day and the
outgoing pieces of mail from the Central Office of the Veterans’ Bureau
is approximately 58,000 pieces of mail per day.

The Veterans’ Bureau as you have been informed relative to the care of
ex-service men of foreign allied countries and of American soldiers
residing in allied countries has a vital contact with the State
Department in addressing their communications to the various foreign
countries and in the utilization of the various U. S. Consuls.

The Department of Justice has charge of all suits filed against the U.
S. Veterans’ Bureau where suit is brought on an insurance contract. The
department of Justice also handles all prosecutions where irregularities
are found under the act creating the U. S. Veterans’ Bureau.

Under the Interior Department you know of the use made of the St.
Elizabeth’s Hospital and of hospitals under the jurisdiction of the
Commissioners of Indian Affairs.

The contact is also quite vital with the Department of the Interior in
obtaining various information from the Pension Bureau as a person may be
filing an application for compensation and also an application for a
pension.

The Department of Agriculture has been of very great assistance to the
Bureau in rendering advice relative to the training of disabled
ex-service men with a vocational handicap who desire to take up
agricultural pursuits, and at the present time the Department of
Agriculture is rendering most valuable service in mapping out
agricultural courses for the first Vocational School of the Government
located at Chillicothe, Ohio.

Many disabled ex-service men taking vocational training have been
assisted by the Department of Commerce in mapping out their careers for
work incident to that of the Department of Commerce.

The Department of Labor has been of very great assistance in aiding the
Bureau to find employment objectives for disabled ex-service men
undergoing training or who have been rehabilitated by the U. S.
Veterans’ Bureau.

This will give you a general view of the relation of the U. S. Veterans’
Bureau to the Executive Departments of the government. The U. S.
Veterans’ Bureau naturally must have a close contact with the Congress.
Congress continually calls upon the Bureau for data and information
which can only be obtained from the other Executive Departments of the
government but which immediately relate to the work of the U. S.
Veterans’ Bureau.

Inasmuch as you Gentlemen are essentially interested in hospital
administration, I should like to speak briefly on the question of
hospital records, and what data the Bureau is required to have when it
is called before Congress relative to Appropriations. As you know,
Congress makes one appropriation to the U. S. Veterans’ Bureau for
Medical and Hospitals Services. Sums from this appropriation are in turn
allotted to the U.S. Public Health Service, the War and the Navy
Departments, the Interior Department, and the National Homes for
Disabled Volunteer’ Soldiers. When the U. S. Veterans’ Bureau is called
before Congress for every appropriation it must show specifically how
the money has been allotted, for what purposes it has been allotted, and
the result accomplished.

It has become imperative for the U. S. Veterans’ Bureau to have
available comprehensive records concerning all hospitals in which there
are being treated its beneficiaries. It is not sufficient that these
records be only those concerning the admission and discharge of patients
and the physical examination report in each instance, but equally
fundamental data concerning the results of treatment, periodical
turn-over of patients, the hospitals’ administration, and of equal
importance, but from a different angle, the cost of operation with the
resulting per diem cost per patient.

A considerable part of the records on patients, their flow in and out of
hospitals and similar data are available or can be made available, the
value of these data so derived, of course, will be proportionate to the
accuracy or thoroughness with which the records of admission and
discharge are prepared and transmitted. The report of admission and
discharge of patients and the report of physical examination are at
present the only reports common to all Government Hospitals. The
necessity for the prompt rendering of accurate admission and discharge
reports and physical examination reports in all instances is apparent.
Such reports are of very great importance to the U. S. Veterans’ Bureau,
for upon them is determined the medical rating of the hospitalized
beneficiaries and any delay or omission in the rendering of records of
this character reflects upon the administration of the U. S. Veterans’
Bureau.

In regard to the individual hospital operation costs, until very
recently the U. S. Veterans’ Bureau has been operating in the dark on
unit costs. It is demanded that the U. S. Veterans’ Bureau have complete
knowledge of the cost of operating all government hospitals, not merely
as a gross item, but classified by purpose of expenditure and by
department of hospital for which spent. The reason for this point is
made two-fold—First, that the Bureau before it can allot money to the
several services for hospital expense, must be in a position to know for
what purpose the money should be disbursed; and second, because the
Congress of the United States is holding the Bureau accountable for all
moneys appropriated to it and unless this Bureau can tell Congress in
detail this money has been spent, or is to be disbursed, our
hospitalization program will be jeopardized until such information can
be secured.

The per diem rates for hospitals of the several services vary materially
so far as our estimates are concerned. The degree to which such a
variation in rates is only an apparent variation due to the different
bases upon which they are calculated is not at present ascertainable,
but it should be. Not only should this Bureau know what it costs for its
own patients at any one institution, but it should know the per diem
cost over a given period for all the patients hospitalized there. The
cost to this Bureau affects not only our appropriation; the cost to the
service operating the hospital, including this Bureau’s share, but it
affects the U. S. Treasury. If the cost of maintenance of certain
hospitals is excessive, it would be poor business not to evacuate that
hospital, if other conditions made it practicable, or if impracticable
to attempt to reduce its operating cost.

Recently the U. S. Public Health Service inaugurated a system of cost
accounting by individual hospitals. With the perfection of this
procedure the U. S. Veterans’ Bureau will be in a position to talk
intelligently about operating costs with these hospitals whether by
departments of hospitals, purposes of disbursement, such as salaries,
repairs, etc., or by unit costs.

The U. S. Veterans’ Bureau looks forward to the time when similar data
are available and regularly submitted by the War Department, the Navy
Department and the National Homes for Volunteer Disabled Soldiers, not
merely as reimbursements due certain appropriations, but by actual
disbursements of detailed purpose of not only for this Bureau’s share,
but for total operations.

The U. S. Veterans’ Bureau also maintains contact with the various
miscellaneous Departments and institutions of the government. Time will
not permit of going into any details or of mentioning these contacts.

The U. S. Veterans’ Bureau when viewed from its huge task of running an
insurance company with over three and one-half billions of insurance in
force, of making payments on 149,000 insurance claims each month, making
payment on 204,000 compensation claims each month, with approximately
29,000 ex-service men and women undergoing hospitalization, and having
caused to be made over 1,000,000 medical examinations and responsible
for 104,000 disabled ex-service men undergoing vocational training,
representing a task which calls for the closest cooperation and
assistance from every department of the government and only by having
the closest cooperation possible will the government, through the U. S.
Veterans’ Bureau, be able to discharge its obligations to the host of
disabled ex-service men and women of this country.

The Bureau has always enjoyed the fullest cooperation from the various
departments of the government and knows that the same cooperation will
be extended with unstinted measure in the future, to the end that every
pledge will be redeemed concerning the care and treatment of the
defenders of this Republic, and to the end that this administration will
go down in history as an administration that did not forget its sick and
wounded soldiers, and brought peace and contentment to every fireside
where assistance on the part of the government was requested and was
due.”


COLONEL JAMES A. MATTISON, N. H. D. V. S, gave the following discussion of
“Economy of Administration in U. S. Veterans’ Hospitals”:

“The subject is so broad that we can only consider certain phases of it
within the time allotted for this paper. We all recognize that there are
certain fundamental essentials which must of necessity be provided in
every hospital regardless of the number of patients cared for. This
necessarily means that overhead expenses of an institution hospitalizing
small numbers of patients will be out of proportion to those of a
hospital caring for a large number.

The general business management, the purchasing of supplies and
equipment, the conservation and dispensing of the same, the elimination
of waste, etc,. will be considered only casually for the purpose of
emphasizing the importance of adhering as closely to strict business
methods as is done in the case of every successful business man, whether
he be a hospital executive, a merchant, or a man in any other line of
business.

In this connection, it might be said that a mistake which is made in
many government institutions, and one which is not made by the most
successful business men, is to attempt to start on economy at a place
where one can least afford to economize, that is in the pay and
allowances of the personnel immediately responsible for the management
of the institution, the responsible heads of departments, etc. In other
words, we are not always willing to pay for brains, a price commensurate
with the business responsibility involved. Again when we have been
fortunate enough to secure the right man the right place, we do not
always recognize his value by paying him a price commensurate with the
value of his work. Furthermore, when we have made the mistake of getting
the wrong man, who in reality is receiving a greater compensation than
his services are worth, and one who, in reality, is a very expensive
employee, we oftentimes make the mistake of not recognizing inefficiency
and promptly correcting it,

In case there is any decided handicap along the lines of inefficiency in
the responsible personnel in the administrative, utility, service or
professional departments, it should be promptly corrected, as it is to
those in such petitions to whom we constantly look to be on the alert in
recognizing the short comings of all subordinate personnel.

In visiting our own or other hospitals we promptly recognize the
presence or absence of evidence of the proper vigilance or efficiency in
every department. In case of a tour of inspection of one of these
institutions there should be found spurting steam valves, leaking water
faucets, extravagant use of electric lights, overheated buildings,
garbage and swill tanks running over with waste food supplies, evidence
of lack of organization and co-operation on the part of the personnel,
professional or otherwise, we should immediately recognize the fact that
there was inefficiency existing in the personnel of such an institution,
and as a result of this, a decided lack of economical and efficient
administration. Finding such conditions in other departments, we should
expect to find unsatisfactory conditions when the patient population was
reached. We should expect to find histories poorly written or not
written at all, patients waiting over-time for special examinations or
special treatments, lack of accurate laboratory and X-ray records, etc.
The matter of such inefficiency and consequent poor administration on
the part of the personnel in any institution would naturally lead to
great dissatisfaction on the part of the patients of such an institution
and to the greatest lack of economy on the part of the administration,
of the hospital.

In connection with the professional department proper, again the
attainment of the most satisfactory results from the standpoint, both of
economy and efficiency, is dependent upon the capacity and co-operation
of the responsible personnel. There has been much discussion in regard
to the number of professional personnel doctors, nurses, attendants,
etc., and on this subject there has been apparently wide differences of
opinion. However, these differences have been based upon differences of
viewpoints of what the actual conditions to be met were.

A definite agreement has been reached in regard to the required
personnel, nurses, doctors, attendants, social service, workers,
etc., to each two hundred patients in a hospital caring for all
acute patients, whether they be major surgical, acute active
neuro-psychiatric, active tuberculosis, or other type of acute
condition requiring active, constructive treatment.

As a matter of fact, however, we all know that in none of our Veterans’
Hospitals, especially the larger ones of 500 to 1000 or more beds, are
all the patients or even a majority of them represented by this type of
patients, on the contrary we have a large group of convalescent patients
who require professionally very much less attention from the standpoint
of active constructive treatment, dietetic attention, etc., and hence
require vastly less personnel, and the expense of their maintenance in
the hospital will be very greatly reduced from that of the acute type.
Again, we have another group which represents the semi-domiciliary type,
many of whom require very slight constructive treatment, and yet they
belong to a type of patients who are capable of being finally
rehabilitated and restored to an earning status in life. This group
requires still less care than the former, and naturally less personnel
and proportionately less per capita cost to the institution caring for
them. Lastly, we pass to a purely domiciliary group who are to a large
measure permanently disabled and are, therefore, many of them, to be
permanent charges oh the Veterans’ Hospitals. The great majority of the
latter group will require little or no special treatment, but will
require only general care and maintenance. In this group we are dealing
with a type who will represent the minimum per capita cost.

As time goes on we shall realize, especially in our larger hospitals,
that the above condition will exist to a larger and larger measure and
the necessity of a very close checking system and a very careful
classification of the patients along the lines indicated above will be a
matter of the very highest importance.

This does not mean that as long as special treatment along any line is
needed that each patient will not have such expert examinations, care
and treatment as his condition calls for. Quite the contrary, the most
careful and competent examinations should be directed by hospital units
composed of the most competent staff of men including surgical; medical;
ear, nose and throat; X-ray., etc., at such intervals as the condition
of the patient calls for. It will be by this system alone that we are to
keep a check on the progress toward recovery of each individual patient
and prevent an undue accumulation of a domiciliary group. By proper
cooperation of such a group with the rehabilitation section, many men
may be selected as suitable persons for rehabilitation in the vocational
schools. The importance of this we all realize as there is a certain
percentage of patients who will be quite content with their state as
long as they are receiving complete maintenance and a liberal
compensation of from $80 to $150 per month and no cares and no
responsibilities to assume in life. That is we should be constantly on
the alert to prevent making permanent residents or charges of any man
who can be restored to an earning status in life.

Contrast, if you please, with the conditions in our hospitals the
patient in private hospital, who is paying from $10 to $50 per day for
private nursing, hospital accommodations, etc., and a correspondingly
high rate for special professional services, and who in addition to this
is losing heavily because of his absence from his personal business. In
the latter case there is a much greater incentive for getting well, a
greater incentive for requesting that special nurses and other expenses
be cut off at the earliest moment it is found that they are no longer
needed and for the additional request that they be discharged from the
hospital as early as possible after the maximum benefits from
hospitalization have been received. In the one case, the private patient
is paying freely a large sum of money to get well. In the other case,
the patients of our Veterans’ hospitals in many cases are paid liberally
for being sick.

In making the above statement, we do not wish to be misunderstood. We
all know that we have among our patients in the Veterans’ Hospitals some
of the best type of men anywhere to be found; some of the most
ambitious; some who are exceedingly anxious to have their health
restored and be returned to an earning status in life at the earliest
possible moment; but, unfortunately, this does not apply by any manner
of means to all the patients whom we are hospitalizing. Out of the
disabled arising from an army of nearly five million men, naturally
there will bob up representative types of every manner of man in
existence. As representatives of Veterans’ Hospitals we owe to our
Government as well as to our patient our best efforts to help, not only
toward the rehabilitation of every soldier who can be rehabilitated but
we are also obligated to help develop this program upon the most
economical basis without sacrificing efficiency and the most
satisfactory constructive results.”


MR. BURKE: stated that the subjects were now open for discussion, and called
on Colonel Patterson for a few words.


COLONEL PATTERSON, of the U.S. Veterans’ Bureau,: stated that it had been a
great personal loss to him that he had been unable to attend all of the
meetings. He then spoke on the policy of the Veterans’ Bureau with
respect to the utilization of contract hospitals and Government
institutions. He stated that the Bureau has been for some months
endeavoring to take the beneficiaries of the Bureau out of contract
institutions and put them into Governmental institutions for several
reasons—first, the law says we must utilize to the maximum extent the
Government facilities in existence. Another reason is that the majority
of contract hospitals are unsatisfactory from the treatment standpoint,
if from no other reason, as many of these contract hospitals are purely
boarding houses which originated merely for the purpose of making money
out of the Government, by taking care of beneficiaries of the Veterans’
Bureau. Of course there are many contract hospitals in which this is not
true, but it has been determined that better treatment at least equal
cost can be obtained in the Government hospital. Another reason is that
the civilian hospital is not particularly interested and does not desire
to make the necessary reports. He also mentioned discipline. The
contract hospitals do not like to discipline a man because it may lead
to the loss of that patient. He stated that every time the Hospital
Section of the Medical Division recommends the closing of a contract
hospital the Bureau is immediately bombarded by letters from
Congressmen, Senators, the American Legion, United Veterans, and other
organizations, but the Veterans’ Bureau has been trying to stand firm.

The next subject he took up was the fact that a beneficiary gets more
compensation while he is in a hospital. This, however, cannot be changed
except by Act of Congress, and the Medical Division has recommended to
the Director that the man’s compensation be reduced while he is in the
hospital.

He took up next disciplinary regulations. With regard to payment of
transportation, he stated that this money could not be deducted from the
man’s compensation without Congressional action.

He spoke also on the fact that under the Vocational Rehabilitation Act a
man discharged with a disability not connected with the service, who has
been denied compensation, can get training even if his disability is the
direct result of his own misconduct, and that he is entitled to
treatment for any disease contracted while taking training if it
interferes with the continuance of his training. The Medical Division
recommended some time ago that Section 3 training be discontinued and
that no man be given training unless his disability is the result of
service or aggravated thereby.


He said he hoped that the gentlemen present would express their opinion
as to whether or not meetings similar to this one should be held
annually.

With regard to the attitude of the Veterans’ Bureau towards the various
Services, he stated that when allegations are made all the Veterans’
Bureau can do is to send them to the Head of the Service, asking him to
take the usual steps to find out whether or not those things are true.
On the other hand, if there is a charge a man is mistreated, the
Veterans’ Bureau must investigate it. It is a very peculiar situation
for one Department to investigate something conducted in another
Department.

Regarding complaints, he cited one case. A letter was received from an
insane man in the west Roxbury Hospital, who signed the letter “All the
patients in the hospital”, and complained about everything in the
institution. A letter was immediately received from a Congressman, then
another, and one from a Senator. The institution had been inspected only
ten days previous and the Veterans’ Bureau was sure the allegations were
not true, but sent out another man to investigate the matter. Later the
Bureau received copies of similar letters which the insane man had sent
to President Harding, King George and the Prince of Wales. He mentioned
this as an illustration of what the Veterans’ Bureau has to put up with.

Speaking about coordination and cooperation, he mentioned the fact that
the Public Health Service is represented in the Veterans’ Bureau by Dr.
Guthrie, Dr. Lloyd and Dr. Long, the Navy by Commander Garrison and
Commander Boone, and the Army by Colonel Brooke and Colonel Hutton. In
this way the Bureau benefits by the advice of these men, and friction
between the Departments is avoided.

Another thing he took up was the situation in Arizona. Attempts have
recently been made to get the Bureau to put hospitals in two towns,
Phoenix and Tucson, both of which he stated were so hot that everybody
would have to get out in the summer. There are 431 vacant beds at
Prescott, within 400 miles, and in a few months 422 more will be
available. Transportation has been offered these men to these hospitals
but many have refused to go. He believed that the Veterans’ Bureau could
do more than this, but wanted an expression of opinion on the subject.


MR. BURKE: asked for further discussions on the questions raised by Colonel
Patterson.


DR. KLAUTZ: stated that he would like to ask Col. Patterson whether the
question of furloughs has been taken up in connection with disciplinary
regulations.


COLONEL PATTERSON: informed him that length or frequency of furloughs had
not been determined, but permission to be absent will be obtained from
District Managers under policies issued by the Central Office from time
to time. He asked for an expression of opinion on this subject.


DR. KLAUTZ: stated in regard to the situation in Arizona that probably all
the hospitals available there were situated in an altitude of 5000 ft.


COL. PATTERSON: informed him that Camp Kearny is lower than this. He stated
that the policy of the Veterans’ Bureau in regard to tuberculosis has
the backing of the National Tuberculosis Association, and that the men
asking for hospitalization had been offered transportation to Kearny or
Prescott.


DR. KLAUTZ: offered the suggestion that somewhere in the mountains North of
Tucson there might be places which were not too high and would be good
all the year round.


COL. PATTERSON: reported that there are already at Prescott 131 vacant beds
and within four months will be 432 additional. Why should we go to
additional expense when we have these other hospitals?


DR. LONG: took up the subject of the speeding up of patients in hospitals,
which is necessary for two reasons—first, in the interest of the man
himself, and, second, in the interest of economy. The average man was
about 25 years of age when he entered the service, and it should be
taken into consideration that his character had not been formed, and
that keeping him in a hospital tends to destroy still further his
initiative, so the sooner a man gets out of the hospital the better it
will be for him. As for economy, it costs about $240 a month to keep a
man in a hospital. He stated that dispensaries are now being established
in the district and sub-offices, where treatment can be obtained, thus a
man should be discharged as soon as he has reached the maximum
improvement. He cited the case of Palo Alto, where arrangements had been
made with Dr. Wheate that when a man had reached the maximum hospital
improvement such further treatment as was needed should be obtained in
the out-patient office. In about six weeks the total number of patients
was reduced from 540 to 417.


DR. ELLIOTT: took up the question of furloughs, stating that at the Naval
Hospital in Washington at Christmas time many Veterans’ Bureau patients
asked for leave, and pursuant to advice from the District Manager they
were given the same amount of leave that the other Naval patients
received, from 5 to 10 days.


DR. DEDMAN: spoke on economy. He said he understood a certain rate per diem
was to be established for the care of patients, and wanted to call
attention to several things in this connection. First, the environment.
Some hospitals have central heating plants; others have stoves. He said
that his hospital was an old cantonment hospital, with a unit heating
system which required the employment of about 45 stokers.

Another thing, some hospitals Are a great distance from markets; also,
prices may be higher. All those things make quite a difference in the
average cost of the care of a patient per day.

With regard to General Order 27, he called attention to the clause which
gives the Medical Officer in charge the privilege of giving the man his
transportation back to his home, and mentioned the case of a man who
come to the hospital from Oteen, where he had been discharged for
disciplinary reasons. The hospital could not admit him, but authority
was obtained from the Veterans’ Bureau to admit him for examination,
and, if active, to hospitalize. The man was examined and found to be
inactive. He then complained to the American Legion because they did not
hospitalize him, and he had no way to get home. However, in this
particular case, transportation was later received from the Veterans’
Bureau. General Order 27–A now gives the Medical Officer authority to
pay transportation.

He then asked whether a man who had been discharged for disciplinary
reasons and was very sick should be hospitalized.


COL. PATTERSON: informed him that General Order 27 has ample authority for
emergency cases.


CAPT. BLACKWOOD: expressed his appreciation of the opportunity to attend the
conference, and of the great value it had been.

He mentioned the fact that the word “discipline” carries with a feeling
of dread. Discipline is purely and simply obedience, and when you have
obedience you have discipline. Orders should be issued in such away that
no antagonism will be created. He gave an example: In the Naval Hospital
the patients are all supposed to stand at attention, if able, when the
Commanding Officer comes thru the wards. The Veterans’ Bureau patients
objected most seriously to this, so an order was issued that they should
sit down, and now you couldn’t make them sit down.

He stated that with regard to the question of absence of a patient over
leave for seven days, under G.O. 27 a man can now stay away six days
without any action other than minor punishments, which he said is
absolutely ridiculous. He thought some other form of punishment, should
be devised, as reduction of compensation would not affect many of the
patients who are not receiving compensation, and believed the Commanding
Officer should be allowed to assign these minor punishments. He did not
believe the patient should be discharged, as in that case he would only
go to another hospital.

Another thing he suggested, with reference to medical records, was that
a skeleton record, at least, of the history of a man’s treatment, his
examination and diagnosis, should be made to follow him around from
place to place. This would save a great deal of work and give the
hospital a line on what has been done for the man in the past. He said
patients had been hospitalized anywhere from one to thirty-five times
prior to coming to his hospital, and it was impossible to get a history
of their previous hospitalization.


HON. CHARLES H. BURKE: I happen to be, as some of you may know, at the head
of the Bureau of Indian Affairs.

In listening to the discussion this morning by Mr. Madden and by General
Dawes, I have had brought to my notice that there are some things in
connection with hospitalization that compare in some respects with some
of the things I have to come in contact with in connection with the
administration of the affairs of the Indians.

Mr. Madden referred to the politicians and the harm they may do by
criticism and comment and so forth. I don’t think he meant when he said
politicians, the men who may participate in politics. I think he had in
mind these demagogues and agitators and sources of propaganda that are
doing more harm in the Government service,—I know it is true of the
Indian Bureau,—than anything else or everything else all put together;
and I think something of that applies to the hospitalization question.
Agitators, I call them. Some of them are perhaps interested in the
Indians and in their purposes, supersensitive, possibly. Others have
selfish motives that they desire to serve; others are just ordinary
trouble makers.

So, in the Indian Service, one of the things that we are handicapped by
is this aggregation that I have just described, that are criticizing and
finding fault with practically everything that is being done. One of the
things that they contend for more than anything else is that the Federal
Government, in supervising and administering the affairs of the Indians
should, before they put into operation any policy for their uplift and
their advancement, have the consent of the Indians. What an absurd
proposition! When you contemplate sending your boy to some educational
institution, are you going to permit him to dictate and say to you what
you shall do, or, when he selects a certain institution and tries it for
a few weeks, say that he does not like it and is going to try some other
institution? How far would a father get with a son if he permitted him
to dictate and dominate the situation?

So it seems to me that this question of hospitalization and caring for
the ex-service man is very largely a medical question and it ought to be
administered with a view to what will be most productive in
rehabilitating and restoring these men to full health; and so it
occurred to me that before this meeting adjourns, and because possibly
the impression may have been given this morning that the principal
question was one of economy, that we should, just for a moment, consider
this other question of what can be done and what should be done for the
best interests of these ex-service men. It will require regulations; it
will require legislation.

If you have not been repaid in the other sessions of this Conference
until this forenoon, I think every one of you who has come from some
distance will feel that he has been fully compensated in listening to
the discussion by General Dawes and Mr. Madden with reference to what
the Government, under our present Chief Executive, is endeavoring to
accomplish in the matter of administering Government. And so we have
this hospitalization proposition and all of the Departments having to
deal with that subject. We have this Federal Board of Hospitalization
made up of representatives or the heads of these different departments.

Now what I want to ask you gentlemen, and I am talking to you now as
experts, as men who are in the field in charge of hospitals, in a
position to see this Question from every angle,—what can you do now that
will help the situation. This is what I want to bring to your attention:
that is, that each and every one of you, through your proper officers,
communicate freely and from time to time what you believe ought to be
done to strengthen and improve this service; and then, these suggestions
coming from every part of the country and all of those different
institutions and services will be concentrated and ultimately have
consideration by the Federal Board of Hospitalization, and a regulation
will be prepared where needed and necessary legislation will be
suggested to Congress in the interest of better caring for and
administering these different hospitals throughout the United States.

My opinion, gentlemen, is this: that when a man goes into a hospital he
is presumed to be ill and should be governed by such regulations and by
such control as will best enable him to recover from his disability at
the earliest practicable time; and if he ought to have considerable
money and if he ought to be permitted to go his way, let him go; but if,
on the contrary, he should be required to live within certain reasonable
discipline as to his personal conduct, if he should be limited in the
amount of money that he should have to spend as he desires he should be
limited by you, who are expert and who have no possible thing in mind
except the welfare of these men.

Now don’t get the impression that you can get all the legislation that
you think perhaps you ought to have. I am not going to speak of the
Congress as constituted now, because a person in the administrative side
of the Government and in a bureau is not supposed to talk about the
Congress and so I am not going to say anything about the present
Congress; but up to about six years ago and for a period of many years,
I happen to know that there were men in Congress that don’t measure up
to what my friend, Mr. Madden, said a member of Congress ought to be.
There used to be members of Congress who kept their ears very close to
the ground listening constantly for any criticism, for any comment on
any part of the Government service, perhaps through a magazine or
newspaper; and they rose on the floor in their might to denounce some
policy or administrative action on the part of the Government simply
because they lacked the courage of their convictions.

Mr. Madden does not come within that class of members of Congress. He is
a man who has always been known to have the courage of his convictions.
Perhaps the entire body is now made up of that type of members, but such
was not the case up to 1915.

These agitators that I have spoken of, these demagogues, have learned
what you can do with a scared member of Congress, and we used to say
that the thing that emphasized most a scared Congressman was two. We
don’t have them I think any more.

My friends, let us hope that Congress is so constituted at the present
time, and we will assume that it is, that it will courageously and
fearlessly and without any regard as to what the results may be to
themselves, rise up and respond to what you gentlemen, through the heads
of these various Departments and the Federal Board of Hospitalization
may indicate and will enact into law such legislation, and if there are
any in the Congress who may have any fears about the results if they do
so act, I would say to them they have less to fear by keeping courageous
and standing for what is right, regardless of the comment at the time,
or the criticism that may come from certain sources.

Gentlemen, I thank you for the privilege of these few words and I hope
that all of you and each of you will be generous and diligent in
communicating, whenever you have any suggestions to make with reference
to bettering this service, in order that they may have the consideration
of these co-ordinating Departments that were so ably described this
morning by General Dawes. I thank you.


GEN. SAWYER: General Ireland, have you anything to say?


GEN. IRELAND: I don’t believe I have. I think it is time well spent and I
trust that there will be further meetings of this kind.


ADMIRAL STITT: I can only repeat what General Ireland has said. I have
learned a great deal from this Conference and feel sure that everyone
agrees that we should have a similar Conference, possibly every year.


GENERAL CUMMING: I have nothing to say except to express what I know is the
appreciation of everybody here to you as Chairman of the Board for
having inaugurated such a Conference, and, secondly, I think we owe
something to Colonel Forbes as an agent for having brought us all
together.


COL. MATTISON, N.H.D.V.S.: I can voice the sentiments just expressed. I
expected this meeting to be exceedingly valuable and it is vastly more
so than I had ever anticipated. I am very glad indeed to have had this
opportunity.


DR. WHITE: I want to express my personal appreciation for having had the
opportunity of coming into personal contact with all of you men who are
engaged in this work. I have long felt that one of the very great values
of a congregation of this sort is that resulting from personal contact
with men who are doing the same work.

I have listened to all of the discussions. I don’t know what I have
learned, but I feel, as I go back to my desk, that during the coming
year I will, in my various decisions, hark back to something that has
been said here that will help me solve the questions of the day. The
real things that one learns on occasions of this sort it is almost
impossible to formulate in one’s mind at the moment but they are always
brought up and proven valuable day by day. Thank you very much,
gentlemen, for the privilege of meeting you and I am going to ask you to
come out to St. Elizabeths and visit with us.


COL. PATTERSON: I have already occupied a great deal of time and so I can
only voice the sentiments expressed by the previous gentlemen. I know
those of us in the Bureau have learned a great deal and I hope that it
will be possible to let us have the benefit of a similar Conference next
year. We in the Bureau will be in a much better condition to profit by
your suggestions than we are this year and we will know better where we
stand than we do at present. Most of us are rather new to the job and
are in a very receptive mood.

In passing I would like to tell Captain Blackwood that the new order,
G.O. 27, covers most of the things he brought up. Some of the other
suggestions as to the way patients got into hospitals I fear will take
some time to rectify. We are in the hands of our agents in the field.
Many of them are not up to the standard. We hope to rectify that. As far
as the hospital question is concerned, I think you understand that the
Medical Bureau is with you and I hope you will take to heart what
Commissioner Burke has said and give us in writing the benefit of your
opinions and send them in through your chiefs. I hope you will give that
your attention and let us have the benefit of your advice. We want
constructive criticism and we need your help.


GENERAL SAWYER: How many of the Commanders present are accompanied by their
wives. Those that are, please stand. (Six stood up) I want to say
furthermore that the reception at the White House is at 8:30; entrance
by the North Portico. I feel sure that I can predict for you a very
pleasant evening.

In summarizing, just in a few words, I would like to give you something
of an idea of the impressions that have come to me and I believe that
you will agree that they are fair and that you should accept the same
impression for yourself.

First, it has been a great delight to me, personally, to meet you
Commanders of these various hospitals. I have a very much better idea of
the kind of men that are caring for these institutions and wish to say
to you that I am more than pleased with the capacity and the efficiency
that you demonstrate. Your contact here with each other has helped you
very greatly. To me the whole hospital question is visualized in a much
broader way. I thought I had a fair conception of what this proposition
meant, but I must say I have enlarged my horizon very materially. As for
myself I have received an inspiration such as I have never had before to
make of this hospitalization subject a matter for consideration and of
engagement of a much higher type. With the idea of its immensity, with a
better understanding of many of the details and requirements and
difficulties, I myself go forth to the undertakings I have before me as
the Chief Coordinator of this Board with much more determination than
ever before, with an ambition that has never quite possessed me before,
so I feel that I myself have been very greatly benefited.

There are some things you will take back with you out of this crowded
program. As the days come and go you will have the experience of
referring to this Conference as having given you new light and as having
given you an assistance you hardly record today.

It is my own wish that we may be able to put in the hands of each of you
quite extensive minutes of all of these proceedings. If I can bring that
about in the course of a reasonable length of time, you shall be
possessed of such a record.

I wish to thank the speakers for conforming so regularly to the
suggestion as to time limit. I wish to thank you for the care with which
you have prepared your papers and presented them. I wish to thank those
of you who have participated in the discussions. I want to express my
appreciation of those of you who have listened so intently and
apparently with such interest.

I would be unfair to the occasion if I did not express my gratitude for
the assistance that has been given us by the nurses in their association
with us here.

One thing I would have you do. You are but single representatives of the
institutions from which you come.

It would be somewhat selfish if you were to go home and bottle up within
yourselves the experiences that you have had here and the observations
you have made. Now, fellows, let me tell you what to do: Go back to your
various fields. Call in your associates and your assistants, take up
your whole administrative family and try to inject into them a little of
the enthusiasm, a little of the spirit, a little of the determination;
give to them some of the ideas you take away from here.

I want you to go while you are still under the influence of the
inspiration of the occasion, and I want to urge that each of you, as
soon as you get home, take up with your administrative family the
various things that have been discussed here, and try to instill in them
the same renewed earnestness and enthusiasm that you possess this
evening, and convey to them for us, this Board of Hospitalization and
the great President of this United States of America, Warren G. Harding,
the assurance that he appreciates every effort that you are putting
forth.

Coming from a doctor’s family, he realizes more fully than you can
possibly guess the difficulties that are confronting you every day; and
be assured that when you act upon your best judgment that you will find
him standing by whatever you may have regarded as necessary to the
bringing about of the end-results in this war veteran’s case.

Let me emphasize once more that the concern that the Administration has
is not how you may entertain them while they are in the hospital, is not
how easy and sympathetic you may be with them, but it is how you
engender in them a spirit of determination to get back into the world
again as productive citizens. That is your job.

In closing, let me say that at the suggestion of Colonel Patterson and
the Veterans’ Bureau which we are serving, that we are hoping that
somehow before another year shall have passed around that we will have a
real place to which we may invite you to participate in the most
interesting program that could possibly be produced. Fellows, I thank
you for your presence.


COMMANDER BOONE: I am sorry we are not able to raise our glasses to a toast
to the Chief Coordinator and the members of the Federal Board of
Hospitalization. The least we can do is to stand for a rising vote of
appreciation.

All stood up.

The meeting adjourned at 4:45 P.M.

------------------------------------------------------------------------




                          TRANSCRIBER’S NOTES


 1. Table of Contents added by transcriber.
 2. Changed “FEDERAL BOARD OF HOSPITALIZATION” to “U.S. FEDERAL BOARD OF
      HOSPITALIZATION”. The “U.S.” was written in on the original draft.
 3. Changed “distance between beds 3 feet” to “distance between beds of
      3 feet”.
 4. Changed “It takes an unusually patriotic citizen to $30 to $60 a
      month” to “It takes an unusually patriotic citizen to take $30 to
      $60 a month”.
 5. Changed “We cannot get them admitted as irresponsibles by the
      Courts. We have no such thing as voluntary commitment” to “We
      cannot get them admitted as irresponsibles by the Courts. We have
      no such thing as involuntary commitment”.
 6. Silently corrected typographical errors and variations in spelling.
 7. Retained anachronistic, non-standard, and uncertain spellings as
      printed.
 8. Footnotes have been re-indexed using numbers.
 9. Enclosed underlined text in _underscores_.