EXHIBIT E

RECONSTRUCTION TRAINING

SUMMARY BY DISTRICTS

January 1, 1922.

Dist.Number of InstitutionsNumber of StaffWar Risk PatientsAssigned to ClassesEnrolled in ClassesPercentage of Avail. Patients Enrolled
1730144365242966
21150228292678284
371681934425775
49612538122884668
586638462053139468
6418118556345280
71949230991675382
81552163191471178
951230326023992
101133143270752174
11219157761734135
1215552646111772565
133964917213881
1411394244230070
Grand Total:1174832360210911788872

ADMIRAL STITT: reminded the men that at the meeting yesterday afternoon a motion was made to discuss the paper on the “The Social Service Worker” this morning, and there were about 25 minutes for the discussion of each of the four subjects—the social service worker, disciplinary regulations, relation of district managers, and physiotherapy and occupational therapy in hospitals.

CAPT. BLACKWOOD: said it was his opinion that the social service worker has done more to aid the Commanding Officer and to follow up the work on the ex-service man, as well as the service man, than anything else he knew of that has been introduced into the hospitals. The social service work in the Navy is all done by the Red Cross, one of the most wonderful organizations in the United States for doing good.

SURGEON CHRONQUEST emphasized the point that diversion and recreation should be distinguished from the social service, with which it is so often linked.

SURGEON LASCHE: stated that at first he was sceptical about the introduction of people under extraneous control into the hospital, but that he incorporated the Red Cross into the official organization of the hospital and made the director a member of the staff. He believed in keeping a fairly close supervision over the activities until he knew the individual, and made a rule that the social worker should send a carbon of every letter written about the patients to the officer in charge. It was found that at the beginning there was no possible reason for about 30% of the letters written, but only one-half of one percent of the letters produced harmful results. He said he was inclined to think that owing to the fact that the Red Cross has the benefit of a nation-wide organization that for the present it is very much better to utilize their services than to establish government employees to do the same work.

COL. BRATTON: said that experience had shown him that the Red Cross is a great aid in carrying on relation to the outside world. He told of the situation in Atlanta. When the hospital was established he found it would be necessary to satisfy the people of Atlanta that the wounded boys were being properly taken care of, and was fortunate to secure the services of a first-class man from the Red Cross. The result was that the people became very interested in the work and sent committees with food, also provided pictures two or three times a week and all kinds of entertainment.

SURGEON PAYNE stated that one of the greatest difficulties he had experienced had been in sidetracking the people who, though kindly disposed, brought food and all kinds of entertainment which were injurious to the patients. He said he did not believe in any kind of athletics in a hospital, unless under the Physiotherapy Department, neither did he believe in dances in a hospital. He said people would bring in all kinds of food and the patients would eat it before going to mess, and then of course would complain of the hospital food furnished. The greatest benefit from the Red Cross had been the coordination of those activities.

COL. BRATTON asked that some of the men who served in General Hospital #6 speak on this subject.

SURGEON WILLHITE: stated he had served under Colonel Bratton, and agreed heartily with all he had said. He stated also that in his work in the hospital in Philadelphia the Red Cross had done the finest kind of social service work, coordinating all the agencies that Dr. Payne spoke of as so detrimental to him, and he believed had been a very great benefit rather than a hindrance.

Dr. Dedman took up the work of the Red Cross in taking care of relatives of patients who come to the hospital. Often these people spend all their money for railroad fare, and have none left when they reach the hospital, and the hospital has to take care of them. He said he had arranged that four or five rooms be fixed up for such people as this and believed some definite authority should be had from the Veterans’ Bureau to house these people and furnish their meals. He stated that some boys will ask for things and others will not. He referred to an instance in which a patient had told a lady that he needed a shirt, and two days later when she brought him one she gave it to him before the whole ward and the boy was ridiculed for a long time afterward. He had had trouble in getting the work done through the social welfare workers in the hospital, as the public wants the individual glory of handing something to the boys themselves. The Red Cross has also been a great aid in investigating home conditions of the patients, especially of tubercular patients who want to go home to die. Also, in the case of a man who asks for a long furlough because his mother or sister is dying, the Red Cross will investigate and get an immediate report, and many times it will be found that the mother or sister is not sick at all.

SURGEON PAYNE: stated that he did not want to be misunderstood, that he did not mean to take credit away from the Red Cross.

LIEUT. BOONE: stated that the discussions had gone afield, that real social service work is summed up in four or five heads—securing social histories and other data for the use of tuberculosis specialists and psychiatrists, securing reports on home conditions for help of physicians in deciding whether or not to discharge a patient to his home, corresponding with home communities to adjust home situations, thereby making it possible for patients to remain in hospitals, and arranging through local communities for men who return home to have proper care and assistance in adjusting themselves to civilian life. He believed a great deal of this entertainment work should be separated from social service.

ADMIRAL STITT stated that the question had been considered by the Federal Board of Hospitalization, and it had been recognized that only the Red Cross has this tremendous machinery and it was considered that the Red Cross is the proper agency and organization to take care of that sort of thing. The Red Cross should coordinate and control these outside agencies. He announced that the next discussion would be on “Disciplinary Regulations”.

DR. KLAUTZ took up first that in tubercular institutions the rules must always be stricter than in the general government hospital. He emphasized the fact that tuberculosis in a civilian is the same as in an ex-service man, that the same methods of procedure must be applied in treatment, and that the patient must recognize the importance of discipline in the tuberculosis hospital.

SURGEON DEDMAN stated he had taken part in the compilation of General Order #27, and that he found one flaw in it now. This was the clause about giving a man his transportation. He believed that a man would soon get restless and if he could get his transportation home against medical advice many of these men would get some wonderful home trips. He said this would make it one of the hardest things on earth to keep sick men in bed. He said the only way for this to be done would be to deduct the transportation from the man’s compensation. He stated that General Order 27 had put Commanding Officers where they could sleep at night, that before there was simply turmoil and strife, like the boy in France whose wife, every time she wrote to him, nagged him, and he of course was never anxious to get her letters. Finally he wrote to her “Dear Maggie—Received your last letter. For God’s sake don’t write me any more. Let me fight this war in peace!.”

DR.LLOYD: referring to Dr. Dedman’s complaint, stated that in the case of a man discharged for disciplinary reasons the man would not have the means to get home, and the community would have to take care of him, that it was a choice between two evils. In the case of a man who goes home against medical advice, if his transportation were not paid he would just do something and get fired for disciplinary reasons. He asked for some further discussions on the matter of patients being sent back to a hospital when they ought not to be.

SURGEON MILLER: referring to General Order 27, stated that in his hospital the patients were willing to pay their own transportation, and would go whether it was paid or not.

ADMIRAL STITT: asked that those who wished to present resolutions be writing them.

DR. GUTHRIE: requested that the medical officers who have complaints in regard to General Order 27 and do not have time to express then write them out and he would be very glad to have them sent to him.

SURGEON WHITE (Speedway Hospital): asked whether, if a patient stays away over night A.W.O.L., paragraphs 3 or 4 on Page 3 of General Order 27–A would apply.

ADMIRAL STITT asked that Dr. Lloyd answer that question.

DR. LLOYD: suggested that if patient stays away less than 24 hours mild disciplinary action might be applied, if longer than 24 hours he should be disciplined, that these matters were covered in the paragraphs referred to.

ADMIRAL STITT: “The next discussions will be on “The Relation of District Managers to Hospitals.””

DR. WILLIAMS: emphasized the point that when a man comes to the hospital he should be treated for everything that is wrong with him.

SURGEON BROWNE: wished to report a plan in operation in Boston. Every two weeks a luncheon conference is held, at which are present the Commanding Officers of the hospitals, the head of the American Legion in the State, head of the New England Red Cross, and the Commissioner of State Aid and Pensions. In this way it was possible to straighten out all difficulties and there is now practically no friction between these departments.

CAPT. ELLIOTT: spoke on the contact with the District Manager here in Washington, that it was very easy to reach him by telephone and obtain advice which facilitates the discharge and treatment of patients very much. The relation of the Naval Hospital with the District Manager has been one of greatest cooperation, that the Veterans’ Bureau had even gone so far as to lend a typist and stenographer to help in the great amount of clerical work necessary in making out papers for Veterans’ Bureau patients.

Another man spoke of the multiplicity of paper work necessary in connection with the new form adopted by the Veterans’ Bureau in place of 1934–B, that it was impossible to manifold this form and it necessitated just twice as much work as before. He suggested that the Committee on Forms consider the feasibility of adopting forms that can be manifolded and thereby make economical saving.

SURGEON YOUNG: stated that in regard to the relation of the District Manager he would like to know whether the representative of the Veterans’ Bureau to be in the hospital is to be there as a man directly connected with the personnel of the District Manager’s office, or whether he is to be there as a representative of the Veterans’ Bureau itself.

DR. RAWLS gave the information that the educational director would be a representative of the District Manager, on the staff of the Commanding Officer of the hospital, who would deal with the District Office in matters pertaining to the District and to the hospitalization of the patient. He stated that it might be that in dealing with certain other phases he would have a direct channel to the Bureau, but this had not been definitely decided.

GENERAL SAWYER: stated that the subject of hospitalization most now be viewed as a much broader field than ever before, that after discussing the subject of an educational department and social service work with people in contact with it it was decided to be absolutely necessary to enlarge the personnel of these hospitals so as to take in these various new things which were coming up for consideration. He emphasized the fact that the end result is the important thing, but that in consideration of all of these subjects it should be understood that these Red Cross representatives and all other employees will be subject to the Commanding Officer. He said he was satisfied that most of the complaint made was by individuals who come into the hospital and do not come in contact with the Commanding Officer. The whole idea of the social service relation is that these men shall be made more resourceful and more capable of earning a living for themselves.

COL. EVANS: took up the number of personnel required, and stated that it had been approved that the average requirements would be—one teacher or one occupational therapist for each twenty individuals actually engaged, and one physiotherapy aide for each twenty treatments per day. He stated that one might not take care of over five patients, but the basis of estimation was one for twenty, and that the average would be one to sixteen if the educational director and his clerical help are included.

SURGEON SPRAGUE: spoke on the value of occupational therapy. He told how after the introduction of occupational therapy in his hospital in New York boys who had been very troublesome before became deeply interested in the work and the wards became as quiet as any other wards. He wished to express himself as most heartily in favor of occupational therapy.

Another discussion on this subject followed. It was stated that there is no question as to the direct therapeutic value of occupational therapy. The disciplinary value is its greatest value. Very often, too, there will be found a boy who has real talent.

SURGEON PAYNE: stated that in his opinion a simpler method of reporting should be adopted, that the system of bookkeeping is perfectly idiotic and that nobody knows just what is meant. He said there was a great deal of sentiment against the Government having any interest in what the man makes, and that in many cases the men buy their own material. He cited the case of a man in his hospital who makes all kinds of toys out of tin cans and has worked up quite a trade. Public sentiment is all on that man’s side.

COL. BRATTON: with regard to paying transportation for men discharged for disciplinary reasons, made the following motion, which was carried;

MOTION

That the Director of the Veterans’ Bureau be requested to secure legislation so that the expenses of the patient’s transportation to his bona fide home, when he has been discharged for disciplinary reasons, be deducted from his compensation, when compensation is being given, or may be given thereafter.

DR. KLAUTZ: said it was his opinion that it was better to put a man right on the train and send him home.

CAPT. BLACKWOOD: “In view of the remarks made at this meeting yesterday in regard to the nurses, and in view of the fact that Congress is contemplating the question of pay for the services, I would like to present this resolution:”

RESOLUTION

Be it resolved that it is the sense of this meeting that the pay of the nurses of all branches of the Government service is far below what it should be and therefore is a detriment to the entrance to or continuance in those services of the better type of nurses, and that it be urged upon Congress by the Federal Board of Hospitalization that legislation be enacted to remedy this condition.

This resolution was adopted.

DR. KLAUTZ: offered the following resolution, which was also adopted:

RESOLUTION

That a standard procedure be adopted for the treatment, medical supervision and control of tuberculous patients in all Government hospitals for ex-service men, including uniformity in matters of furlough, application of occupational therapy and pre-vocational training, as far as it may be possible, without sacrificing individualization of treatment.

The meeting adjourned at 12:25 P. M.

Sixth Session Thursday, January 19, 1922.

Present: Members of the Federal Board of Hospitalization and about one hundred Conferees.

GENERAL SAWYER: In arranging the program of this afternoon, we wish you to consider it as open for discussion for bringing to the attention of the Conference any subject which you may have in mind.

We have divided the work in this way. In order that we might have some leading thought from which to start and upon which to base our discussions, I would remind you that in the n.p, and tubercular case, the Government has its greatest liability.

I would remind you also that particularly in the n.p. case the medical man has his greatest responsibility.

We have learned by comparison month by month since taking over this work that the general medical case has already become a quite rapidly decreasing case in numbers. We find, however, that the mental case and the tubercular subject are both increasing in number. We realize that in the general medical case ultimately we must get to a place where we shall have finished largely with that character of case.

But with the n.p. case we know that so long as we have a remnant of the World War Army in existence, we have these neuro-psychiatric cases under our observation.

I would like to charge you, while I have this opportunity, with this particular responsibility on your part, and I would like to tell you how I think you can do greater justice to the soldier and how you can certainly help your Government best in considering this subject.

For myself, after a very close personal contact of ten years in the specialty of treating mental and nervous diseases, I am satisfied that in 99% of all of these cases,—perhaps that is a little strong,—I should say in 90 per cent of these cases you will find, where the case is genuine, that you have some physical cause at the bottom of the mental trouble.

Therefore I wish to suggest that in the consideration of this case, that you never allow one of them to pass you excepting you give him the most careful examination; that you go over him in the most thorough way; that you look into his case, so far as his history is concerned, taking into consideration the decade in which he is living; go over it with every laboratory refinement of diagnostic assistance that you can possibly give and see if you cannot find somewhere some physical trouble that is behind the mental symptoms.

For myself, I am convinced that there is no case, excepting those that have gone on to the degenerate class of diseases, which usually appear after fifty, but has some physical derangement the overcoming of which may help very materially in the curing of the case.

So I would like to emphasize this thought: that you have not exhausted the service that you can render, you have not relieved yourselves of the responsibility, you have not acted as loyal doctors of modern times should have acted, excepting that you take the greatest care in the preliminary examination of these patients.

And then I would like to emphasize also that your preliminary examination, by comparison with frequently recurring examinations, so long as they are under your observation, will help you very materially.

I wish you to know that I am impressed with this idea. This is what I believe:

That many of these cases that come to you will be better off outside of institutions than in them, and I want you all, all of you, to help us to try and correct this impression that is now existing, that the Government does not give this class of cases proper attention.

If the Government is not giving them proper attention, it is not because of their disposition to do so, but it is because they have not had time enough to develop resources by which they can handle these cases well.

I would feel that I have not performed my function here as a doctor if I did not say to you to be thus careful in your diagnosis and then help to work out a plan whereby, if this subject cannot be made well, he can at least be made more self-dependent. Use all of your influence to help to cite where these men can find niches into which they can go and make it possible through the influence you can bring to bear upon the people who are associated and connected with them that they are better when they really are established in their homes. There is no case in the world that is more unfairly treated than the neuro-psychiatric case. We all know that by many experiences and observations. So let us give particular and special attention to this subject.

They say to us we have no specialists in this line. I am not so sure but we are better off for that. This is what I do believe: that every man who has broad experience of a general practice of medicine is competent and capable of quickly developing himself to conduct these cases along carefully.

You have no greater field, men, either for yourselves, for the patient, or for your Government, than in this field.

Now as to the tubercular case. The error we find in the matter of the tubercular case is this: We find a great many cases are diagnosed tubercular when really they are not,—a very bad impression, as you can imagine, to give to any subject. So let us be very sure, let us leave no influence, or power, or activity unused that will help us to define the exact attitude of these cases.

We know, as was related here yesterday, that many of the so-called cases of shell shock are really due to other causes. This is my own observation of those cases, we had a number immediately after the war, at the Institution with which I am connected, and we found a most invariably these men were the subject of the toxemias of fatigue, and by relieving the toxemic conditions, whether it be uremic infection, or what not, these cases soon got well and their mental symptoms soon subsided. So be sure that you be perfectly fair with these men, and you are never fair with them until you have exhausted every resource in discovering whether or not, as the basis of their mental or nervous disturbance, there may not be some physical condition.

The meeting is now in charge of Dr. White.

DR. WHITE: I hope there will be free discussion of this matter. There are a good many men who have had charge of neuro-psychiatric hospitals, and I hope you will feel free to get up and briefly set forth such vital problems as you may have in mind. In order that we may cover as many problems as possible, I will, with your permission, let you know when the five minutes is up, so we can cover the ground as fully as possible.

DR. KOLB: In relation to the examinations made of these neuro-psychiatric cases which were sent to us, I want to outline the procedure we use at Waukesha in arriving at correct diagnosis and methods of treatment. The patient is given to one special doctor. This doctor is supposed to make the first preliminary examination, which included a complete physical, neurological and psychiatric examination, and do all the work in connection with these patients while in hospital. In making this examination we have on our staff a number of very competent attending specialists in order that we can obviate the mistake General Sawyer has mentioned of assuming that these men are simply neurotics and passing over important physical conditions. By this method we have caught a number of cases which have been passed over as cases of neurasthenia. For instance, I have in mind a case diagnosed neurasthenia which was treated six months ago, which was a case of brain tumor.

After we have made the first preliminary examination the man is carefully observed in hospital, not only by his own officer but by the clinical director, and notes are made from time to time. Examinations are also made by the dentist, x-ray examinations and various laboratory examinations, including serological and base metabolism. In the end, after all the data is assembled and written up, he is brought to the staff and there his case is thoroughly discussed by all the members of the staff; a diagnosis is arrived at, methods of treatment discussed and afterwards put into effect.

Now as to the organic conditions with which our neurotics suffer. It is true a large proportion of them do have organic disorders in connection with their neuroses. We find that most of them do have functional disorders originating purely in their mind, or because of some constitutional nervous defect and that the real fundamental condition from which they are suffering is not an organic condition but is nervous or mental and must be approached along lines of psycho-therapy.

Now I will not go into the subject of psycho-therapy. We pay special attention to mental questions but we do not neglect the physical by any means. Every physical disorder which is found is corrected, if correction is possible. We have complete physio-therapy and occupational therapy and all other facilities for treating nervous cases. We are careful never to stress too much on the physical treatment we give these patients, because by so doing we suggest to them conditions they really do not have and by that means prolong their functional disorders.

Regarding occupational therapy. We all know that this is a very important method of treatment. It should always, as Colonel Evans said, be directed treatment and should not be given in a hap-hazard way. All of our occupational therapy treatment has been given a definite prescription. For eighteen months we have had a bright young medical officer interested in this subject, whom we have made reconstruction officer and who observes the effect of treatment and changes the prescriptions of the other physicians when he finds the treatment given does not have the desired effect.

With reference to reconstruction aides, every week our reconstruction officer gives them a talk on some phase either of occupational therapy or physio-therapy or of mental disorders. We cover any subject in which the neuro-psychiatrist should be interested. This officer has devised a system of observation which the aides are supposed to make on patients and which they do make on each patient who takes occupational therapy and which is looked over by our reconstruction officer and the officer in special charge of the case. We are getting up data and statistics which we think will be of interest to the general profession when it is finally published,

DR. TREADWAY: I think that the Public Health Service has had a very grave and serious problem affecting the N.P. Veterans of the World War. We have included in that term, besides the mental and nervous cases, the neuro-surgical cases as well.

There are a number of problems which still confront us, and one of these is the question of personnel. I am sorry that Dr. Kolb did not say something about the training school he had started in connection with his hospital. We sent some young officers over to learn technique and methods of handling the psycho-neurotics. We have also sent some officers to the Public Health Service clinic at the Psychopathic Institute in Boston and we hope that some of our other hospitals will start a similar school. The question of personnel is an exceedingly grave one. A great many young men want to become surgeons.

They are not interested in mental or nervous cases. They want to go into general medicine. Last year we sent two officers to the Southern University and to the Northern and Western universities to meet the graduating classes and the internes, and from that we have been recruiting some younger men who are manifesting considerable interest. We hope to get additional personnel by interesting the young graduate.

Another problem is the question of creating, in connection with General hospitals, wards where patients of this sort may receive at the beginning of their treatment, their preliminary examination, where they may be evacuated home with compensation or without compensation, or evacuated to a prolonged treatment hospital for further care.

It has sometimes been difficult to get enough men, trained personnel, to man these wards.

We have believed all along that the proper method of treating the pyscho-neurotic, so-called, is in out-patient clinic and we have attempted to develop out-patient clinics with the old dispensaries maintained by the Public Health Service; but the question of personnel again entered into it, and we were unable to develop as many out-patients clinics as we should like. We think, however, that the mild, mental case, as General Sawyer has said, is far better off in the outside world than he is in an institution. If such cases go to a hospital, it tends to have their symptoms crystallized and they believe they are sicker than they really are. In other words, they seek out some minor physical disability as a peg on which to hang what they think is a grave disorder.

The question of compensation for these cases is an important one which must be worked out. The man who believes he is seriously ill when he has but a minor defect, if he has compensation and has a weak will, will not make a strenuous effort to get back on his feet. The question of maximum compensation for these cases many times interferes with rehabilitation.

We believe that this is a new method of handling mental patients and it may serve as a copy to other States to prevent this enormous building program which every State has had to go through and which has not met the needs of the insane.

Compensation for epileptics and their examination is a very important question and has been a serious problem to us.

We find among neuroses not infrequently mild convulsions. We don’t know a great deal about these convulsions; some are epileptic and some are not. The true epileptic, however, has great difficulty in making a go in the outside world. The number of convulsions per month is not an indication of his disability, entirely, because the passage of the Employees Compensation Act in the several States, has interfered with the employment of men with an epileptic past.

It is as hard for the man who has a seizure once a month to get a position as the one with four, so the question of treating epileptics is one largely of social service and compensation.

The hospitalization of epileptics has not been a success in the hands of the Public Health Service. One of the Western States that built a large colony for epileptics some years ago has now turned it into an institution for feeble-minded.

The question of vocational training is also a big problem in connection with this type of disability. A man, for example, whom I saw a few weeks ago, had been a jewelry polisher in Boston. Before the war he had to get up every morning early and go to his work. He gave most of his earnings to his family. He was suddenly taken out of that situation by the draft and put into a situation where it was simple for him. All he had to do was to get up and move around when some one told him to. He was furnished with his clothing; he was furnished with his food. When he got over on the other side he painted a rosy picture about how things were at home. When he got back home it was not like what he imagined it was. He had to get up and go back to his old job. It was hard for him to make the effort. He quit his job. He goes to the Vocational people (he had a seventh-grade education). He wants to become a civil-engineer. Obviously he cannot. He tries another occupation, etc. Now the attempt of that man to better his condition is a laudable one, but very often that desire to get away from a difficult situation is a part of his mental disorder. He must be made to understand and meet that problem frankly and not be seeking round-about paths without very much continuity of purpose. Vocational training in connection with epileptics has not been very successful. Dr. Ellison who has had charge of a hospital for epileptics can give us some valuable information on the problems of the epileptics.

I think that Dr. Wilbur, who has had charge of a large station at Chicago, can give us some valuable information about preliminary examinations, the social service aspect of these cases, the need of social service and the handling of the psychoneurotic in out-patient clinics. Dr. Wilbur and Dr. Chronquest can tell us about the problem affecting the insane. Mr. Chairman, I suggest that you call on them.

Dr. ELLISON: I want to say the program as outlined in the afternoon session is one of vital interest to me, because I have been in charge of one of the most problematic Government Institutions in the country, that is, an epileptic hospital in East Norfolk. The administrative program in hospital of this kind, taking into consideration the application of general orders, hospital regulations and internal regulations as within the hospital, is entirely different from any other class of hospital under Federal control.

The very fact that you attempt to apply certain regulations in a hospital of this kind where the morale is naturally at a low ebb, due to the mental phases under which these men are suffering, sometimes results in disaster and the breaking down of the morale you have in the hospital.

I would like to go on record in stating it is my belief that voluntary hospitalization of the epileptic is anything but desirable.

From the standpoint of rehabilitation of the epileptic, I must take into consideration the particular type of epileptic we have in the hospital. As Dr. Treadway stated, the majority of these man have not reached probably the school grade of seven years. There has been an attempt on the part of the rehabilitation department to make lawyers, doctors, diplomats out of these epileptics. It is absurd and cannot be done. These men are social and economic lepers, so far as their rehabilitation is concerned. The communities do not want them. Their families do not want them and the responsibility for their care rests upon the Government. Then what is to be the solution of the disposition of these men? I can see but probably two solutions to the question. Voluntary hospitalisation is out of the question. I believe that that part of the Bureau concerned with the compensation of these men, from an economical standpoint, must take into consideration the question of the grouping of these epileptics. There is a class which can live at home. There is another class, not definitely formidable, which does need custodial care. Then there is the psychiatric epileptic who needs psychopathic institutional care. In arriving at the disposition of these men you must take into consideration those three groups.

Then there is another group, there is a mixed group of epileptics. In many instances we have noted, after a long period of observation, that a man may react to some situation, starting out in a hysterical seizure and wind up in a definite epileptic attack. That has been true in quite a number of cases and I should like to urge upon the Bureau District officers and those concerned, this one thing:

In referring cases to East Norfolk, I think a very careful examination should be made of these men to determine as nearly as possible that they are epileptics.

At East Norfolk there is a situation existing which I have endeavored to correct; that is hospitalizing psycho-neurotics,—neuropsychiatry cases which are not definitely epileptic, which are made worse by contact with the epileptic patient. These men are being made worse every day. Some of them simulate very closely the epileptic; many have learned to bite their tongues as the epileptic does. They should not be hospitalized; about 25% of the cases are not epileptic. I think that should be taken into consideration and a careful survey made of these patients before they are transferred to East Norfolk.

As to these cases, very much the same program is carried out as Dr. Kolb’s. Complete preliminary physical and neurological examinations are made and patients are placed under observation of one man, who observes them and makes notes from time to time. As for the treatment of these men, there is little to be done in a way. I think it resolves itself into occupation mostly. I think the occupational measure as applied to the epileptic is the only solution. I think they should be kept busy every moment, for many reasons. They are naturally fault finding and if they have something to do it will lessen the time they have to think of these things. It will promote interest in their surroundings. It will lessen the liability of deterioration but as the thing now stands that cannot be done, under the present method of hospitalization. The solution covering that is, I believe, for the Government to formulate, properly taking into consideration these districts, and build an epileptic colony, under proper supervision, and I believe from an economic standpoint, it could be made almost self-supporting.

In regard to the medical treatment, we have been instituting at East Norfolk a very careful treatment,—careful observation—to determine the real value of luminol in the treatment of epilepsy and we have found that it has been beneficial in many ways; that it lessens the severity of the shock, prolongs the intervals between shocks and in many instances effects complete cessation; the patient becomes more alert, more active, more interested in his surroundings. This treatment must be continued day after day. If there is a cessation, or lack of it, or a failure or inability on our part to obtain luminol, these men immediately react to the lack of it. I should say we have had at least four deaths at East Norfolk due absolutely to the lack of luminol.

DR. WILBUR: At Chicago we developed a diagnostic clinic at the Marine Hospital and had two departments: in-patient and out-patient departments. We had a capacity for in-patients of about 150. The out-patient department was unlimited and developed to approximately 160 to 175 patients at one time. The in-patient department is divided into five groups for the investigation of cases;

1. Cases which would be immediately transferred to some other hospital as soon as arrangements could be made;

2. Certain disorders taken up under direction of an officer particularly interested in such disorders and investigated as fully as possible;

3. Hyper-thyroidism, following operations, where the pulse is still high. When such cases were sent to us, an attempt was made to stabilize the patient and bring him down to a nearly normal basis so that he could go out and take Federal Board training.

4. Psycho-neurotics.

5. Epileptic and hysterical cases.

I might say that out of every fifteen cases sent in with diagnosis of epilepsy, about twelve or thirteen of them proved, after careful observation for a period of from two to three months, to be hysterical. That was about our ratio on cases sent in.

Our procedure was much like Dr. Kolb’s at Waukesha. The man was given complete physical, neurological, examination first. We had a special consultant who visited the hospital about once a week. After a man had his examination, he was checked as needing further examination in eye, ear, nose and throat, or x-ray,—whatever was indicated in the case, and that was tabulated on the chart and checked against his examination. At the end of that time each ward surgeon prepared a summary of the case and a decision was made as to whether the patient needed a short term of treatment in our own hospital,—we had there occupational therapy and other methods of treatment,—and then be discharged and sent back to his home.

In connection with the in-patient hospital work, we had a committee at the district supervisor’s office made up of one representative at the Bureau of War Risk Insurance, one from the Federal Board, the neuro-psychiatric contact officer and one representative from the Public Health Service. We tried to place the men in some definite schedule,—the Federal Board, if possible, after he was discharged from the hospital, and we would bring our problem cases to this meeting, where they would be taken up and such arrangements made for their further treatment as necessary. The contact man visited the station once or twice a week to familiarize himself with the problems of each man.

The out-patient department was naturally on a different schedule; that is, certain hours of the day were set aside and definite offices assigned to the out-patient department; they kept track of their own patients, who reported in at intervals of two or three times a week, every two or three weeks, according to the needs of the case. If the man needed some special treatment, he came into the hospital for that treatment and at the same time he saw this ward surgeon and talked the case over with him. Just as soon as that patient was ready for vocational training, he was put into touch with our contact officer and a schedule was made out for him.

In regard to the vocational training for epileptics, a great many cases during the year I was at Chicago, came up to that board for consideration. We tried the epileptic at various occupations; kept him away from machinery so as no injury would come to him, and we succeeded in rehabilitating only two epileptics out of the whole group. These two were given positions in factories that were owned or governed by some relative or friend who had taken an interest in then, disregarding the compensation laws and disregarding the inability of the men to work when they would have a seizure. In two instances only have we succeeded in putting men into training where it proved a success.

DR. MCLAKE: I represent the National Sanitorium in Marion, Indiana. Presume all of you have heard more or less about it. It was organized about a year ago; opened on the first of January as a sanitorium. During the past year we have cared for about 1500 patients. The present Census is 800.

Now this institution was opened under a provision that it was to be used for the hospitalization of reasonably curable cases. In other words, it was not to be an asylum. It was not a place for merely domiciliary residence or custodial care. The needs of hospitalization, however, this year, have been such that we have taken all sorts of cases. As this has been a matter of discussion for many hospitals and in many districts, I want to take half a minute to show you that during the past year and at the present time, I am hospitalizing at Marion nearly every variety of n.p. case which we have.

Up to the present time we have had no special accommodation whatsoever for n.p.-t.b. patients. Our institution is built on the cottage plan and in the preliminary survey and construction no provision was mode for t.b. patients. However, at the present time I have one ward which is filled with eleven of these cases. I may say in this connection that we are expecting to build a t.b.-n.p. unit of eighty beds and will start construction in about five or six months, which will be gratifying to you men who have these combined cases and would like to unload them and as soon as we can take these cases off your hands we will be glad to do so.

In that connection I want to emphasize one thing: that in your general hospitals and in your t.b. hospitals you get many cases toward the end of this t.b. condition, which present n.p. symptoms. Now I know from experience at Fort Bayard and in other t.b. sanitoriums, especially at Fort Bayard, where I was associated several years with Colonel Burke, that these patients become exceedingly troublesome and exceedingly annoying. However, if you are perfectly frank with yourself and perfectly frank with the n.p. man, you will admit that these cases are not primarily n.p. cases, but cases of terminal toxemia. I don’t believe myself that these cases should be hospitalized as n.p. I believe in your t.b. hospitals you should set aside a ward or two or three wards where you can take care of your terminal toxemias whose symptoms are principally mental; they should not be unloaded on the n.p. hospitals which are built and equipped for reasonably curable cases of n.p. disease.

As to what General Sawyer said about many of these n.p. cases living outside. I want to most heartily indorse that attitude, and I will say in that connection that during the past year I have turned out between two and three hundred men because I firmly believe in that view. My method for turning out these n.p. cases is as follows:

After a final conference on a man after preliminary observation, if we feel that he has come to the point where he should be given a chance, we give that man a thirty-day parole. If he has a guardian, his guardian must report every ten days. If he has not a guardian he is placed in communication with the Veterans’ Bureau officer, or a Red Cross worker in the District, in which he is paroled.

In other words, during the first thirty days I get three reports as to his condition. If after thirty days he is still doing well, I grant an extension of thirty days. During the second thirty days he reports in twice. If he is still doing well at the end of sixty days, the parole is extended to ninety. I believe in the majority of our cases that if a man makes good for ninety days, it is reasonable to suppose that he is going to make sufficient adjustment to stay outside of the institution. If, as I said, his report at the end of ninety days is a good one, he is then discharged from the Institution, with the privilege, of course, of returning. Now of all the men I have sent out under that scheme this year, I have had less than eight per cent of returns, and I consider that in the first year a fairly good average.

I want to commend that scheme to every man who has charge of an n.p. hospital and after this conference adjourns, I would like to correspond with you on that subject. I would like to compare notes because I believe it is worthy of attention.

There is one other thing brought up in a previous meeting and that was the question of our constitutional psychopath, and drug addict and the building of special hospitals for these men. I personally am not in favor of such a scheme and I will tell you why. I have a considerable number of these men. I believe that every complete n.p. hospital should have a department with definite numbers assigned from the staff who are particularly clever in handling this line of case. I think that they should be handled in your regular n.p. hospital as a separate unit.

Now there is just one thing in connection with that statement I wish to emphasize. There are a certain number of these men who do eventually make an adjustment. For the sake of that percentage alone we should not place the stigma upon them of being sent to practically a penal institution, and that is what it means if you set aside a place and brand it as a place for those of criminal tendencies and drug addicts. We tried that in New York and you all know from the papers what it resulted in.

There has been another plea. Dr. Treadway spoke of the shortage of personnel. It is acute everywhere in every department. Then on top of that comes the plea from the general hospital men, from the t.b. hospital men, for neuro-psychiatrists to be assigned to his staff. That is a physical impossibility. There are not enough n.p. men to go around and I have a solution of that which I have put up to numerous men and that is just this. Along with what General Sawyer said today about every one’s being a well-rounded out man, every man who has charge of a hospital, every man who is on the staff of a hospital taking care of ex-service men ought to go down and buy a copy of White’s Outlines and study it for the next six months. If you will do that you don’t need specialists on your staff. You can make a near enough diagnosis so you will be reasonably certain in 95% of your cases as to whether they ought to be sent to an n.p. hospital or not.

DR. FULLER: I an particularly interested in the question of personnel. The shortage of neuro-psychiatric trained personnel and physicians is a real and very acute problem. We have any number of vacancies for such men in the Public Health Service at the present time. I dare say the same conditions exist in the Army and Navy. I believe that the only way of solving the problem that Dr. McLake spoke of is for the Commending Officers of those hospitals who have one psychiatrist on their staff,—and practically all the large hospitals have one on their staff,—to insist that these psychiatrists interest other members of the staff. The fact that Dr. Treadway brought out, that most young men are not interested in psychiatry is due to the fact they do not know anything about it. I was one of the men who visited the schools last year. I was suddenly confronted by statements made by the deans or their assistants: “Oh, neuro-psychiatry, I don’t expect you will get much enthusiasm from any of the schools on that subject, because that is a post-graduate subject and we don’t make any attempt to teach it during the under-graduate years.” Any number of young men who will state a preference for general medicine can be interested in this subject about which they know nothing. The solution, therefore, depends upon the commanding officers of these hospitals and upon the psychiatrists on their staffs; depends upon their willingness to detail one or more young men to the psychiatrists, who are interested in the subject. I don’t believe that the problem is going to be solved in any other way because there are not enough men outside who are willing to come into the Government service, who are interested.

DR. MILLER: We have a specialist at Oteen who lectures to our entire medical staff Tuesday and Friday of each week. They are very much interested in it and we think it is a very great benefit to the institution and the patients.

COL. EVANS: What are you going to do with the group the doctor describes that ought to be in a colony? What are you going to do with the mentally deficient who will never be able to carry on? There is no appropriation available for that group. If the Soldiers’ Homes are not properly supplied with means or some other special effort made, every community will have these individuals as a reproach upon them, and it occurs to me there is no group of men that would be as able as this group to have the propaganda go forward that there is a problem to be solved in these cases.

DR. WHITE: I had this in mind about some of these difficult problems, some of these border-line cases I didn’t have a chance to speak of the other morning. I suggested there in just a word that in connection with these disciplinary measured such as have recently been promulgated in this order we got this morning, No. 27–A, probably we shall have to come to some form of disciplinary treatment with a considerable group of these border-line cases, and the plea I wanted to make was that discipline should not be used as discipline per se, but that we should seek for all of the possibilities that are incorporated in disciplinary measures which can be brought to bear upon the patient for his welfare; In other words, if we can make out of discipline a therapeutic tool.

Now we are dealing for the most part, in these border-line cases and in the delinquent group, with types of individuals that are more or less defective. Almost all of them are defective in some sort of way, not necessarily intellectually defective but frequently on the affective side; but there undoubtedly has to be some kind of disciplinary pressure brought to bear.

I have in mind a fellow who is a high-grade defective, who has passed through a praecox attack, who has come back to comparative normality. He is a reasonably useful citizen around the institution but he can’t get on outside the institution and he has periods of not getting on well in the institution, because every once in a while he will go out and get drunk. Now what are you going to do with that sort of fellow? Such an individual does not always stand discipline very well. A doctor came to me and talked to me about him the other day and wanted to know what should we do with this fellow. I said, “Shut him up; take his privileges away from him and watch him very carefully, because I don’t believe he will stand shutting up very well. When you have made the maximum impression upon him from that discipline, let him cut.” You have constantly to shift between severity and almost lack of discipline with these people to keep them at their level, and you have to realize all the time it is a matter of very fine adjustment and that after all you can very easily do them a great deal of harm. Therefore I am always more or less disturbed by the constant effort that is being made in bodies like this to standardize all kinds of rules and regulations, because I realize that in this class of cases particularly there are individual problems and they must be left for the individual judgment of the physician who has charge of them.

I have, for example, a clerk in the office, a man who is probably sixty odd years of age. When he is sober he is as efficient a clerk as we have in our office, but he persistently gets drunk and stays drunk for days at a time. Now the easiest thing on earth is to discharge that man. What is going to become of him? He can’t take care of himself. He has a family dependent upon him. That would mean to pauperize him and make him a public charge. I developed some time ago a method of dealing with him. I penalized him every time he got drunk by taking away a certain amount of his pay. It was hard punishment. He does not get much pay. The result was I pushed him to the limit, because it cost him too much to drink. The result was he had longer periods of sobriety than he ever had before, but he did break down once in a while, and when he did we had to forgive him.

Now we have to deal with that sort of problem among our employees and patients, and we are put to it constantly to devise out of our ingenuity how best to meet it; and one of the agencies at our command is the disciplinary measure, which, if wisely enforced, can be used to push the patient to the highest possibility of his adjustment.

Then, in that connection, as to our friends, the morons and epileptics. I am fond of saying that practically everybody, no matter how defective he may be, has a certain capacity for usefulness. There is almost nobody who is, under proper arrangements, a total loss socially. A Moron, of six or seven years of age, may be ten per cent efficient. He may be ten per cent efficient under one set at social conditions, maybe fifteen per cent efficient under another set. He may be total loss under other sets of conditions.

Now a lot of these people, like the young fellow I spoke of a while ago, are very useful citizens in the hospital community. They would be a total liability outside that community. We have always had these people in the community and we always shall have them probably. It is perhaps a worth-while endeavor to try to get the community, through these various social agencies, to appreciate them for certain values. One of the medical officers of the Army was discussing with me, a while ago, this problem in the South, in the cotton mill districts, where there is a large number of mentally deficient people. They do not do much of anything, except perhaps, drink whiskey, breed and make trouble. They go into the mills and either get injured or discharged. A lot of that material is really capable of utilization. The mental defectives, as a whole, are fairly good natured and tractable. There were lots of mental defectives in the Army, enlisted men, who carried on and made good soldiers. Some young fellows went into the Army from the School of Feeble Minded, in Massachusetts, and had excellent records. The Superintendent there kept track of his feeble-minded boys in the Army, and they made excellent records because they belong to that type of individual which has a very strong leaning upon persons in authority and will follow his officer like a Newfoundland dog his master, will obey orders to the letter and they make most valuable persons. So this officer suggested to me that these feeble-minded groups running around might be assembled into industrial units. They could be worked in factories. In order to avoid the possibility of exploiting that type of labor they could be employed under proper social conditions and placed under the eye of a neuro-psychiatrist; and where there was an immense shortage of labor, perhaps factory owners would be pleased to get these men.

In other words there is a lot of this defective material which exists in our society today which has absolutely lost motion, which could be put to a great deal of use if we were wise enough to do it, if public sentiment would support us and assist. It is easy to talk of that here. It is another thing to get public sentiment to help us. There is no longer hospitals organization than this in the world and perhaps the hundred hospitals represented here might do something to bring about that public sentiment. So I am disposed to look at people not from a strictly diagnostic point of view to look at them from the social point of view as to the possibility of their becoming useful to a certain degree as social units and the possibility of society metabolizing them.

Just one more word. There has been an enormous amount said the last few years on heredity, and there is a great deal of feeling that there is a great deal due to heredity. The study is very interesting, scientifically very important, but the only attitude we should assume is to practically throw out of consideration the whole question of inheritance. If you are going to say this fellow has got a certain disease, and you are going to conclude it is inherited, that is a fatalistic diagnosis and the tendency of the diagnosis is to hamstring any effort that may be made in his behalf. The only way we can find out the percentage of salvageable material is to endeavor to make the adjustment. If we put them down as hereditary, our inclination will be to throw them out of the possibility of consideration. We should rather stress the possibilities to the utmost and find some solution or partial solution of a great many of these problems.

DR. CHRONQUEST (U.S.P.H.S.): So much has been said that I shall not go on with the problem. I would mention the Compensation side. I have been wondering for some time, especially among the neuroses, if by our present system of compensation we are not tending to make crystallized neuroses. I do not pretend to answer the question. Take, for example, a chap who has been in the service, who has done good work, whose social scale has not been high, whose life prior to service has been, as you might say, from hand to mouth. He has come out of the service with a definite, known disability acquired by service. By being hospitalized he has been compensated justly by the Government; he has received the treatment to which he is entitled; but during the days of his treatment he has found that he is able to get along more easily under these conditions than he did prior to service, and decides that one of the best ways he can make a living is by Compensation. I do not say that that is true with all, but it is with some of the cases.

I have wondered whether or not our present system of compensation to that type of individual was the best, or whether the system of Canada or England would be better. In other words, they do not put a premium on a man to go to a hospital. If I am correct, a man gets less money when he goes into a hospital than when he is out. It is my meagre opinion that in that type of neurosis, he would tend to fight harder as an individual to put himself back into a financial, gainful pursuit; and with the advantages the Government offers him now, especially through rehabilitation, I feel he could be put on a much better adjustment than he was before.

Another point which has recently come to the attention of us locally is the question of guardianship; and I am going to ask Dr. Guthrie if it is a known fact that two men in the same hospital, with the same disease—that one will draw his compensation without a guardian, the other is required to have one.

DR. GUTHRIE: It was our understanding that a man who is a psychotic by reason of service should at least have a guardian. If that is not true, I suggest to the Hospital Committee that it is a point for consideration, as it puts the man in the field between the devil and the deep, blue sea.

DR. W. A. WHITE: I think the man who has a guardian has one usually because his people have applied for such. I believe the Bureau never relinquishes the right to control of the funds, and is not obliged to pay the funds to the guardian. Legally the patient can be paid if he is competent.

DR. CHRONQUEST: In looking over histories of cases that come to West Roxbury and information received, I believe that a point that would be of help to the service as a whole is the getting of accurate histories. We find patients being transferred to N.P. hospitals, who have a diagnosis which is not correct according to the past histories taken, due to the fact that careful search has not been made in gathering the facts of the men’s disabilities. At times it may be the fault of the examining physician. It may be the fault of the social service department. Again, it may be the fault of the individual, or of the family itself in trying to protect the patient in question. I believe that those errors, which are seen every once in a while, should be overcome; and I feel that all of us, whether Neuro-psychiatrists or not, who have anything to do with either neuroses or psychoses, should be extremely careful of the histories and get them complete, detailed and accurate.

COLONEL MATTISON: (acting for General Geo. Wood) The Tuberculosis Section has to deal with a group of patients,—the largest group that the Veterans’ Bureau has to handle. I am sure that we have many men here who are interested in this subject, and I hope we shall have a very free discussion of the subject. We shall begin by having each subject opened, and then the program will be given to general discussion. We shall ask Dr. Stites to open the session on “The Segregation of Cases”.

SURGEON T. H. A. STITES (R) U.S.P.H.S.: This question of segregation of Tubercular cases is one that has been vexing all of us for a long while. To understand it at all we have got to review the history of T.B.,—from the ancient times when T.B. was looked upon as a sort of visitation from Heaven, and looked upon as a disgrace to the family, on down to the period when Koch, with his great discovery, found the disease to be infectious. During that time there came on an organized propaganda for the control of T.B. upon the ground that any infectious disease is a preventable disease. This propaganda, as is true of all propaganda, ran to an extreme. It was so hard for those interested in proving that T.B. was an infectious disease to impress it upon the public and to compel them to accept the proposition of its infectiousness, that we went to the extreme of leading everybody to the idea that it was a virulent infection; that it was as contagious possibly as some of the acute infections like scarlatina.

There were those who believed that every case should be sent to a T.B. hospital, absolutely isolated from his family and the world in general. Then the pendulum began to swing back, and we came to a sensible conclusion,—that while T.B. is an infectious disease, it is only slightly so to the adult; and if virulent at all, it is so only among children and the adolescent. This being so, we had to change from the separate and isolated hospital for T.B. It has been accepted that every general hospital should receive its quota of T.B. patients, T.B. being one of the most common forms of illness, and that in sending out patients to a strictly T.B. hospital; they should be sent only after the presence of the disease has been fully well proven.

The control of T.B. is after all the big problem before all of us in T.B. work today. I have often heard it said that any benefit that comes to the individual is necessarily more or less incidental, and that the big object we are laboring for is the control of the disease and the care of the general public health. Be that as it may, the problem that faces us in the care of the veteran of the World War is the actual care of the sick.

The question of prevention of T. B. must be dealt with, first, upon educational grounds,—to educate the public and the individual to the point where we can more or less limit the spread of the infection; secondly, and perhaps more important,—by a campaign for the improved living conditions of our people in general, especially in childhood.

As a matter of fact, when you get right down to it, T.B. is a social disease; it is a social problem even more than it is a medical problem. We know that when the good Lord made us, he put into us a certain amount of quality which, for lack of a better term, we have called natural resistance. If we can keep that natural resistance at a high point,—build it up,—the infection, though it may strike us, will not produce the clinical disease, T.B.

In the second place, we come to the actual treatment of the sick. This, too, is largely a hygienic measure. Since time immemorial, those interested in T.B. have been searching, have been praying for a specific cure. Every now and then somebody bobs up with a story of how he is going to cure T.B. overnight by this or that injection, treatment, etc. In each of these cases there is a grain of fundamental truth. We have got to put these things together; and when we get down to the final conclusion we can not get away from the fact that the treatment of T.B. is the building up, the bringing back to normal, and in fact if you can, the reaction to the point beyond the normal, of that quality I spoke of, natural resistance.

In order to accomplish this, I believe one of the most important points lies in the word, morale; and to encourage your morale, it is wise to get your classes classified, and to get your T.B. patients working together in classes in sufficiently large numbers so that you get that inspiration that comes from what my friend used to speak of as “the psychology of the crowd.” The thing the soldiers know as the touch of the elbow; there is a certain magic in it. It is easier to get farther when you know that somebody besides yourself is going through the same thing. I think we men in charge of hospitals feel that. That is one of the inspirations that comes to me from meeting with such a crowd of my fellows here. Away off there in the swamps of Louisiana there comes a sort of feeling, “We are here alone; it is hopeless”. When we are all here together exchanging experiences, there comes the inspiration, “We are not alone”.

In your general hospitals you have T.B. beds; have them in sections by themselves,—not because you are afraid of the spreading of the disease, not because the T.B. patient is an outcast,—but because you can do more successful work for the patient, not by segregation, but by classes.

In your T.B. sections, have your sub-divisions; have your places to which you are going to send your ambulatory cases, your far advanced, etc. Keep them far apart. Use the class system, but be sure that your personnel is sufficient, so as not to get away from the personal touch.

Perhaps a little outline of the organization of at least two of the hospitals with which I am familiar will illustrate my point.

The first essential thing when a patient enters a hospital is a complete examination. Do not let that examination be routine because it is a T.B. patient. Do not be satisfied with punching the man in the chest and sticking your ear to his heart. Have somebody who understands neurological conditions, test his nerve reactions; have someone to test his mental reactions, as well as the surgical and general medical. Have your examination ward in which this can be done.

Next is your general medical and, possibly, observation ward. I don’t care how you try to keep observation cases out of T.B. hospitals,—they are going to get in. If a patient, after being in a month, is found to be a T.B. case, he is apt to say, “I caught it here”. Put him where you can answer, “You did not get it here. You have not been in sufficiently close contact with the disease to catch it.”

Have your surgical ward; and then your strictly T.B. section.

Have first your infirmary or hospital.

The T.B. man needs special treatment, nursing care and dietetic care. One of the chief things to give to a T.B. infirmary is good dietetic care;—place the food before your patient in an appetizing manner; too much will disgust him.

Then have your ambulant section and sub-divide it into the section in which there is clinical activity of the disease, and into the section in which the clinical condition of the disease is quiescent. By doing this you can give your people graduated exercises, whatever diets they may need, periods of rest, and occupational therapy; and you can do it in an organized, scientific way, and get away from the everlasting complaint, “You let the fellow in the next bed do it; why won’t you let me do it?”

You have got to study the psychology of your patient. It may be a little out of the line of segregation of cases. We have heard the talk here of cases, of hospital management, and all that; but be sure in dealing with the ex-service man, or any other case, that you do not treat him merely as a case; that you do not segregate the medical officer in charge. I find there in the South that one of my life-savers is the fact that my office door is open to any patient. When I first got to be understood there was a line-up. I gave an hour every day. Now, since the patients know that everyone can come to me, I have possibly three or four in a day. And I don’t do it either by reversing the decisions of my ward surgeon and my executive officer; I back them up.

DR. KLAUTZ (N.H.D.V.S., Johnson City, Tenn.):

The subject of occupation in connection with T.B., is not only an extremely important one but an extremely difficult one to administer, particularly in the large government institution, and especially in connection with the psychology of the ex-service man, which has been referred to a number of times. He is apt to misunderstand and to be resentful toward any application of work; and yet at the same time, if we are going to measure the results of the sanitarium treatment of T.B. by the functional restoration to activity and usefulness, we still find that it results in a great many failures. That has been one of the complaints on the part of T.B. workers not only in government but in civil institutions as well.

We still find relapses occurring after the patient has been discharged from the sanitarium or T.B. hospital. Men go into training, and in a short time undergo another course of treatment, and so on. The reason for that is that they have not been given the necessary physical rehabilitation while still in the sanitarium, while under institutional protection and medical supervision.

The question of occupation is so broad that it is impossible to take it up extensively here today. We can point out one or two of the basic principles in connection with its application in the treatment of T.B. One very important feature brought out this morning is the psychotherapeutic object,—the point of view of relaxation or recreation, that is, giving the man something to occupy his mind and improve his morale, helping him to forget his home anxieties and anxiety about compensation.

The second point, or 2 A, deals with muscular reconstruction,—conversion of recently acquired adipose tissue into working force by rebuilding flabby muscular tissue which has resulted from the long period of rest.

2 A is the acquiring of a tolerance for T.B, toxins. This is important. We do know that in the recently toxic stage, exercise or work does produce a reaction which is shown by a rise in pulse rate. We know that if exercise is begun in small doses and gradually increased, the time will come when the patient can be made to take a fairly large amount of exercise continuing over a fairly long period of time, without manifesting the symptoms of reaction. Formerly we gave Tuberculin in gradual doses until we reached the point where the man could take an injection which surely would have killed him at the beginning of the course. The main point is if a man leaves the sanitarium before he reaches this toxin tolerance, he is more likely to break down. This is the reason for the man’s frequently returning to the sanitarium for treatment.

The third point deals with applying occupation as a means of training or retraining the man for some new occupation or modification of his former occupation; and here is where a great deal of judgment and study of the individual case becomes necessary. It is very difficult to find out just what is the best kind of work for the man from a physical and mental point of view; but the important thing is to have the man try it out and test it, and begin this physical reconstruction and rehabilitation if we are to get permanent results from sanitarium treatment. I don’t believe we have solved the problem completely, and I believe other agencies will have to be called in.

In this connection the question of dispensary work and social and nursing follow-up work is going to be extremely important. The man who leaves an institution ought to be followed up very carefully, and effort should be made to bring him back to some medical unit for re-examination at least every two months in order to see if there is any relapse of the former activity.

SENIOR SURGEON R. H. STANLEY, USPHS (R): It is always interesting of course, to be told what we ought to do and how to do it, but it seems to me it would be a great deal more interesting to take the little time we have this afternoon and discuss some of our real problems, and I mean by that problems that we as commanding officers of the hospitals have to contend with every day. I know and you know there are thousands of little things come up upon which we would like to have advice. There are many problems I might be able to solve readily; there are others you would be able to solve. I believe it would be worth more to tell how to get rid of some of these problems.

I believe that the success of running a hospital rests entirely upon the confidence that your patients have in you. If you are sincere they know it, and when they know that they will do anything for you. If you are not sincere they are going to know it mighty quick and you are going to have trouble. If you tell the men you are with them, that you are going to be 50–50 with them, if you call them in and talk to them as you would to a son, and if you let them see you are not doing it because of a matter of necessity, you can get by without writing petitions into Washington.

I found the other day a petition had gone to Washington from my hospital. It was necessary to discharge two men for drinking. It was their first offense. They came to me and said, “You have not treated us fair because it is our first offense.” Just before I left my station I received a letter which was addressed to these men by Colonel Forbes. In that letter he said “I have received your petition signed by 27 patients and asking that the hospital be investigated on account of a few patients being discharged for drinking. I wish to state for your benefit that I have given the matter consideration and I am standing right behind the medical officer in charge.” Leaving out the names, I had copies made of those letters and placed one of them on the bulletin board of the hospital.

When I went out to Whipple Barracks there had been some little disturbance there among the men. They were dissatisfied in various ways and it seemed like a big problem how to handle these men. When I once had their confidence I handled them.

I have found this in my experience, that I have never been able to have a satisfied personnel unless I give them the best I can. So long as you feed them well you will not have much trouble, because that will keep up the morale better than any other one thing I know. If you will feed them, be honest with them, be fair, you will have very little trouble in running the hospital.

SURGEON J. F. WALLACE, USPHS (R): The subject of entertainment probably would cover the subject of recreation at hospitals. It is rather hard for me to describe what recreation should be given at a tuberculous hospital because it depends on the location of the hospital. At the hospital at Fort Stanton where I am located we do not have any entertainment. If any social workers come down there I will be glad to entertain them, because we have only three visitors a year down there. That is one of the things in which I would compare our institution with some of these other institutions.

For many years I have been connected with a large sanitorium where we had strict discipline and little entertainment. The patients were satisfied. Our average stay of patients is six months. In looking over your sanitoriums you don’t find many patients staying six months.

When I was in the Army I was in one of the largest t.b. sanitoriums of the country. They sent back hundreds of men to this hospital and people came out and entertained them. They were entertained every night by the Red Cross with moving pictures, they were entertained in the afternoons by a local organization; they were entertained to death. These men afterwards got out and were not satisfied unless they were placed in an institution which was a social center. After I went out I was Chief of the Eleventh t. b. district of Denver. I noticed that the men who were treated at Fort Lyon were a better class to handle because they were not so much entertained. Once in a while I would talk to some of these men and ask them if they wanted to get well, as I could tell them a place to go and frequently I used to send them to Fort Stanton where they could not be entertained and they could get well.

If you have ever lived in an isolated place, you can appreciate it. My wife and I had pioneered this sanitorium together for quite a while. Once in a while we used to go to Denver and we could enjoy any show they had in Denver, even the 10–cent and 20–cent ones. I have heard men criticize entertainments at Fitzsimmons; they would swear and walk out while Madame Schumann-Heinck was singing, because they were dissatisfied; they were saturated with entertainment. I am against entertainment for tuberculous patients only in a very mild degree. We have one picture show a week and they enjoy that picture show. We have only Sunday School Sunday morning. The minister will bring in a few amateur singers and the boys think they are wonderful; they are wonderful; and they will all sing.

I have some fifty War Risk patients at my Sanitorium. I have known them for three years. I know them all by name. They were kicked out from Sanitorium to Sanitorium. They came down to Stanton. I went there on the first of July and no man has asked for his transfer or discharge. I suppose there is less turn-over of t.b. patients at any place than at Fort Stanton, where there is no entertainment. These men can go anywhere. We have a 30,000 or 40,000 acre farm. We try to get these men interested in the different things in the Sanitorium. On Christmas we let the men arrange the Christmas trees. They amuse themselves down there. The men trap quite a number of wild animals, bob cats, etc. and they are interested in the place we have, which is close to nature. You would be surprised how little amusement you need for entertainment if you get away from it. You have got to control these men and direct them every minute in the day. You have got to give them a task. Have their hours for rest; their hours for exercise. It is up to you who are running Sanitoriums to entertain your men. You might lecture to them; that is entertainment; but don’t have them twice a week or three times a week. Once in a great while the men are interested in the study of their disease. Don’t speak to them in scientific terms, let them understand the disease. They say in the curing of tuberculosis it depends more upon what a man has from his neck up than what he has from the neck down. Impress upon them that they have got to live a careful life. Keep people out who want to entertain them. Your men will be just as well and better satisfied with little entertainment if you keep them busy all day long.

DR. SMITH, U.S.P.H.S.: I wanted to discuss this afternoon a matter which is of great concern to all branches of the service, and that is Order 59 as applied to transfers from hospital to hospital. Order 59 is going to be watched rather carefully by the Veterans’ Bureau. Order 59 lists hospitals and gives a certain number of hospitals to each district. A district manager in New York may take a tuberculous patient and send him to a local hospital or he may send him away to a certain designated hospital to which he has blanket authority to send him, Oteen or Fitzsimmons; but according to Order 59, once they send a man to a local hospital, the district manager may not remove the man from that hospital and send the man to Fitzsimmons Hospital in Denver. In other words, it is worth watching to see whether Order 59 will not rather tempt the district managers to make a snap diagnosis on the ground and send away to the hospital to which he has blanket authorization to make transfers, on the one hand, a man whose disease is so far advanced, that it might be unwise to send him; or, on the other hand, men with questionable diagnosis. It will be worth watching. I am sure the Veterans’ Bureau will desire information on the subject as to whether you who are out in the tuberculous hospitals will receive classes of patients who are unsuitable in the usual sense of the word for transfer.

Here is another thing we shall all need to watch and concerning which the Veterans’ Bureau will I know desire information. Will the practice of sending patients to the local general hospitals result in a piling up of patients who need to be transferred and whose transfers will be delayed. We all know that a transfer is indicated not only for the purpose of providing a climatic change and we all know that in certain sections of the country there are provided beds for tuberculous patients and it is necessary to keep these beds filled.

According to the present practice and strict interpretation of order 59, if the medical officer in charge of the Naval Hospital in New York has a tuberculous patient and wants to effect his discharge to Fitzsimmons, he first asks the district manager for permission to transfer the patient. The district manager in turn asks the Director of the Veterans’ Bureau; the Director of the Veterans’ Bureau advises the district manager, who in turn advises the officer in charge of the Navy Hospital. Now it will be necessary to watch and see whether this effects an undesirable delay in making the transfers. The Veterans’ Bureau will desire to be informed if such is the case.

There is another thing. A patient under treatment at Fort Bayard, New Mexico, and fit for discharge cannot, according to a strict interpretation of Order 59 be discharged without invoking the same authorities who sent him there. In other words, he must take it up with the district manager, who then advises the man in charge of the hospital.

Order 59 is magnificent in this, if it works out: that no man will be transferred from one hospital to another except upon the recommendation of the medical officer in charge, and you who have had experience in this matter will know what that means. It means that it is not the man with the longest and strongest pull who will be transferred but the man whose transfer is recommended by the officer in charge of the hospital. We are prepared to assist in every possible way in carrying out that order but it is necessary for us to watch the effect from the field and get advices from all hospitals concerned, as to whether this order will not need modification.

SURGEON F. H. MCKEON, USPHS: Some have stated that they were in ignorance of the existence of G. O. 27. At Hospital # 64, upon the receipt of that order we immediately had about one hundred copies made and the entire hospital personnel was supplied therewith. After that every man upon admission was furnished with a copy, together with a copy of the rules of the hospital, for which he signed a receipt. I offer that as a suggestion.

On Tuesday the statement was made here that a man who is able to take five or six hours prevocational training at a hospital has no place in a hospital and should be in training. I think that statement should be qualified somewhat. It may easily happen that a man who can safely take five or six hours prevocational training in a hospital would soon break down under vocational training, for the reason that while he is in hospital his entire life is supervised; he must take a rest hour; he must turn in at a given time at night; he is assured of three or possibly more proper meals a day. Those conditions do not obtain when that man becomes a trainee and I sincerely hope that the follow-up nursing system which the Veterans’ Bureau is putting into effect now will result in a more careful supervision of the trainee’s life, so that when it is found he is living not wisely but too well he may be given proper advice and be returned to the hospital before the breakdown occurs.

This afternoon the subject of hospitalizing the tuberculous veteran in n. p. hospitals was discussed. I rather think it a somewhat sweeping assertion to say that every tuberculous individual with mental symptoms should be hospitalized in a t. b. sanitorium. We will all grant that men with signs and symptoms of an active tuberculosis disease should be hospitalized in an institution for the treatment of tuberculous. But to my mind that does not hold where the disability is clearly a mental disorder; that man is ambulant. The other man gives no trouble whatever because he is bed-ridden. I have no doubt that every t. b. hospital commander here today has had such cases. Your ambulant case, with few if any indications of active tuberculosis but who notwithstanding is tubercular, when he develops mental symptoms is not only a source of annoyance in the tuberculosis hospital but is destructive of morale. His place is clearly in a hospital for the treatment of mental cases.

DR. M. C. GUTHRIE, U. S. VETERANS’ BUREAU: This matter affects us administratively from a different angle. Many of the general hospitals have wards for the cure of tuberculosis. We presume that the turn-over must be fairly rapid. When men have accumulated in sufficient number and their disposition is determined as to whether they should go to a tuberculous institution, and they refuse to go, shall we turn them out or shall we let them stay?

SURGEON L. M. WILBUR, USPHS: If the transfer is suggested in the interest of the physical welfare of the patient and he refuses to accept that transfer, he is interfering with treatment. The regulations provide for that.

SENIOR SURGEON T. R. PAYNE, USPHS: I don’t agree with some of the t. b. men. I think a man can make a fight if he is dissatisfied and does not want to go and I think you will do harm in transferring him. If a man is home-sick and will not improve, I think he will do very much better to stay just where he is and you ought not force that man to go somewhere where he will not be satisfied. A sanatorium is a school to teach men how to live. In a general hospital you will have trouble in enforcing a rest hour because there are a great many other men in the institution who are not compelled to do so. The pass privilege is another thing. Some patients have but one pass a week and other patients get passes frequently. It serves to dissatisfy the t. b. men as they felt they were not on an equal footing. That is the only objection I can see.

SENIOR SURGEON J. E. DEDMAN, USPHS (R): There are several things that occur to me. In the first place there is the question of food. Of course that is the vital thing in every hospital. In our hospital, as I said before, we have a large number of negroes and what you give to the white boys in the north is not satisfactory to the colored patient. I think it is an important thing to try to give the men what they want in the way of food.

When I went to Greenville it was the custom to give the men breakfast at about seven o’clock; luncheon at 10:30; noon meal at 12 o’clock; at noon the men were not hungry and were generally dissatisfied with the food; at 3 o’clock, after the rest hour, they would have another nourishment; supper was served at five o’clock and as a rule they did not care much for that. Then we would send over to the wards large quantities of milk and eggs and bread and butter. They did not need any base balls. They played ball with apples.

It occurred to me that that was a bad system. We omitted the morning nourishment and the afternoon nourishment and I substituted an evening cafeteria luncheon thinking that it was a long gap from the supper at five o’clock to breakfast at 7. We thereby saved a great deal of money and since we did that we find the patients think the food is fine. We also find that they sleep better by taking this light luncheon just before they retire. I mention that for what it is worth.

The rest hour is important in tuberculosis. That is why hospitalization is so essential, because men will not take proper rest. We have a morning rest from 9 to 10, afternoon rest from 1 to 3 and evening rest from 6 to 6:45. The last period is not universal, and we wonder how you can get an accurate record of a man’s condition when you do not get his evening temperature. We find that it has been a great help to us. When I instituted this rest period from 6 to 6:45 I told the men it was for their good and although they objected at first, it appealed to their reason, after they were told why it was done, and we have had no trouble.

Another thing we have inaugurated along this line. I talked with Dr. Smith last spring. He agreed to send to our hospital a school for chiefs. I think this was a most helpful thing, because we had chiefs of medical staffs come to us and take a course that would tend to make for uniformity in administrative medical work in our tuberculous hospitals. I have talked since that time with several of the men who came down to take that course and I believe every one of them expressed the opinion that it was very helpful to him to have an opportunity to exchange ideas and to have the same methods for carrying of medical staff work which required tact and executive ability.

There is one thing I could not pass by because it is of such great importance to the Federal Employees Compensation Commission. We have sometimes employees engaged along various lines, and shortly after I arrived at the station I found one or two who said they had tuberculosis. I think it is most essential to see that not only one man but a board of medical officers examine every employee when he comes into a tuberculous hospital to make sure that he does not show activity in tuberculosis so that later he will not have a claim against the Federal Employees Compensation Commission by saying that he was working in a tuberculosis hospital and contracted tuberculosis while in the hospital.

There are many things I would like to speak of. I was very much impressed with what the doctor said about entertainment. I believe it helps the morale and is the most wonderful thing in the world. We can spend sleepless nights building up morale in a hospital and one man can disturb the entire morale.

In closing I want to say, after all is said and done, the big thing with us is the backing we get from the heads of our department and from the Surgeon General. I have known times I felt like throwing up the sponge. All of us have gone through these moments. The main and only thing that keeps us up is the encouragement we get from the heads of the department and I want to take this opportunity to express my appreciation.

GEN. SAWYER: This meeting was called for the week of the 20th, with the understanding of the Budget Director, General Dawes, that on tomorrow the Chiefs of the various Departments of the Government were to hold their semi-annual session and we thought that you would enjoy that occasion. It has been found impossible in the compilation of the facts and figures necessary to hold that meeting tomorrow. Therefore it becomes necessary for us to change our program and I am happy to announce to you that I feel sure you will have quite as interesting a program as you would have otherwise, for tomorrow we will have as the first speaker of the morning, Congressman Madden, the head of the Appropriations Committee. If you have not heard him I am sure you will be very much interested both in what he has to say and in the way he says it. We are then to have as the next speaker of the morning, General Dawes. General Dawes is remaining over tomorrow that he may have the pleasure of meeting you personally, and I predict that you will agree, after you have heard General Dawes, that if you have had no other excuse or no other compensation in coming to this meeting, you will have it in hearing General Dawes. For the balance of the program of tomorrow forenoon, it comes to my mind that possibly it would be most interesting to you all if we were to take up some of the questions that come to your mind that have not been presented in this program. This was suggested to me by one of the gentlemen here who I noticed does not talk much but who evidently thinks a lot, that it would be to the interest of a good many if they might bring up some subject that they are particularly interested in. So we are going to have in the morning a question box, and if any of you have questions in which you are particularly interested and will present them at the desk of the Secretary, we shall try to have them taken up for discussion at this round-table hour tomorrow forenoon.

President Harding will not be here in the morning. When I spoke to President Harding to come over and address this meeting, he said to me, “General, you know Mrs. Harding and I are to receive this body tomorrow evening.” I am sure that you are going to have in that reception, in the personal contact with the President and Mrs. Harding, a joy such as you have not contemplated.

Seventh Session Friday, January 20, 1922.

GENERAL SAWYER: Fellows of the conference, as I told you yesterday we had expected this morning to be here with the Chiefs of the Bureaus. I explained to you why that program was changed. I told you also that you would not be disappointed in today’s program, and now I am going to prove it.

America produces many things. It is wonderful in agriculture, in industry, in commerce, but one of the greatest products of America is its men, and, strange as it may seem if you will stop to study it from that aspect, you will find that each State of the Union has its record for producing certain kinds of men. For instance, from Wyoming we get our stock men; from Iowa, our farmers; from Indiana, our authors, particularly our fiction writers; from Ohio, of course, we get our presidents; from Illinois, a thousand miles from Wall Street, we get the greatest of financiers. It is true that Illinois has produced more financiers than any other State, and men who have been at the head of the greatest banking institutions of the United States have come from this great corn-raising, middle-western State.

I should like to remind you, before I introduce this speaker, that this Federal Board of Hospitalization represented last year an expenditure, in all of their various lines of work, of $750,000,000.00. We have in our employ this morning something like 42,000 individuals, for which it is costing us something like $42,000,000. Today we are providing 132,000 meals for the people in the government hospitals and the employees that are necessary to take care of them. Tonight, if this northern blizzard continues, it will require 132,000 blankets to cover them; and in the most economical way in which we can provide for the needs of these sick men it will cost us—it does cost us—in round numbers, a hundred thousand dollars each day, with institutions operated as economically as they can be.

I only relate this that all of you may know and may carry this message to the country—that Uncle Sam is certainly not stingy; that Uncle Sam is really putting forth every energy he possibly can to carry out the idea of the best treatment of the World War Veteran.

This is my story in brief.

I have pleasure now in introducing to you Congressman Madden, Chairman of the Appropriations Committee of the House.

CONGRESSMAN MADDEN:—

“Mr. Chairman, ladies and gentlemen:

The most sacred obligation we have today imposed upon the Government is the proper care of the men who came back from the War less physically fit than they were when they went away. Provision is being made for their care to the extent that it is possible to make it. I think it may be safe to say that no country in all the world has been so generous in its care of its wounded soldiers, as America.

Hospitalization is one thing that we must provide, and we must provide every necessary comfort for those who gave to the country in its hour of direct need. We must not be foolish, however, in what we do. We must have a care as weal of other things as of the men themselves. I think the American people would be willing to make any sacrifice for the comfort of the men who served the nation either in the late war or any other war; and the best evidence of their willingness to do that and of the willingness of the Congress to cooperate is the fact that we are spending out of the public treasury for the allotments, allowances, hospitalization, vocational training, insurance, and other things for the comfort of these men, 489 million dollars a year; and it is growing and, as far as I can see, it will continue to grow.

Now we may be doing some things in connection with this expenditure that are not for the best interests of the men, and I sometimes have doubt as to whether we are wise or unwise. I sometimes have doubt as to whether we are managing this expenditure as it ought to be managed,—whether we are giving the proper care to the moral situation surrounding the hospitals where these men are being treated. We have evidence before my committee in the record testified to by those in charge of hospitals in which these men are being cared for, to show the most demoralizing situation as the result of the extravagance and expenditure of money by the men being hospitalized at the expense of the Government.

I have a suggestion to make in this connection. I have no desire whatsoever to take away from any man anything that ought to be given to him in the way of service or care by the Government. On the contrary, no man will go as far as I will to see that proper care and proper attention is given to every man that served the nation; but I believe that in the payments we make to these men who are being hospitalized, we ought to have some control over where that money goes, while they are in the hospital. (APPLAUSE).

I would suggest two thoughts, either the thought that while they are in the hospital they must deposit their money with those in charge, and be allowed to expend only a limited sum, and thereby prevent the assemblage in the neighborhood of the institution which the Government of the United States is maintaining for the care of its patriotic men, from becoming the nest of demoralization or prostitution. You can’t make it too strong. The facts disclose the situation. Now, we have an obligation greater than the obligation to care for the man, and that is to see that while we are caring for them we do not destroy them. (APPLAUSE). We have got to have the courage to adopt a plan.

Up to the present moment most men connected with the government service have been afraid to express an opinion in connection with the ex-service men, lest somebody might become offended at his attitude. (APPLAUSE) Now I am not one of these men. I believe the time has come when the man in public office has got to have the courage of his convictions; there is nobody in the world that people hate so much as the man in high public place who has not the courage of his convictions. The man in high public place has got to have sufficient courage to protect the rank and file of those who are being protected by the Government from the folly of their own deeds; and that applies as well to the Legion and all other organizations connected with the ex-service men, as well as anybody else, for it can.

Now we have a two-fold obligation,—I may say three-fold. We have the obligation to the men, to give them proper care. We have the obligation to the Treasury to see that that care is not conducted at an outrageous expense; and we have the obligation to the Nation to see that the moral standpoint of the communities in which these men are being cared for, is not degraded as a result of our attempt to help the men; and the only way you can stop that is to prevent the men while in the care of the Government, from having unlimited right to spend the money allotted to them out of the Treasury of the United States. It would be far better for them, far better for the community, for the nation, far better for the future of all if we could arbitrarily take the money away from them while they are in our control; place it on deposit, and see that it is applied for some useful purpose for their families after they leave our care. We can do it. We have the power. Have we the courage? I think we have, and if you will join me, we will do it! (APPLAUSE)

I think the men themselves will be happier. Their organizations will be more pleased. You will have some grumbling, but you will have it anyhow. Far better to have the grumbling when the men are sober than otherwise. Far better to have the grumbling when men are likely to be contented than when they are discontented; and I don’t know of any individual more happy than he who knows that when we get through with the treatment we are giving him he can look forward to having a bank account somewhere.

You know we are liable to destroy the usefulness of this man. The citizenship of the future may depend upon our actions, and we must be careful. The obligation is ours today; it must be somebody else’s tomorrow; but the transfer of obligation from one man to another ought not to make any difference. Any man afraid of the obligation to do this work ought to be transferred, because he is not fit for his job. Public office is just an opportunity to serve; that is all. The man who is in public office, who trims his sails to meet every passing wind is not fit for the job. He must have courage, integrity, purpose in life; and the man who cannot do the things that are dictated by conscience and right in a great public office ought not to be returned to it. The man that cannot feel the consciousness of his own rectitude, but rather the political bee buzzing, is not fit for a public office; and the men who are in the great service in which you men are employed have obligations, wonderful obligations, wonderful opportunities.

We depend upon you for the outline of the plan that we must follow in our treatment of this great army of patriotic men that have come back, eyeless, legless, armless, and sick in many other ways; but we must also depend upon you to cooperate with us in an effort to prevent the looting of the public Treasury and the reduction of the moral standpoint of the nation.

You need not be afraid to suggest. We should like to have your suggestions. We invite them; we welcome then. You need not be afraid to criticize; we are glad to have that. But we want you not only to remember that money is a factor as well as a help, but we want you to learn how to spend money. Most doctors do not know how, especially Army doctors. I have discovered that. I don’t blame them. Their minds run along other lines, but somebody has to watch this side of the case.

Now one thing we ought to remember is that the estimates for the expenses of the Government of the United States for the fiscal year, 1923, sent to the Congress amount to 167 million dollars more than we have got; and since these estimates came, 50, 60, 70 million dollars more have come, adding that much more to that which we have not got. I just want to say to you, gentlemen, right here that it does not make any difference how many estimates come, there won’t be a bit appropriated beyond the revenue, and I don’t care from whom the estimates come.

Our job is to represent the tax-payers. Somebody must visualize the nation. You men visualize the thing before you; you see the local picture. We see more than that; we see the whole picture; and our job is not only to see that the rights of those under our care are protected and preserved, but that the rights of the people who are not under our care and under whose care we are, are protected. We represent the tax-payers of the nation. They have been mighty patriotic; they have been liberal; they have not grumbled; they have paid the price; they have paid it with courage; and they have shown their patriotism. They have shown their unselfish devotion to liberty. They are willing to meet any expense that may be imposed for the proper care of those who fell before the bullets of the enemy; but they want and will insist upon proper supervision of the expenditures.

They have a right to that. They have a right to relief from the burdens of taxation to the extent that we can help to give them that relief; and it is your job and mine and that of every other man in the government service,—whether he be a dollar-a-year man or whether he be given fifty thousand dollars a year for the privilege of service,—to do everything in his power to make the people of America feel that they are not misrepresented in anything we may do.

The expenses of the Government for 1919 were nineteen billions; for 1920, seven billion, five hundred; for 1921, six billion, five hundred; for 1922, four billion, thirty-four millions; but a billion, eight hundred and forty-five millions of that are in three fixed charges, i.e., nine hundred and seventy-five million dollars a year for interest on the public debt, which did not exist before the war; three hundred and eighty-one million dollars a year for the sinking-fund, which did not exist before the war; four hundred and eighty-nine million dollars a year for the care of the men that you are here to represent, for their hospitalization, allotments, allowances, insurance, and so on; so that we have that fixed charge in these three items that never existed before. Our Government in the future is bound to cost twice what it ever cost before, and so we have everybody in the United States watching every dollar of expenditure.

We have seven million tax-payers now that pay out of their incomes,—seven million people watching what we do. Before the war we did not have any of these people. They did not care what you did; how much money you spent, or where you got it. They did not have to pay it; it was not being paid directly. Now it is paid direct, and the more tax-payers you have got paying into the Treasury, the more account you have got to have of what you do with the government funds.

I am just here today to say to you, gentlemen, that I know you can help a lot both in effecting economy of expenditure and in creating a better condition, from the moral standpoint, in all of the surroundings where our men are being treated and cared for. You can cooperate by suggesting to our Committee on Appropriations how we can best meet the situation that will prevent extravagant waste of money by the men who are being cared for, while they are in the institutions, and how we can preserve the funds for them and their families; also, how we can preserve the moral standards of the institutions.

Why, the statements that come to me are appalling about the low moral standards around some of these institutions. I heard a good deal about the Army camps during the war, but it was not any worse than now. It is for you men to say what we shall do to prevent it, and we want you to cooperate fairly, loyally, actively, unitedly and promptly, because we must at any hazard and at any cost prevent any condition that will bring stench to the institution that we are trying to preserve.

We must not under any circumstances allow the fund that is being used to preserve the health to the limit and build up the men who served us during the war, to be used for any purpose that will create scandal in the nation; and it is bound to create scandal if we do not watch out for the moral standard in every community.

Now, pave the way. Show us how we can tie the fund up, and help us to help the people of the nation to preserve the men who are the wards of the nation. We must not demoralize them; we must not make them mendicants; we must not encourage them to leave their normal, legitimate employment to become wards of the nation; but we must encourage these men in every way that we can to become so useful that they will be able to help themselves and be willing to do it, and not depend upon the nation.

If I have been able to express a thought at all here that will be of any value in the long run, I shall feel well repaid for having come. I know of no more patriotic men than those who confront me, and no more patriotic women than those who devoted themselves to the service of the nation during the war. There are no more patriotic men and women than these anywhere. They made the sacrifice during the darkest hours. Many of you men could go out and, as far as dollars go, be much better off; but you prefer to do a service to the nation.

Now, couple with your medical service the two suggestions that I made. Let me repeat them,—the up-building of the moral standard, and the maintenance of an economic expenditure of the funds that may be placed under your charge.

Thank You.”

GENERAL SAWYER: “Fellows, as an expression of your appreciation of the presence of Congressman Madden this morning, I would ask you to rise to your feet, that he may know we believe in him and are for him.”

The assembly responded by standing up.

GENERAL SAWYER: I would lose a great opportunity if I did not take advantage of this particular moment to say to you that I should like—being a doctor myself—that we relieve ourselves of the charge of not being business men. Certainly in the administration of year affairs you have the greatest opportunity that can come to men now to demonstrate that you have some business sense as well as professional sense, and to me it is a great pleasure to have this program this morning because it gives us a new idea of what it means to think in the language of dollars and cents.

This administration has great ambitions to develop within the Government a business organization. The President of the United States believes that the machinery conducting the affairs of the Government of the United States is about as complete, is about as capable as any machinery that could possibly be devised, providing it has a perfect system of organization and business operation of these affairs.

The experiences of the past have shown that we have gone on in our governmental affairs without due regard to where we were to get out. We have depended upon deficiency bills to help us in our extravagance or our over-expenditures. The time has come when that policy is a matter of the past.

Realizing that it was only possible to carry on the affairs of our Government along business lines, the President sought what he regards—and I know this personally because I have heard him express it many times—one of the biggest and best and most potent business men of the United States of America to take charge of the direction of the budget; and I now have great pleasure in introducing to you, follows, my dearest, closest friend, General Charles G. Dawes, of Chicago, Illinois.

“Mr. Chairman and Members of the Conference:

The trouble with most of the Government meetings is that they do not assume the nature of a business meeting. We have something that is entirely different from the atmosphere which surrounds the meeting of any private business organization.

In my work down here for this year, I look upon the Government simply as a business organization and unless I get formality out of my mind, I do not get close to the people with whom I do business. So this morning I just simply want to explain—because when you can give the reasons for the imposition of discipline and rules of action, you make these rules of action doubly effective.

I want to explain, and grasp this opportunity to explain something of the working of the machinery which has been set in motion by the President, creating by Executive Order for the first time, a machine for the imposition of an Executive plan, and a pressure upon Governmental business. In other words, the President, for the first time, has assumed his responsibility as business head of the organization. He has established certain agencies for the imposition of executive policies and I wanted to explain something about them.

This meeting, itself, is the result of the creation of one of these coordinating agencies by Executive Order. And what is involved in this meeting?

Suppose a private corporation was spending, apart from the interest it paid on its debts, about one-fourth of all its expenditures along one certain line of activity. That is what this Government is doing through the Boards represented here,—Army, Navy, Veterans’ Bureau, etc. Supposing that business had run along for a hundred years and somebody would come in and say to the head of the business, “How much money are you spending on this particular activity?”

“Well, so much, one-fourth of all we spend.”

“Have you ever had a meeting of the heads of the agencies for the expenditure?”

“No.”

“Well, how do you know you are not duplicating facilities? How do you know there is any coordination between the establishments you are building in the securing of supplies, in the hiring of men?”

“We don’t know. We never have had, in this business organization, even a meeting to discuss the question of proper expenditure of money upon the standpoint of one corporation as distinguished from five separate departments of a corporation.”

Now what a ridiculous situation that is and yet that is what has pertained from the beginning of Government. We have forty-one independent governmental departments and establishments and each of them has been going on its own way and the result has been chaos in business, absolute chaos. It is a remarkable thing that here for the first time in the history of the Government you have got together the elements to determine the proper administration of this most important matter of the care of the sick and the disabled among the veterans of the war. For the first time it is possible, by this juxtaposition, to properly consider policies to prevent duplication, to devise ways and means and it is a comment upon the terrible conditions under which the business of this Government has been transacted, and that is the first instance where you could get them all together to discuss a coordinated policy. That has been so with everything. The meeting never would have gotten together, you never could have gotten together physically in connection with this thing unless you had been ordered together by the use of the Executive power of the President of the United States. Now don’t get that out of your head,—that underneath this reorganization of government, which is not to be effected, but which has been effected in this routine business, there is the idea of force, and if the idea of force was not there we would not have gotten anywhere in connection with the securing of these results, which small as they are, represent an immense advance upon the old situation. I speak now from the standpoint of the accomplishment of these coordinating boards,—not as predicting something that is going to be done, but of the result of that which has been done during the last six months through coordinating agencies such as your Federal Board, established by the President of the United States through the use of his authority and running the routine business of the Government for the first time upon a business basis.

I make this distinction (for Mr. Burke, for instance) as some misapprehension may be had in connection with this matter of policy. The Budget Bureau, is not concerned with policy save that of economy and efficiency. We are concerned with the routine expenditure of money, of proper conduct of routine business. It is our business to see that when money is appropriated by Congress along a certain line or policy with which we have nothing to do, that that money is spent as economically and as judiciously and carefully as possible in order to secure the greatest results along the line of the policy imposed by Congress.

If Congress as a matter of policy should pass a law to put garbage on the White House steps, it becomes our duty, regrettable as it might be, to advise Congress and the Executive as to how the largest amount of garbage may be most expeditiously and economically spread on the White House steps. And that is why we are safe in demanding what is absolutely necessary, in every business, in routine matters,—a centralized authority. There is no democracy in a properly organized business so far as routine business is concerned. It is a monarchy, and if the sense of responsibility on the part of the agent to the man at the head of the corporation, who is responsible for the policy, is lost, the business goes to pieces, and, if a private business, you go into the hands of the sheriff.

The trouble is that in the past the Presidents of the United States have not done their full duty and assumed the control of the routine business organization of Government. The result is, as is always the case, with a private or public organization, that when the money is spent by parties interested alone in spending the money, the plan of the unit over which the spending head presides takes precedence over the plan of the organization as a whole.

Now that has been exactly the situation in the United States up to this time, and in dollars and cents, to say nothing of the matter of the use of facilities, there has been a waste that is incalculable in the past.

Now, for instance, take this. All this is preliminary but it is very important. Let me talk about human nature in connection with this matter of taking order,—this matter of jealousy of prerogative. I sometimes think we ought all to take a course of study in human nature. I sometimes think that while in the A. E. F. charged by the Commander-in-Chief with this same job of coordinating separated services, the independent services of the Army in connection with the unified business plan of the A. E. F., and afterwards in trying to couple up the allies in the same line of endeavor, I had a better chance than most people to see in its full majesty,—if you choose to look at it that way—that desire for absolute independence,—that willingness to subordinate practically everything on earth to hold power which is characteristic of human nature.

When you have to approach independent power, to induce voluntary surrender, I have found you might as well give it up in advance. There is nothing a man holds to like this right to exercise power, and the best illustration of that is shown by the fact that the greatest war of all ages was fought for four years without a central command. Napoleon’s 44th maxim in war was that nothing is more important in war than a unified command, under one chief. Everybody knew it, but it was not until the unnecessary loss of hundreds of thousands of lives and billions of dollars worth of material that Great Britain bent its pride and accepted that plain, common-sense provision of unified command of the allies under Foch. Not until the fourth year of the war when the allied cause faced annihilation was such a plain, common-sense provision as that for central command possible to be made for the allies, and the certainty of annihilation alone made it possible.

Now do you think it is any different in connection with the independent jurisdiction of these Government Departments, from the independent services of the Army?

They talked in the past about Interdepartmental Boards, to correct this old chaos, when they had no Executive leadership. An effort was made from time to time by Interdepartmental Boards, acting as a committee without relinquishment of the independent authority represented to undertake some of these reforms, the necessity of which everybody saw. Nothing was ever done to amount to anything. Why? They would meet together and talk and outline the situation and necessity for action until some question came up where somebody was going to lose control of something or a part of his jurisdiction by some coordinated action for the benefit of the whole Government. Then immediately the whole thing died out and nothing was accomplished practically by any Interdepartmental Board, where anything vital had to be given up by one of the independent members of it, whose jurisdiction and power would be cut down in the interest of the common plan of the Government.

When the President of the United States assumed this central control of routine business, he did what any man would do in connection with a private corporation; he called together in conference the business administration,—everybody connected with the business of the Government as head of department or independent establishment—Cabinet Officers correspond to Vice Presidents in a business corporation. Of necessity they had allowed this disgraceful system of chaos and extravagance to go on. It was not their fault any more than it is the fault of you gentlemen, who have been running along independent lines, because you were not joined together in a system operating under a central authority. We all were properly subject to the indictment of loose business methods because the President of the United States had not imposed a unified plan and system over us nor had he created the machinery by which this plan would be carried into effect, as he has since done.

In connection with surplus supplies, every department formerly was selling its supplies in the open-market, and other departments were buying the same kind of supplies in open market. In a number of cases speculators would come and buy our public sales material from one department to sell it to another department at two or three times the price. Real estate was being leased in cities right along from private owners, when the Government had vacant property to rent. This was the custom also in connection with motor transport. If any Department wanted something moved and did not have motor transport, it would go out and hire motor transportation. There was no machinery by which the empty motor trucks and idle men of the other departments could be used.

When goods were to be shipped, everybody would route them as they pleased. There was no unified central authority which could deal with the services as a whole as regards the classification of freight and the whole transportation question.

The same thing existed in the making of contracts.

The same thing existed in Government purchasing. There was competition between the Departments, the Departments themselves not being coordinated. In the Treasury Department alone we found 18 separate points of purchasing activity. Everything was run in Government business as if it was composed of 41 separate corporations. How were things changed for the better? It is all simple enough. It all depended on the President because he alone had the authority to impose the methods of coordinating and controlling this great general business, just as he is coordinating these great activities here today through this Board, presided over by his appointee, General Sawyer, a co-ordinator.

The plan which the President adopted was simple enough,—just what would be done in any business organization—without asking for any additional legislation for additional employees, but by simply taking from the body of the employees, officials of the United States, those men especially qualified by knowledge and experience to act as his agents, and then creating the machinery through which they could transmit his policy and plan of unified business to the general organization.

It is the simplest thing in the world, and the only possible objection I have ever heard was urged the other day where it was said that the detail of Army and Navy Officers for this central work by the President might not result in giving him the benefit of absolute impartiality of judgment because of their former connection with the War and Navy departments. That nonsense!

For instance, in my bank,—supposing I wanted to take a man from the Discount Department, from the Foreign Exchange Department, or the Real Estate Department,—what folly to say that I would be justly afraid that he would not be my loyal and faithful agent in the imposition of a plan for the interest of the institution as a whole because of his former connection with those departments of the bank. What folly to say that the President of the United States with all his power over personnel can not receive from men detailed for co-ordinating work the same loyalty as he would receive from men appointed from the outside to come into this complex machine. And I say now that the plan must stand or fall upon that proposition. Regarding Colonel Smither, the Chief Coordinator, or Commander Stanley, or any of these men who have been connected with the Army or Navy,—so far as this work is concerned, as agents for the President of the United States, they are as independent as if they had never been in the Army or Navy. If anybody thinks they are not, let us give him an example. We have not found anything but cooperation from the heads of these departments and the heads of these services because their personal interests lie parallel now with the unified plan of the government since the President of the United States to whom they are responsible, is behind that plan.

If the President becomes indifferent,—if he loses his eyes, and ears and fingers in matters of routine business in the shape of the Chief Coordinators of the Boards,—if he lets them drift, immediately there will come the effort from you and everybody else to pull to pieces this coordinating machinery which alone is able to impose a unified plan upon the governmental business.

Now why is it necessary for you to accept, without mental reservation, the necessity of the existence of this coordinating board under which you act and the authority of the Chief Coordinator of that board as representing the President? Let me say in connection with this that the rights of the independent departments and establishments are jealously regarded under these executive orders.

What I want to impress upon the minds of all is the necessity of these co-ordinating boards to enable you to do your work properly.

Take it in ships. In coordinating shipping transportation, you have got to have Mr. Weeks, Mr. Denby and Mr. Lasker in contact in connection with a decision involving the economical use of ships. How can anybody get them together without the authority of the President? Suppose I was expected to call them together without the authority of the President. I would go to Mr. Weeks for example and wait until the Senators were through seeing him, and then perhaps because of his personal friendship persuade him to go over with me to see Mr. Denby. When we had seen Denby how could we get the two together with Lasker? You could not get anywhere in this co-ordinating work without a delegated authority from the President to compel contact between high officials.

In connection with this great work of yours in which you spent last year three-fourths of a billion dollars, you cannot have it run right without the existence of this co-ordinating Board,—without that authority to make a bird’s-eye view of the whole situation,—without that authority to say why this building, for example, is unnecessary, because there exists a superfluity of this sort of building in another department. What’s the use of endeavoring to catalogue those activities in which there is duplication, in which you have got to have the bird’s-eye view, and would never get proper action taken, unless you have in existence this Board created by the authority of the President!

In connection with the rights of your department, for instance, there is preserved for you at all times in connection with the coordinating order of the Federal Board of Hospitalization, a right of appeal to the President of the United States. If this Coordinating Board interferes to such an extent with the plans of your unit that you think the disadvantage so great that it counterbalances the beneficial effect to the government as a whole, the right of appeal to the President is with you. But for the first time in the government, as you know, there will be presented to the President by the Chief Coordinator the interests of the government treated from the standpoint of the Coordinating Board, so that the President of the United States in making his decision on your matter has the strongest possible statement of the needs of the unit from you, and the strongest possible statement of the needs of the government as a whole from the President of the Board. But the final authority, of course, is in the President of the United States and he will exercise it. In all of these orders the right of the head of the independent unit to a proper examination, by the supreme authority, of his plan is preserved, and it has been so in connection with all of these coordinating agencies and with the Director of the Budget.

Let me tell you something as to the spirit of cooperation shown. I have never had a contest before the President with a cabinet officer or head of a department in connection with a coordinating action. I have never had one for this reason. Take in connection with the transfer of ships,—we have independent agencies for the examination of conditions. We have the right, as agents of the President, of obtaining information from any bureau chief or head of a department.

We have, through Colonel Smither’s wonderful organization of course, the means for securing essential knowledge about these things.

Regarding ships,—we asked the Navy the other day for a couple of mine sweepers for the Coast and Geodetic Survey. They refused. That was always the case in the old days. Of course, everybody looks out for the interest of his own department. Well I called over one of the Assistant Secretaries of the Navy, and gave him a bird’s-eye view of the situation.

They had 49 mine sweepers; and they were going out of commission. If they went to the Coast and Geodetic Survey, they would be kept in commission and would not deteriorate so rapidly. What is more, if they didn’t go to the Geodetic Survey, the United States would have to ask for a million dollars to build new ships.

That matter was taken back and proper attention given to it with this knowledge of the whole situation and the Secretary of the Navy joined in the request that the ships be transferred.

It was not the Secretary of the Navy who had really been responsible for the first decision. It was some fellow along down the line, without the bird’s-eye view, who has been safe for a hundred years from the eye of a central authority, thinking in terms of the whole government—doing what he believed his duty, I admit, in directing things for the best interests of his unit, but who, without the bird’s-eye view would have thrown the Government into an unnecessary expense of a million dollars.

It then developed when the Coast and Geodetic Survey people went to get the mine sweepers, that they were in process of repair; that the engines were disassembled. Now the Coast and Geodetic Survey had no appropriation available for repairing work and so the Navy said, “We won’t spend our money on those ships.”

“Why?”

“Because the President of the United States told us to be economical.”

Now supposing there had not been in existence an agency acting under the President, such as the one here presided over by General Sawyer which could see what was really involved in that action on the part of the head of that subordinate unit of the Navy. Because the Navy wanted to save a repair bill of $10,240.00 the Government would have spent unnecessarily $1,000,000 for new ships. Do not think that was an unusual case! It was almost always so in the old days.

Now nobody has been more anxious than the Secretary of the Navy to cooperate in those matters but he must have information,—and you must have the information,—to enable one to cooperate. All that was necessary for me to do was to write to the Secretary of the Navy, that unless these ships were repaired out of the Navy appropriation at a cost of $10,240 we would have had to ask for a million dollars appropriation for new ships. But what if that information had not been given?

The existence of these agencies is necessary to enable this Government to be run on a business basis. I have given you a simple illustration in connection with the ships. We transferred thirteen ships with the acquiescence of the heads of the departments concerned by simply developing the bird’s-eye view of the situation without ever taking the matter up with the President, except for the issuance of the Executive order by agreement.

The patriotic head of a unit really welcomes this system by which he is given the information which enables him to run the activities of his particular institution in the interest of the Government as a whole.

I repeat you must have that bird’s-eye view of the necessities of the Government as a whole, which alone you can secure through the authority of the President as exercised through the Coordinator of the Board you have here. It is absolutely necessary that there should be no withholding of the spirit of cooperation and loyalty to your Coordinator. There should be no feeling that your independent jurisdiction is going to be unnecessarily curtailed and interfered with. There is the right of appeal, and it is just as important to the proper functioning of the whole governmental business machine that you have courageous defense of the department unit as you have courageous defense of the policies of coordination.

There is no proper room for friction; and so far as the Budget Bureau is concerned and the coordinating agencies headed by Colonel Smithers, we have had a minimum of friction with the departments. There have been transferred over $112,000,000 dollars worth of property between these departments within the last six months. $100,000 per year is being saved in the comparatively small thing right here in the District of Motor transportation.

Anybody who stands against the principle of this thing is a man, in the first place, who is not intelligent. He is a man in the second place who is not loyal; and he is a man, in the third place, who is in danger, in view of the accomplishments of this coordinating work. What excuses are there for anyone not to give his loyal cooperation to the President of the United States, who, for the first time, has undertaken to be responsible for a correct system of routine business?

One other thing in connection with the spirit of economy:—the President of the United States has asked it. He asked it here in the first meeting of the Govt. business organization last June at which some of you were present. That request of his has received response. I find over the country that for the first time in government, economy has become fashionable, and extravagance dangerous; and all over the country, in the post office service, the Army service—in all Govt. activities. There is the spirit of loyal cooperation under the leadership of the President in the matter of economy.

We know, too, what you have been trying to do in that way in your own service is resulting in an immense saving to the Government.

What we need are men in authority to help us find out where savings can be made. We have only scratched the surface, but it is possible now, as we get the business of the Government in the proper, organized shape, to determine where the limit of economy is. We do not know yet, because our reorganization of routine business methods has not gone on long enough. We have only been in operation four or five months. It will be a year or two possibly before the extent of economies can be determined.

But in directing the prevention of duplication, etc., in the general attitude of being desirous to save, as opposed to the old attitude of being desirous to spend,—all that means that the Government of the United States can be run more economically than at present provided the President of the United States gives his attention to the business organization and he will.”

General Dawes concluded his remarks, and as he walked from the stage General Ireland made a suggestion that he say something in connection with coordination within the limits of a department itself. General Dawes then said:

“General Ireland asks that I speak about a most important matter. We cannot get general coordination among the departments unless each department is coordinated within itself. For instance, we found that in the Treasury Department there were about eighteen separate points of purchasing activity. No one man was in touch with all these agencies. The representative of the Treasury department on the coordinating board, therefore, could not speak for the eighteen agencies. Therefore, each institution must coordinate within itself in order that its representative can properly speak for it on the coordinating board, to say nothing about the desirability of coordination from the standpoint of the business of that particular department. Therefore, get your units coordinated.

In connection with this whole matter of hospitalization, the eyes of the country are on you, who are charged with this great responsibility. No body of men in Government service has more complexing situations to meet than you have. You are surrounded by every embarrassment. In these days, when the pinhead demagogues are flourishing; when the mere politician is willing to capitalize anything, even a wounded soldier, to catch votes, you know that you are liable to have your constructive work unjustly attacked. To get into the lime-light many men will sacrifice right principles, and it is distressing to see the antics of the puny men in public life seeking to ingratiate themselves in public favor in connection with soldier relief. The demagogue has no hesitation in attacking those things which are right only provided they happen to be unpopular. His mind, unlike yours, is not on the real good of the soldier. He is thinking what the newspapers may say about him.

You must be courageous; you must work for the real good of the soldier; you must work for the real good of the Government; and I will tell you something. There is no privilege so great, which comes with public life, as to courageously stand for that which is right, and in so doing take castigation from demagogues for doing one’s duty. It all comes out right in the long run.

In the midst of your discouraging embarrassments, when carefully thought out measures of sane relief for wounded veterans are often attacked by unscrupulous men, who thereby can advertise for a little time their insignificant personalities; if you sometimes are tempted to take the easy way and join the yelping pack of destructive critics, be comforted in the thought of that everlasting truth that in the long run the man who fearlessly does right in public place survives, and the man who weakly takes the wrong way because it is easy receives only ignominy.”

GEN. SAWYER: It seems unnecessary for me to say, still it is only fair to General Dawes, that he has injected into the affairs of Government the greatest enthusiasm and the most interest that has been known in Government affairs in all the history of the Republic.

His idea of coordination, which came to him out of the trying experience of the war on the other side has certainly served him a wonderful purpose in the effects that he has brought about in this new plan of conducting the affairs of the Administration on a business basis, and I certainly hope that each of you, as you go back to your fields of activity, will carry with you the idea that you have a most responsible position. No matter how small your institution, the responsibilities, the liabilities and the needs are all the same.

It may interest you to know that in the few weeks this present Board has existed, we have been able to turn over to the various hospitals of the country in which we have been particularly and necessarily interested, in a hurry, several million dollars worth of property. Arrangements are now in operation whereby in caring and preparing for nearly 11,000 new beds, we have in mind to avail ourselves of the great resources of the Army and Navy in supplying these needs; and I must say out of fairness to the heads of those Departments, as represented by the medical departments, that more hearty cooperation could not be obtained. To give you an evidence of something of the difference of today and yesterday, early last summer an appeal came to me to provide some cots for one of your institutions. It was impossible for me to locate cots that I could make accessible for the purpose, and one day one of our own representatives from this Board looking about found 80 car-loads of these cots at Des Moines, Iowa. Now when we are in need of cots, we know where to find them and know how to get possession of them; and this is true of all the things that are really necessary in the conduct of your affairs.

I am here to say to you without any fear of contradiction that this Hospitalization Board has already accomplished some very helpful things, and we have many more things in mind. One thing we do not assume, and that is authority. We have no idea or desire of being autocratic in our administration but we have a firm determination that regardless of any sentiment or any emotion which may be brought to influence the affairs of this Board, we will go on with what we believe to be the best thing for the men we are trying to serve.

I believe that the service we should render and that we must render, and the only service that is worth while to the veteran, is to make him well if possible, and, if not, to make him as nearly well as he can be and as resourceful as he can be and put him back into life again with confidence in himself, with respect to his Government and with ambition to make America the leading Government of all the governments of the world.

I am here to say to you that while you are talking to your patients about the affairs that arise with you each day, do not forget as a part of your responsibility and your duty that you help to create a spirit and a determination on the part of the man you are serving to get back into life again. Discourage in every way you possibly can the idea of his becoming a barnacle upon this great Ship of State. Encourage him to believe that the responsibility of the debts that are incurred here now are debts his children and his grandchildren will have to pay; and so, while we are talking economy to you, I would impress upon you this one thought: that economy is only the assurance to yourself that every hundred cents buys a dollar’s worth. We do not mean by the economy we are trying to preach here economy that might be regarded as penuriousness. We want you to have all you need in the best way that it can be provided for you, but we want you to have concern enough in the property that is turned over to you to see that it is worth what you pay for it and that it is used to the best advantage possible.

Yesterday, we decided, I believe, that we would devote an hour this morning to the answering of some miscellaneous interrogations. Dr. White, have you received any?

DR. WHITE: No.

SURGEON W. H. SANFORD (R): Having spent the last year and a half in the Inspection Division, the subject of this excessive amount of money in the hands of the sick soldier has impressed itself on me more and more as I inspected the hospitals. It was the cause of great trouble, and is in my opinion doing more to hinder the patient than any one factor. Without this $80.00 or $157.50 a month, the vice and crime and drinking around the institutions could not exist, and therefore I believe that one of the greatest things that could be accomplished at this Conference would be for the Committee to promulgate some way of preventing these men from using that money in the way it is being used today.

I have inspected Ft. Bayard, Ft. Stanton and other large institutions in the West, and I know these men in charge will agree with me when I say that the thing that hampers the recovery of the patients is their right to expend the money the way they want. If they didn’t have it, the rum-runner and the other vices that come would not be there. I think it is one of the most important subjects we could settle, and suggest that it would be well if the Committee would recommend that we give these men, say, $15.00 a month, and take care of the rest of their money until they are ready to go back to their homes.

SURGEON J. E. MILLER (R): At our hospital we have a canteen. I suppose most hospitals have canteens. We have had $3,000 paid into the hospital—$3,000 a year profit on sales to soldiers. I think such money could be turned in for the benefit of the soldiers, for entertainments, Christmas dinners, etc., as that seems the proper place for it.

MR. M. SANGER (St. Elizabeths Hospital): With reference to those funds of the beneficiaries who are in hospitals, a similar condition

existed for a while with reference to those drawing pensions. That proposition had to be met. Congress passed a law whereby those people receiving pensions, who entered soldiers’ homes or hospitals had to pay that money either to the superintendent of the hospital, the President of the Soldiers’ Home, or the Governor of the Home, to be cared for the benefit of the pensioner. Those who had beneficiaries at home received the benefit of their portion of the pension under supervision of the Pension Office, the Pension Office having machinery to find out what beneficiaries had dependents, etc., and what proportion of the pension should be paid to them.

The only thing in connection with these funds paid to the hospitals which led to complaint was the money paid to heads of hospitals or Soldiers’ Homes for deposit in the Treasury, but which was not drawing interest. This needs corrective legislation. Precedents are at hand. Moneys paid into the Treasury by beneficiaries or enlisted men of the Army or Navy are drawing interest. The money from these pensioners should be drawing interest. These funds, whether from the pensioners or beneficiaries of the War Risk Bureau should be used as a sinking-fund possibly to retire the debt of the Government and in that manner to draw interest. It would help the Government in becoming part of the sinking-fund; it would help the veteran in that it would permit the money received to be deposited for his benefit, and would give an opportunity for regulations to be made to safeguard him; to prevent these people from coming around the institutions by preventing his having excessive money to spend. Then when the man is discharged, he would have an estate with which to begin life and to provide for the future.

I think this organization should give some consideration to this matter. I refer to Acts of February 20, 1905 and February 7, 1909, and similar acts in regard to Soldiers’ Homes. I think the one thing to be considered is a means of investing these funds for drawing interest.

MAJOR GENERAL M. W. IRELAND: The question of patients having money while in the hospital is one of the most demoralizing things that can happen. It has been recognized in the Army for many years.

In the Philippines we had a sympathetic commanding officer and we received permission to with-hold a certain portion of the funds. Then we received word from the Secretary of War that it was contrary to law; that the money was earned by the soldier, and had to be paid to him.

I think you are going to find the same is true of compensation. If you are going to hold the compensation of the man while he is in the hospital, you will have to get an Act of Congress. I think, therefore, that you should consider the amount of compensation the man should get while in the hospital; consider the proposition of maybe reducing his compensation while in the hospital, being cared for by the Government.

SENIOR SURGEON J. E. DEDMAN (R): I am glad this subject came up. A year and a half ago, a committee of T. B. experts came to our hospital and we discussed that question. I made the statement that many of the men in our hospitals were getting too much money. It was immediately taken up by the American Legion, and they said all kinds of unkind things about me. I said that men who never had any money in their lives single boys, etc., were getting $80.00 a month and that this was too much money.

I cited the instance of where a lady came into my office, weeping. She said she had been dependent upon her son; that he had gotten that day a check for $1200; had bought an automobile for $1500; and had gone $300 in debt.

The greatest set of vultures we have to contend with are the automobile salesmen. For instance, they come and sell to our boys for $700 cars which would sell for $400. If the boy has $500, they charge him $750 in order to get notes and keep him in debt.

I am in favor of getting an Act of Congress to put the man’s money at interest, so that when he is rehabilitated he will have something to take care of himself. As it is now the boys are spending their money for hootch, automobiles, etc., and instead of rehabilitating them we are ruining them.

MR. M. SANGER, St. Elizabeths’ Hospital: In regard to the question of General Ireland, the pension regulations include a provision that one part of the pension shall be devoted to reimbursing the hospital for part of the care. I think that would serve in a way to admit of those in hospital getting less while there than when outside.

SENIOR SURGEON G. B. YOUNG, U.S.P.H.S. While on the subject I offer the suggestion that something might be done along this line in connection with the disciplinary regulations, which provide that when a man is discharged for disciplinary reasons his compensation will be withheld for a certain period. We all know that we sometimes will have to discharge people for disciplinary reasons, and it may happen that the offense is of such a character and the man of such a character as to make you feel that the sentence you have to impose upon him as compared to that which you have to impose upon a flagrant offender is lacking in elasticity. It seems to me that it would be well in this connection to consider whether the regulations could provide for the with-holding of compensation by the Veterans’ Bureau for a greater period as an incentive to better conduct, so that the man might be returned to the hospital with the incentive that if he behaves satisfactorily that this money which had been withheld would be restored. As it is a man has to be discharged and he goes out penniless, because he hasn’t anything coming to him for several months. If he could look forward to a suspended sentence, I think that would save some of the better element among these possible unintentional offenders and get them back into a line of good behavior.

COLONEL JAMES A. MATTISON, N.H.D.V.S. This question which was brought up by Congressman Madden, General Ireland and others is a very pertinent one. This method of handling the funds of men of former wars has been in effect in the National Home service for many years. The matter just spoken of in regard to handling this money in a disciplinary way has also been a feature. In regard to the men who have been offenders, who have been continually guilty of getting drunk, the commanding officer of each hospital had the authority to with-hold, as a disciplinary measure, any part or the whole of a man’s pension until such time as he saw fit to turn the money over to the man or a part of it. Of course the matter of with-holding pension money in the case of men of former wars is of much less importance. Formerly, these men were getting $10, $20 and $25 a month, and when Congress passed a pension law providing $30 a month, they saved money. That does not compare with the pensions our soldiers of the recent war are receiving, $80, $100 and $150 a month, and, as has been stated by several men already, it has been and is going to continue to be one of the greatest factors in preventing these men from being restored to an active state in life again.

In the matter of the corrupt conditions which have been described as existing around these hospitals, it is something that cannot be prevented. Every effort has been made. The civil authorities have been appealed to and in most cases they have given undivided co-operation. Personally, I feel that it is an exceedingly important matter.

SURGEON J. B. ANDERSON (R): If I have interpreted the regulations correctly, we are not permitted to have a canteen around the hospital. If I am in error, I should like to know it.

LIEUT. COL. W. H. MONCRIEF, U.S.A.: Contrary to the impression given here yesterday afternoon, revelry does not maintain at Fitzsimmons Hospital. I think we have a well-ordered institution. The matter of compensation does give us some concern.

We have four classes of patients,—Army, Navy, beneficiaries of Soldiers’ Homes and of the Veterans’ Bureau. On the day I left, we had a total of 980 patients, 719 of which were Veterans’ Bureau beneficiaries. These are officers, ex-nurses and ex-enlisted men. I will say that the behavior of these people during my tour of duty at the hospital compares favorably with that of any other institution. We have our troubles; if we didn’t have them, I don’t suppose the institution would need a commanding officer.

But the question of compensation is one that is not easily adjusted unless it is adjusted at the source. It is impossible to give you an idea—unless you have charge of one of these institutions—of how much trouble the commanding officer is going to have if the responsibility of withholding this compensation is put on him.

We are near a large city—not too near and not too far—but we are surrounded by people who want to offer at all times every inducement to the enlisted men to spend this amount of compensation in the most advantageous manner. This class ranges from the peddler of tin toys to the most reliable banking firms in the city of Denver. Those bank representatives wait on us. Since I have been there, I have had to pursue the policy of excluding from the reservation all solicitation whatsoever, my argument being that it was my duty, to protect the T. B. patients; that if one solicitor were allowed, others must be allowed; and that I had no time nor inclination to pass upon the merits of the various propositions offered. I have not had a great deal of trouble; and since I have been able to get the representative people to understand this situation—and I take particular pains to inform all my personnel that reputable firms and others are aware of this prohibition—it is assumed that anyone soliciting on the reservation is not reputable.

I think a great deal can be done in regard to taking care of this matter by the social service work in the hospitals. The good people of Denver have been very kind in every way.

DR. BUTLER: In view of the fact that economy seems to be the order of the day, and to have economy the bird’s-eye view has been pointed out to organizations this morning, I suggest that as a fitting slogan for this body, the words. “Cultivate a bird’s-eye view” be adopted.

GENERAL SAWYER: I don’t know just what authority you gentlemen have in regard to the matter of solicitors, but at White Oaks Farm if interruptions such as these attempted to exist, somebody would get hurt. I would not tolerate the existence of such affairs. There is no reason why you should, and if there is any reason why you shouldn’t, this Board can help you to bring about some regulation or some rule whereby it will be possible for you to protect yourselves and your people against such imposition as this. Be assured that this Board is going to provide it; but I really think that if you will exercise your authority as commanding officers and not allow these people to intrude upon you, you will be able to cure a lot of your difficulties at home.

SURGEON J. M. WHEATE (R), U.S.P.H.S.: A year ago we were swarmed with agents, and I sent out a hospital regulation prohibiting that. It is easy to issue regulations, but hard to put them into effect, so I have made it a rule to make my regulations as few as possible. This, however, I found to be a necessary regulation, and I prohibited agents of all kinds from access to the hospital.

We have a hundred-acre field, which is approachable in a hundred different ways, and there is no way of keeping such agents out of the reservation. I had my Captain of the Watch made a Deputy United States Marshal. I had my head orderly made a constable for the county. They helped me to maintain order outside the reservation.

The matter of compensation has been a big problem with all of us. I recall that about the first time I got “in bad” with my patients was early in the game. I was waited on by a delegation of patients in my office one morning, who asked if I were properly quoted in the morning paper. I had not seen the paper.

A day or two before, a committee of Legion men called at my office (we had most happy relations with the local Legion heads). One of this Committee was the editor of a local paper. Among the general things we discussed was the abuse of compensation. I said I wished we had some law like Canada, whereby all but one-fourth of the compensation could be withheld, as I believed that ten dollars a month was enough for a sick man in the hospital. This was discussed and it sounded reasonable.

The next day, to my surprise, the editor of the local paper printed the story of my recommendation; and the young chap, thinking I suppose to give me the credit for the thought, quoted me freely.

The soldiers appointed a committee to wait on me. They wanted to know if I thought it fair to the United States soldier. They said it was their money and that they proposed to spend it as they saw fit.

Out of this controversy grow consideration by the Legion; and in course of time that Legion Post sent a committee man to Washington, who had a long conference with Mr. Sweet; and indirectly I may be much to be condemned or praised for introducing into the Sweet Bill the measure of withholding compensation. Our committee man who went up there stated that it was a rather new thought to Mr. Sweet and that he waved it aside at first, but that later he showed interest and finally said he was going to rewrite his bill, incorporating that idea.

But it did not go nearly as far as I recommended; that is, the adoption of the Canadian form of withholding all but one-fourth. There is no need to discuss that. Mr. Sweet said it was illegal; that compensation is a wage; but he compromised by saying we could fine the men.

Regarding my drastic order, I might add that I do allow the agents of the banks to come in, and I am proud to say that we do handle much of our trouble by depositing money either for checking accounts or savings. I think that about forty per cent of our men are carrying savings accounts in the local banks.

We have at least 160 N. P. cases in my hospital, although it is officially a T. B. hospital. As you know, the regulation provides that if a man is not capable of handling his money, his compensation check will be sent to the Commanding Officer, who is held responsible for the money. I put the money in the bank, giving to the man, after conferring with the Chief of the N. P. Section, such funds as he may need.

SURGEON M. J. WHITE: Early in 1919, when I first opened Palo Alto, I made recommendation for the amendment of the Act, so that the Compensation of a patient might be held until he had completely recovered, and I see no reason why there is a legal bar to it. I think Congress can say that Compensation is payable when a man has completely recovered and is discharged from the hospital. We cannot undertake to protect the patients from sharks. For instance, we give a man a pass; he goes down town and spends his money. As long as he has money in his pocket, he will spend it. I think it would be legal for Congress to say that Compensation will be payable when the man has reached maximum hospital treatment or when he is properly discharged. Otherwise, if a patient has accumulated, say, $160, he starts a disturbance and you have to give him the money.

CAPTAIN F. W. Wieber, U.S.N.:—I am glad to say that we have had very little trouble with our Veterans’ Bureau patients. We have, however, had trouble occasionally, but I have always been able to attend to these matters myself, for I have a good understanding with a U. S. Attorney, who helps me out.

Regarding money, it would be the best thing if most of the Compensation to the men could be withheld. They may have dependent families, so no uniform rule could guide us in our action. I do not think it should be left to the Commanding Officer, for in the first place, we do not know how much money the men should receive.

With regard to the matter of smuggling into the reservation, I sent a request to the Surgeon General to be allowed to put up a fence but I have never heard from it. I am going to recommend to my successor that he call attention to that matter again. The reservation at Fort Lyon covers 1100 acres, and a portion should be enclosed with a fence. There has been much stealing there, and we have often found the stolen articles in houses around the reservation. The building of a fence would be expensive, but it would counter-balance the loss of government property.

For the benefit of the gentlemen who may succeed at Fort Lyon soon, I might say that when I was ordered to Fort Lyon I was very much grieved; I knew it was in a desert, and everybody who had been there gave such a discouraging report. My sentiment in that matter has changed to such an extent that if the place had remained in the hands of the Navy, I should have liked to have remained there. We are a happy family of about fourteen commissioned officers and we have formed a little community of ourselves, being independent of the outside world to a large extent. We have our power house, ice plant, community house, social meetings, and in fact we are as independent as can be.

During the flood, we were able, for about two weeks to attend to our own things, and after that we were able to help the outsiders. So, to those gentlemen I want to say that they need not be disconsolate upon receiving orders to go to Fort Lyon.

I think it is ideal for the T. B. patients. We have the dry climate, constant sun-shiny days, cool nights, and everything conducive to the proper treatment of T. B. Everything is complete, and the people are greatly benefited by their stay in our vicinity, as can be attested by the fact that many former Navy People, who had been in the institution, are now living there and are as strong as any person in the East.

I might say that the people who have had T. B. and who are doing well out west had better make up their minds to stay our there for fear that change of conditions might bring about activity again in their cases.

Regarding a uniform system of treatment as suggested, I do not believe any strict rules should be set. We can have a sort of general system, but no uniform method as to the hours of rest, food, etc. At Fort Lyon, rest is now being enforced, and every patient gets two rest periods, i. e., from 9 to 11 A.M. and from 1 to 3 P.M. Liberty is allowed only once a week; and overnight, once a month. Those who would be discontented anywhere have left, and those who have stayed feel they have our sympathy and support and are doing well.

GENERAL SAWYER asked for resolutions from the Resolutions Committee.

GENERAL IRELAND: “Your committee has gone over the resolutions that have been presented, and we find all of them in order, with the exception of one submitted by Colonel Bratton with reference to transportation home. We would inform you that there will have to be legislation to carry out that resolution. We have changed the resolution to read as follows:

‘That the Director of the U.S. Veterans’ Bureau be requested to secure legislation so that the expenses of the patient’s transportation to his bona fide home, when he has been discharged for disciplinary reasons, be deducted from his compensation, when compensation is being given, or may be given thereafter.’

As changed, I recommend that the resolution be adopted by the meeting as read.”

This Motion was seconded, and carried.

CAPTAIN N. J. BLACKWOOD, U. S. N.:—The Committee on Forms has held two meetings at which the general subject of this work was discussed and plans agreed upon. This work is so great that your Committee finds it impossible to report more than progress at present. The whole matter must be gone into carefully and thoroughly in order to avoid mistakes and duplications of the past. The work, to be a success, will require frequent meetings, careful study and cooperation. Therefore, it seems wise that all members of the Committee be officers on duty in Washington, and I recommend that the present chairman, Captain Blackwood, be relieved, and that his place be filled by Captain M. S. Elliott, Commanding Officer of the Naval Hospital; also, that all Commanding Officers here present shall, as soon as possible after returning to their respective commands, take up the subject of forms and paper work regarding Veterans’ Bureau patients, and as soon thereafter as possible submit to the Veterans’ Bureau, Washington, recommendations and suggestions for the elimination, provision and simplification both of the forms themselves and their numbers.

Upon receipt of these letters, your Committee will then take up the whole subject in a more comprehensive way and will, as soon as possible, submit its recommendations for your consideration and approval.

The MOTION was seconded and carried.

Meeting adjourned at 12:30 P. M.

Eighth Session Friday, January 20, 1922.

Honorable Charles H. Burke presiding.

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

MR. BURKE: “We will proceed with the afternoon program. The first subject is “Foreign Relations of the U.S. Veterans’ Bureau in care of ex-soldiers of the former allied countries.” It will be discussed by Dr. F. D. Hester of the Veterans’ Bureau”.

DR. HESTER: read as follows:

“FOREIGN RELATIONS OF THE U.S. VETERANS’ BUREAU

IN CARE OF

EX-SOLDIERS OF THE FORMER ALLIED COUNTRIES.

Mr. Chairman, Ladies and Gentlemen:

As I note that the program upon which I have been placed refers to foreign relations of the U.S. Veterans’ Bureau in care of ex-soldiers of the formed-allied countries, with your permission I will add to that, the care of U.S. ex-service men in foreign countries. The care of U.S. ex-service men in this country has been discussed from every angle, and it would seem proper that we should also refer to his care in foreign countries from a medical standpoint, as well as to the care of the allied ex-service man in this country.

THE LAW PROVIDING FOR THE CARE OF U.S. EX-SERVICE MEN IN FOREIGN COUNTRIES

As act of Congress, Public 104, Sixty-sixth Congress, approved December 24, 1919, provides that the Bureau of War Risk Insurance, now the Veterans’ Bureau, is authorized, to furnish transportation, also medical, surgical, and hospital services to discharged members of the military or naval forces of those Governments which have been associated in war with the United States since April 6, 1917, and come within the provisions of laws of such Governments similar to the War Risk Insurance Act, at such rates and under such regulations as the Director of the Bureau of War Risk Insurance may prescribe, etc.

AUTHORIZATION FOR SERVICE

You will note that this provision of the law stipulates at such rates and under such regulations as the Director of the Bureau of War Risk Insurance may prescribe. The regulation that has been issued by the Director of the U.S. Veterans’ Bureau provides that in all cases where application for treatment is made by ex-members of the military or naval forces of the allies, such treatment will be furnished only on the specific authorization of the Director of the U.S. Veterans’ Bureau upon authority obtained from the Government concerned, to incur the expense of treatment in each case. When treatment is so authorized, the same procedure is to be followed as in cases of application made by ex-members of the Canadian forces, which is as follows: