VETERANS’ BUREAU CASES TREATED IN MILITARY HOSPITALS

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

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

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

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

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

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

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

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

ADMIRAL STITT:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GENERAL CUMMING:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DR. WHITE:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mr. Burke read extracts from: Section 3679 Act of March 3, 1905. Section 5503.

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

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

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

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

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

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

The meeting adjourned at 12:15 P.M.

Second Session Tuesday, January 17, 1922.

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

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

COLONEL FORBES:

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

DR. RAWLS:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GENERAL SAWYER: stated that the correction would be made.

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

COLONEL FORBES: stated that they do.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CAPTAIN BLACKWOOD: “Yes.”

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

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

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

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

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

COL. HANNER: represented Colonel Kennedy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MOTION

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

Motion was seconded by Surgeon General Cumming.

Motion carried.

SURGEON KOLB: offered a resolution:

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

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

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

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

Motion carried.

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

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

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

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

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

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

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

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

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

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

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

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

Third Session Wednesday, January 18, 1922.

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

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

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

Committee on Resolutions.

Major General Merritte W. Ireland, U. S. A.,

Rear Admiral Edward E. Stitt, U. S. N.,

Surgeon General H. S. Cumming, U.S.P.H.S.

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

Committee on Forms:

Captain Norman J. Blackwood, U.S.N.,

Surgeon M. C. Guthrie, U. S. Veterans’ Bureau,

Asst. Surg. Gen. J. W. Kerr, U.S.P.H.S.,

Colonel James A. Mattison, N.H.D.V.S.,

Major L. L. Hopwood, U.S.A.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) Loss of property such as valuables and clothing of patients. Investigation has shown, that patients were not informed of the hospital regulations regarding the disposition to be made of these articles upon admission; adequate lockers not available, or total disregard by patients of existing hospital regulations. (2) Preparation and shipment of remains of deceased;—casket too small, shabby lining; no flag furnished; shipping-box broken, due to lack of reinforcements; shroud of cheap material. Investigation usually shows gross exaggeration. In some instances specifications for the casket, shroud and shipping-box have been such that cheap material is provided. Due to this fact the contract price has been too low. The Director is willing to provide sufficient amount and desires that presentable casket and substantial shipping-box be furnished. Investigation has also shown that record is not always kept that the remains have been inspected by a medical officer, before shipment. (3) Poor food, especially weak coffee, and food cold when served. Investigation usually shows fares as a rule, are good, the complainant usually being tired of institutional menus.

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

File No. 89960

UNITED STATES VETERANS’ BUREAU. September 9, 1921.

GENERAL ORDER NO. 28

Subject: STANDARD OF REQUIREMENTS FOR HOSPITALS.

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

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

REQUIREMENTS FOR ALL HOSPITALS

1. The hospital should maintain a service whereby at least one resident physician is on duty at all times. 2. There should be an organized medical staff composed of men competent in their respective fields of medicine and actively meeting their responsibilities for the direction of the professional policies, for the medical work of the institution and also for the professional care of the patients in the hospital. 3. Provision for examination and treatment by dentists and specialists in eye, ear, nose and throat and genitourinary work. 4. Resident trained nurses—not less than 1 for each 10 or any part of 10 bed patients. 5. There should be facilities and personnel for the proper administration of dietetics.

1. Errors of diagnosis. 2. Unsatisfactory results of operative or medical treatment. 3. Autopsy results.

ADDITIONAL REQUIREMENTS FOR TUBERCULOSIS HOSPITALS

1. Resident physicians skilled in tuberculosis—if not living actually on the premises, to be available in five minutes or less. (Not less than 1 for 50 patients.) 2. Outdoor sleeping facilities, or in lieu thereof, provisions for unlimited ventilation of rooms. 3. Suitable rules prescribed for conduct and published rules providing for a satisfactory regimen of treatment in tuberculosis hospitals. 4. Satisfactory treatment conditions, including measures for enforcing suitable discipline and to prevent absence without leave and to prevent excessive exercise, whether from amusement or otherwise.

ADDITIONAL REQUIREMENTS FOR NEURO-PSYCHIATRIC HOSPITALS

1. Direction of the administration of the hospital and leadership in its medical work by physicians trained in the diagnosis and treatment of mental diseases. 2. An adequate medical staff organized so that duties are divided in accordance with the training of its different members and with the requirements of the clinical work. 3. Regular and frequent conferences of the medical staff at which the diagnosis, treatment and prognosis of each new case admitted are considered and at which cases about to be discharged are presented, training in psychiatry for new members of the staff being considered as a special object.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

October 14, 1921.

PSR/jcs L 10–DMO

District Manager,

District No. 1,

U. S. Veterans’ Bureau,

101 Milk Street,

Boston, Mass.

Dear Sir:

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

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

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

1st. Whether the patient is in need of out-patient, dental, physiotherapy, or other treatment, or convalescent care. If so, District Managers will make the necessary arrangements to continue the treatment indicated after discharge of the patient from the hospital. 2nd. Whether the patient desires vocational training: If so, his eligibility and feasibility will be determined and arrangements made for placing him in training promptly upon his discharge from the hospital. 3rd. Necessary adjustment or readjustment of all matters pertaining to his compensation will also be completed promptly upon his discharge from the hospital.

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

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

Very truly yours,

ROBERT U. PATTERSON,

Assistant Director,

U. S. Veterans’ Bureau.

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

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

Rightly interpreted, these orders are in no wise contradictory.

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

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

(2) To determine their feasibility for training.

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

(4) To accomplish everything necessary to adjudicate claims.

(5) Provision for outpatient treatment when required.

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

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

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

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

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

Under date of September 1st, about the time of the issuance of General Order No. 26 there were 9,592 patients in 862 private hospitals; there were 18,698 patients in 92 Government hospitals. Today there are 8924 patients in 757 contract hospitals and 20339 patients in 92 Government hospitals. From these figures it would appear as though the clearing out of hospitals, as provided for in General Order No. 26, has not been productive of results. This, however, must be viewed in the light of what is actually taking place in the field. About the time of the issuance of General Order No. 26, or a little before, every District was putting into the field a Clean-up Squad for practically every state, the function of which Squad was to make contact with all potential beneficiaries of the U. S. Veterans’ Bureau for the purpose of establishing claims, of offering hospitalization for examination, for emergency treatment, and for other situations. These Clean-up Squads served to feed a considerably increased number of patients of all types into hospitals. Anticipating that such period of hospitalization would be brief, they have used contract hospitals because of this fact, and because of their location in the near or immediate vicinity of the patients handled. The turnover has thus been largely increased. The increase of patients in Government hospitals has risen steadily at the rate of approximately 600 a month until it has reached the figure of 20339 patients, as against 18698 patients in the early part of September. There has been a slow but gradual decline of patients hospitalized in contract institutions, notwithstanding the very material influx into the hospitals by reason of the Clean-up Squads just spoken of. It might appear to you who are actually caring for patients in your institutions that notwithstanding the explanation of the meaning of General Order No. 26 and 26–A, that the holding of a patient in a hospital until all of the several matters necessary can be taken care of, will result in undue delay in discharge. This doubtless would be true if each hospital were required to assemble data called for and make the other necessary provisions and forward the reports to the District office to await return and receive transportation before a patient could be discharged.

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

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

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

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

Motion:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The following motion was adopted:

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

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

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

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

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

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

The meeting adjourned at 12:30 p.m.

Fourth Session Wednesday, January 18, 1922.

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

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

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

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

Dr. W. H. Allen, of Boise, Idaho.

Dr. W. C. Billings, of Ellis Island, N.Y.

Dr. R. L. Allen, of Arrowhead Springs, Cal.

Dr. A. P. Chronquest, of West Roxbury, Mass.

Dr. E. R. Marshall, of Detroit, Mich.”

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

ASST. SURGEON GENERAL C. H. LAVINDER:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NURSING.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GEN. CUMMING: asked Captain Wieber to talk.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) Provide entertainment. (b) Regulate visiting under the Commanding Officer’s direction. (c) Receive proper donations previously authorized by the Commanding Officer. (d) Stimulate in the adjacent community resources which can be beneficial to the patients.

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

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

(a) Securing social histories and other significant data for use of tuberculosis specialists and psychiatrists. (b) Securing reports on home conditions for help of physicians in deciding whether or not to discharge a patient to his home.

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

(a) Helping to connect men approved for vocational training to get in contact with the proper government officials later. With a Veteran Bureau’s representative in the hospital, this should be much simplified. (b) Following up patients who leave the hospital A.W.O.L. or against advice, to see if they return or if leaving against advice that they are placed under proper supervision in the home community.

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

(a) Communicating with family doctors and others to assist in securing affidavits necessary to substantiate government claims. (b) Information to families regarding patients’ personal and family affairs when advised to do so by the Commanding Officer. (c) Furnishing information to patients regarding government legislation. (d) Furnishing information regarding government insurance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Fifth Session Thursday, January 19, 1922.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. There are four classifications:

(a) Patients leaving institutions against medical advice. (b) Patients leaving institutions without permission. (c) Patients discharged from institutions for disciplinary reasons. (d) Patients disciplined by forfeiture of compensation without discharge.

1. No patient who is mentally irresponsible shall be discharged for disciplinary reasons. 2. No patient shall be discharged for disciplinary reasons, if his physical condition is such as to endanger his life by reason of such discharge. 3. No patient shall be discharged for disciplinary reasons, except on the recommendations of a Board of Officers approved by the Medical Officer in Charge of the institution.

Provision is made for minor punishments.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mr. Chairman, Ladies, and Gentlemen:

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

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

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

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

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

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

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

During the past month the Follow-up Nurses performed the duties as shown in Exhibit D.

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

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

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

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

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

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

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