Chapter III: Part 3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

GENERAL SAWYER: stated that the correction would be made.

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

COLONEL FORBES: stated that they do.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CAPTAIN BLACKWOOD: “Yes.”

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

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

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

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

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

COL. HANNER: represented Colonel Kennedy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Motion was seconded by Surgeon General Cumming.

Motion carried.

SURGEON KOLB: offered a resolution:

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

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

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

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

Motion carried.

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

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

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

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

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

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

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

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

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

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

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

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

_Third Session_ Wednesday, January 18, 1922.

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

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

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

Committee on Resolutions.

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

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

Committee on Forms:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(9) Rest periods not enforced.

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

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

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

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

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

(15) Bed linen not changed sufficiently often.

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

File No. 89960

UNITED STATES VETERANS’ BUREAU. September 9, 1921.

_GENERAL ORDER NO. 28_

Subject: STANDARD OF REQUIREMENTS FOR HOSPITALS.

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

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

_REQUIREMENTS FOR ALL HOSPITALS_

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

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

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

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

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

6. There should be periodic staff meetings to discuss—

1. Errors of diagnosis.

2. Unsatisfactory results of operative or medical treatment.

3. Autopsy results.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_ADDITIONAL REQUIREMENTS FOR TUBERCULOSIS HOSPITALS_

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

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

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

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

_ADDITIONAL REQUIREMENTS FOR NEURO-PSYCHIATRIC HOSPITALS_

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

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

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

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

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

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

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

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

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

10. Special provision for the tuberculous.

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

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.