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

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:

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 102 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 103 to his own immediate superior.

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:

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 104 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:

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:

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.

106 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.

107 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 108 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 109 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.

110 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:

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

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 112 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:

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 113 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.

114 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 115 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:

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.

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

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 118 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:

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.

119 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 120 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.

121 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 122 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 123 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 124 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 125 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, 126 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 127 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. 128 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 129 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 130 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 131 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.

132 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 133 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 134 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.

135 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 136 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 137 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.

138 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.

139 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.

140 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.”

141 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.

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 202 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 203 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 204 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.”

205 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.

206 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.

207 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.

208 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.

209 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.

210 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.

211 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.

212 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:

Motion was seconded by Surgeon General Cumming.

Motion carried.

213 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.

214 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.”

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.

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

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.

302 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.

303 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.

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(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.”

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.

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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.

307

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.

308

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.

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

309 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.

310 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 311 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 312 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.”

313 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.

314 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 315 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.

316 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.”

317 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.

318 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:

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.”

319 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.

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 320 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.”

321 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 322 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.

323 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:

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.

325 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.

326 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.

327 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.

328 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 329 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.

330 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.

331 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.

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:

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.

402 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.

403 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. 404 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.

405 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.

406 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. 407 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. 408 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? 409 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.

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 411 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.”

412 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 413 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.”

414 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 415 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.

416 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.

417 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.”

418 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.

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.

419 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.

420 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.

421 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.

422 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.

423 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.”

424 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 425 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.

426

(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.

427 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 428 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. 429 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 430 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 431 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.

432 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.

433 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.”

434 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.

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.

502 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.

503 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 504 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.

505 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 506 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:

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.

507 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.

508 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.

509 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.

510 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

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) 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 511 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 512 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. 513 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 514 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.

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 516 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.

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.

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.

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.

C. R. Forbes.
Director, U. S. Veterans’ Bureau.

File No.

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 521 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.

522 (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 523 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.

524 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.

EXHIBIT D

526 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 527 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.

528 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.

529 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 530 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 531 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;

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:”

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 532 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:

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.

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.

602 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.

603 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.

604 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.

605 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.

606 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 607 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. 608 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.

609 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.

610 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.

611 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.

612 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; 613 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.

614 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. 615 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.

616 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 617 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.

618 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.

619 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.

620 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.

621 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.

622 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 623 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.

624 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 625 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.

626 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 627 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.

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 702 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 ). 703 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 704 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.

705 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 706 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 707 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.

708 “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 709 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 710 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?

711 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.

712 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 713 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 714 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 715 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, 716 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 717 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.”

718 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 719 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

720 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 721 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 722 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 723 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.

724 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.

725 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.

726 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 727 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.

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:

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.

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.

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:

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. 803 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. 804 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.

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.

806 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.”

807 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.

808 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.

809 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.

810 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.

811 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.

812 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.

813 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.

814 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 815 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.”

816 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.

817 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.

818 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.

819 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. 820 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. 821 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. 822 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. 823 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.

824 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 825 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.