Chapter VI: Part 6

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(a) Provide entertainment.

(b) Regulate visiting under the Commanding Officer’s direction.

(c) Receive proper donations previously authorized by the Commanding
Officer.

(d) Stimulate in the adjacent community resources which can be
beneficial to the patients.

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

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

(a) Securing social histories and other significant data for use of
tuberculosis specialists and psychiatrists.

(b) Securing reports on home conditions for help of physicians in
deciding whether or not to discharge a patient to his home.

(c) Correspondence with home communities to adjust home situations,
thereby making it possible for patients to remain in hospitals.
This sometimes involves financial aid to families.

(d) Arranging through local communities for men who return home to have
proper care and assistance in adjusting him to civilian life.

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

(a) Helping to connect men approved for vocational training to get in
contact with the proper government officials later. With a
Veteran Bureau’s representative in the hospital, this should be
much simplified.

(b) Following up patients who leave the hospital A.W.O.L. or against
advice, to see if they return or if leaving against advice that
they are placed under proper supervision in the home community.

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

(a) Communicating with family doctors and others to assist in securing
affidavits necessary to substantiate government claims.

(b) Information to families regarding patients’ personal and family
affairs when advised to do so by the Commanding Officer.

(c) Furnishing information to patients regarding government
legislation.

(d) Furnishing information regarding government insurance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_Fifth Session_ Thursday, January 19, 1922.

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

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

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

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

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

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

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

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

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

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

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