Chapter VIII: Part 8

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

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

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

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

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

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

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

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

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

ADMIRAL STITT asked that Dr. Lloyd answer that question.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_MOTION_

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

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

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

_RESOLUTION_

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

This resolution was adopted.

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

_RESOLUTION_

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

The meeting adjourned at 12:25 P. M.

_Sixth Session_ Thursday, January 19, 1922.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The meeting is now in charge of Dr. White.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

4. Psycho-neurotics.

5. Epileptic and hysterical cases.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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