Chapter IV: Part 4

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.