Chapter IX: Part 9

In other words there is a lot of this defective material which exists in our society today which has absolutely lost motion, which could be put to a great deal of use if we were wise enough to do it, if public sentiment would support us and assist. It is easy to talk of that here. It is another thing to get public sentiment to help us. There is no longer hospitals organization than this in the world and perhaps the hundred hospitals represented here might do something to bring about that public sentiment. So I am disposed to look at people not from a strictly diagnostic point of view to look at them from the social point of view as to the possibility of their becoming useful to a certain degree as social units and the possibility of society metabolizing them.

Just one more word. There has been an enormous amount said the last few years on heredity, and there is a great deal of feeling that there is a great deal due to heredity. The study is very interesting, scientifically very important, but the only attitude we should assume is to practically throw out of consideration the whole question of inheritance. If you are going to say this fellow has got a certain disease, and you are going to conclude it is inherited, that is a fatalistic diagnosis and the tendency of the diagnosis is to hamstring any effort that may be made in his behalf. The only way we can find out the percentage of salvageable material is to endeavor to make the adjustment. If we put them down as hereditary, our inclination will be to throw them out of the possibility of consideration. We should rather stress the possibilities to the utmost and find some solution or partial solution of a great many of these problems.

DR. CHRONQUEST (U.S.P.H.S.): So much has been said that I shall not go on with the problem. I would mention the Compensation side. I have been wondering for some time, especially among the neuroses, if by our present system of compensation we are not tending to make crystallized neuroses. I do not pretend to answer the question. Take, for example, a chap who has been in the service, who has done good work, whose social scale has not been high, whose life prior to service has been, as you might say, from hand to mouth. He has come out of the service with a definite, known disability acquired by service. By being hospitalized he has been compensated justly by the Government; he has received the treatment to which he is entitled; but during the days of his treatment he has found that he is able to get along more easily under these conditions than he did prior to service, and decides that one of the best ways he can make a living is by Compensation. I do not say that that is true with all, but it is with some of the cases.

I have wondered whether or not our present system of compensation to that type of individual was the best, or whether the system of Canada or England would be better. In other words, they do not put a premium on a man to go to a hospital. If I am correct, a man gets less money when he goes into a hospital than when he is out. It is my meagre opinion that in that type of neurosis, he would tend to fight harder as an individual to put himself back into a financial, gainful pursuit; and with the advantages the Government offers him now, especially through rehabilitation, I feel he could be put on a much better adjustment than he was before.

Another point which has recently come to the attention of us locally is the question of guardianship; and I am going to ask Dr. Guthrie if it is a known fact that two men in the same hospital, with the same disease—that one will draw his compensation without a guardian, the other is required to have one.

DR. GUTHRIE: It was our understanding that a man who is a psychotic by reason of service should at least have a guardian. If that is not true, I suggest to the Hospital Committee that it is a point for consideration, as it puts the man in the field between the devil and the deep, blue sea.

DR. W. A. WHITE: I think the man who has a guardian has one usually because his people have applied for such. I believe the Bureau never relinquishes the right to control of the funds, and is not obliged to pay the funds to the guardian. Legally the patient can be paid if he is competent.

DR. CHRONQUEST: In looking over histories of cases that come to West Roxbury and information received, I believe that a point that would be of help to the service as a whole is the getting of accurate histories. We find patients being transferred to N.P. hospitals, who have a diagnosis which is not correct according to the past histories taken, due to the fact that careful search has not been made in gathering the facts of the men’s disabilities. At times it may be the fault of the examining physician. It may be the fault of the social service department. Again, it may be the fault of the individual, or of the family itself in trying to protect the patient in question. I believe that those errors, which are seen every once in a while, should be overcome; and I feel that all of us, whether Neuro-psychiatrists or not, who have anything to do with either neuroses or psychoses, should be extremely careful of the histories and get them complete, detailed and accurate.

COLONEL MATTISON: (acting for General Geo. Wood) The Tuberculosis Section has to deal with a group of patients,—the largest group that the Veterans’ Bureau has to handle. I am sure that we have many men here who are interested in this subject, and I hope we shall have a very free discussion of the subject. We shall begin by having each subject opened, and then the program will be given to general discussion. We shall ask Dr. Stites to open the session on “The Segregation of Cases”.

SURGEON T. H. A. STITES (R) U.S.P.H.S.: This question of segregation of Tubercular cases is one that has been vexing all of us for a long while. To understand it at all we have got to review the history of T.B.,—from the ancient times when T.B. was looked upon as a sort of visitation from Heaven, and looked upon as a disgrace to the family, on down to the period when Koch, with his great discovery, found the disease to be infectious. During that time there came on an organized propaganda for the control of T.B. upon the ground that any infectious disease is a preventable disease. This propaganda, as is true of all propaganda, ran to an extreme. It was so hard for those interested in proving that T.B. was an infectious disease to impress it upon the public and to compel them to accept the proposition of its infectiousness, that we went to the extreme of leading everybody to the idea that it was a virulent infection; that it was as contagious possibly as some of the acute infections like scarlatina.

There were those who believed that every case should be sent to a T.B. hospital, absolutely isolated from his family and the world in general. Then the pendulum began to swing back, and we came to a sensible conclusion,—that while T.B. is an infectious disease, it is only slightly so to the adult; and if virulent at all, it is so only among children and the adolescent. This being so, we had to change from the separate and isolated hospital for T.B. It has been accepted that every general hospital should receive its quota of T.B. patients, T.B. being one of the most common forms of illness, and that in sending out patients to a strictly T.B. hospital; they should be sent only after the presence of the disease has been fully well proven.

The control of T.B. is after all the big problem before all of us in T.B. work today. I have often heard it said that any benefit that comes to the individual is necessarily more or less incidental, and that the big object we are laboring for is the control of the disease and the care of the general public health. Be that as it may, the problem that faces us in the care of the veteran of the World War is the actual care of the sick.

The question of prevention of T. B. must be dealt with, first, upon educational grounds,—to educate the public and the individual to the point where we can more or less limit the spread of the infection; secondly, and perhaps more important,—by a campaign for the improved living conditions of our people in general, especially in childhood.

As a matter of fact, when you get right down to it, T.B. is a social disease; it is a social problem even more than it is a medical problem. We know that when the good Lord made us, he put into us a certain amount of quality which, for lack of a better term, we have called natural resistance. If we can keep that natural resistance at a high point,—build it up,—the infection, though it may strike us, will not produce the clinical disease, T.B.

In the second place, we come to the actual treatment of the sick. This, too, is largely a hygienic measure. Since time immemorial, those interested in T.B. have been searching, have been praying for a specific cure. Every now and then somebody bobs up with a story of how he is going to cure T.B. overnight by this or that injection, treatment, etc. In each of these cases there is a grain of fundamental truth. We have got to put these things together; and when we get down to the final conclusion we can not get away from the fact that the treatment of T.B. is the building up, the bringing back to normal, and in fact if you can, the reaction to the point beyond the normal, of that quality I spoke of, natural resistance.

In order to accomplish this, I believe one of the most important points lies in the word, morale; and to encourage your morale, it is wise to get your classes classified, and to get your T.B. patients working together in classes in sufficiently large numbers so that you get that inspiration that comes from what my friend used to speak of as “the psychology of the crowd.” The thing the soldiers know as the touch of the elbow; there is a certain magic in it. It is easier to get farther when you know that somebody besides yourself is going through the same thing. I think we men in charge of hospitals feel that. That is one of the inspirations that comes to me from meeting with such a crowd of my fellows here. Away off there in the swamps of Louisiana there comes a sort of feeling, “We are here alone; it is hopeless”. When we are all here together exchanging experiences, there comes the inspiration, “We are not alone”.

In your general hospitals you have T.B. beds; have them in sections by themselves,—not because you are afraid of the spreading of the disease, not because the T.B. patient is an outcast,—but because you can do more successful work for the patient, not by segregation, but by classes.

In your T.B. sections, have your sub-divisions; have your places to which you are going to send your ambulatory cases, your far advanced, etc. Keep them far apart. Use the class system, but be sure that your personnel is sufficient, so as not to get away from the personal touch.

Perhaps a little outline of the organization of at least two of the hospitals with which I am familiar will illustrate my point.

The first essential thing when a patient enters a hospital is a complete examination. Do not let that examination be routine because it is a T.B. patient. Do not be satisfied with punching the man in the chest and sticking your ear to his heart. Have somebody who understands neurological conditions, test his nerve reactions; have someone to test his mental reactions, as well as the surgical and general medical. Have your examination ward in which this can be done.

Next is your general medical and, possibly, observation ward. I don’t care how you try to keep observation cases out of T.B. hospitals,—they are going to get in. If a patient, after being in a month, is found to be a T.B. case, he is apt to say, “I caught it here”. Put him where you can answer, “You did not get it here. You have not been in sufficiently close contact with the disease to catch it.”

Have your surgical ward; and then your strictly T.B. section.

Have first your infirmary or hospital.

The T.B. man needs special treatment, nursing care and dietetic care. One of the chief things to give to a T.B. infirmary is good dietetic care;—place the food before your patient in an appetizing manner; too much will disgust him.

Then have your ambulant section and sub-divide it into the section in which there is clinical activity of the disease, and into the section in which the clinical condition of the disease is quiescent. By doing this you can give your people graduated exercises, whatever diets they may need, periods of rest, and occupational therapy; and you can do it in an organized, scientific way, and get away from the everlasting complaint, “You let the fellow in the next bed do it; why won’t you let me do it?”

You have got to study the psychology of your patient. It may be a little out of the line of segregation of cases. We have heard the talk here of cases, of hospital management, and all that; but be sure in dealing with the ex-service man, or any other case, that you do not treat him merely as a case; that you do not segregate the medical officer in charge. I find there in the South that one of my life-savers is the fact that my office door is open to any patient. When I first got to be understood there was a line-up. I gave an hour every day. Now, since the patients know that everyone can come to me, I have possibly three or four in a day. And I don’t do it either by reversing the decisions of my ward surgeon and my executive officer; I back them up.

* * * * *

DR. KLAUTZ (N.H.D.V.S., Johnson City, Tenn.):

The subject of occupation in connection with T.B., is not only an extremely important one but an extremely difficult one to administer, particularly in the large government institution, and especially in connection with the psychology of the ex-service man, which has been referred to a number of times. He is apt to misunderstand and to be resentful toward any application of work; and yet at the same time, if we are going to measure the results of the sanitarium treatment of T.B. by the functional restoration to activity and usefulness, we still find that it results in a great many failures. That has been one of the complaints on the part of T.B. workers not only in government but in civil institutions as well.

We still find relapses occurring after the patient has been discharged from the sanitarium or T.B. hospital. Men go into training, and in a short time undergo another course of treatment, and so on. The reason for that is that they have not been given the necessary physical rehabilitation while still in the sanitarium, while under institutional protection and medical supervision.

The question of occupation is so broad that it is impossible to take it up extensively here today. We can point out one or two of the basic principles in connection with its application in the treatment of T.B. One very important feature brought out this morning is the psychotherapeutic object,—the point of view of relaxation or recreation, that is, giving the man something to occupy his mind and improve his morale, helping him to forget his home anxieties and anxiety about compensation.

The second point, or 2 A, deals with muscular reconstruction,—conversion of recently acquired adipose tissue into working force by rebuilding flabby muscular tissue which has resulted from the long period of rest.

2 A is the acquiring of a tolerance for T.B, toxins. This is important. We do know that in the recently toxic stage, exercise or work does produce a reaction which is shown by a rise in pulse rate. We know that if exercise is begun in small doses and gradually increased, the time will come when the patient can be made to take a fairly large amount of exercise continuing over a fairly long period of time, without manifesting the symptoms of reaction. Formerly we gave Tuberculin in gradual doses until we reached the point where the man could take an injection which surely would have killed him at the beginning of the course. The main point is if a man leaves the sanitarium before he reaches this toxin tolerance, he is more likely to break down. This is the reason for the man’s frequently returning to the sanitarium for treatment.

The third point deals with applying occupation as a means of training or retraining the man for some new occupation or modification of his former occupation; and here is where a great deal of judgment and study of the individual case becomes necessary. It is very difficult to find out just what is the best kind of work for the man from a physical and mental point of view; but the important thing is to have the man try it out and test it, and begin this physical reconstruction and rehabilitation if we are to get permanent results from sanitarium treatment. I don’t believe we have solved the problem completely, and I believe other agencies will have to be called in.

In this connection the question of dispensary work and social and nursing follow-up work is going to be extremely important. The man who leaves an institution ought to be followed up very carefully, and effort should be made to bring him back to some medical unit for re-examination at least every two months in order to see if there is any relapse of the former activity.

SENIOR SURGEON R. H. STANLEY, USPHS (R): It is always interesting of course, to be told what we ought to do and how to do it, but it seems to me it would be a great deal more interesting to take the little time we have this afternoon and discuss some of our real problems, and I mean by that problems that we as commanding officers of the hospitals have to contend with every day. I know and you know there are thousands of little things come up upon which we would like to have advice. There are many problems I might be able to solve readily; there are others you would be able to solve. I believe it would be worth more to tell how to get rid of some of these problems.

I believe that the success of running a hospital rests entirely upon the confidence that your patients have in you. If you are sincere they know it, and when they know that they will do anything for you. If you are not sincere they are going to know it mighty quick and you are going to have trouble. If you tell the men you are with them, that you are going to be 50–50 with them, if you call them in and talk to them as you would to a son, and if you let them see you are not doing it because of a matter of necessity, you can get by without writing petitions into Washington.

I found the other day a petition had gone to Washington from my hospital. It was necessary to discharge two men for drinking. It was their first offense. They came to me and said, “You have not treated us fair because it is our first offense.” Just before I left my station I received a letter which was addressed to these men by Colonel Forbes. In that letter he said “I have received your petition signed by 27 patients and asking that the hospital be investigated on account of a few patients being discharged for drinking. I wish to state for your benefit that I have given the matter consideration and I am standing right behind the medical officer in charge.” Leaving out the names, I had copies made of those letters and placed one of them on the bulletin board of the hospital.

When I went out to Whipple Barracks there had been some little disturbance there among the men. They were dissatisfied in various ways and it seemed like a big problem how to handle these men. When I once had their confidence I handled them.

I have found this in my experience, that I have never been able to have a satisfied personnel unless I give them the best I can. So long as you feed them well you will not have much trouble, because that will keep up the morale better than any other one thing I know. If you will feed them, be honest with them, be fair, you will have very little trouble in running the hospital.

SURGEON J. F. WALLACE, USPHS (R): The subject of entertainment probably would cover the subject of recreation at hospitals. It is rather hard for me to describe what recreation should be given at a tuberculous hospital because it depends on the location of the hospital. At the hospital at Fort Stanton where I am located we do not have any entertainment. If any social workers come down there I will be glad to entertain them, because we have only three visitors a year down there. That is one of the things in which I would compare our institution with some of these other institutions.

For many years I have been connected with a large sanitorium where we had strict discipline and little entertainment. The patients were satisfied. Our average stay of patients is six months. In looking over your sanitoriums you don’t find many patients staying six months.

When I was in the Army I was in one of the largest t.b. sanitoriums of the country. They sent back hundreds of men to this hospital and people came out and entertained them. They were entertained every night by the Red Cross with moving pictures, they were entertained in the afternoons by a local organization; they were entertained to death. These men afterwards got out and were not satisfied unless they were placed in an institution which was a social center. After I went out I was Chief of the Eleventh t. b. district of Denver. I noticed that the men who were treated at Fort Lyon were a better class to handle because they were not so much entertained. Once in a while I would talk to some of these men and ask them if they wanted to get well, as I could tell them a place to go and frequently I used to send them to Fort Stanton where they could not be entertained and they could get well.

If you have ever lived in an isolated place, you can appreciate it. My wife and I had pioneered this sanitorium together for quite a while. Once in a while we used to go to Denver and we could enjoy any show they had in Denver, even the 10–cent and 20–cent ones. I have heard men criticize entertainments at Fitzsimmons; they would swear and walk out while Madame Schumann-Heinck was singing, because they were dissatisfied; they were saturated with entertainment. I am against entertainment for tuberculous patients only in a very mild degree. We have one picture show a week and they enjoy that picture show. We have only Sunday School Sunday morning. The minister will bring in a few amateur singers and the boys think they are wonderful; they are wonderful; and they will all sing.

I have some fifty War Risk patients at my Sanitorium. I have known them for three years. I know them all by name. They were kicked out from Sanitorium to Sanitorium. They came down to Stanton. I went there on the first of July and no man has asked for his transfer or discharge. I suppose there is less turn-over of t.b. patients at any place than at Fort Stanton, where there is no entertainment. These men can go anywhere. We have a 30,000 or 40,000 acre farm. We try to get these men interested in the different things in the Sanitorium. On Christmas we let the men arrange the Christmas trees. They amuse themselves down there. The men trap quite a number of wild animals, bob cats, etc. and they are interested in the place we have, which is close to nature. You would be surprised how little amusement you need for entertainment if you get away from it. You have got to control these men and direct them every minute in the day. You have got to give them a task. Have their hours for rest; their hours for exercise. It is up to you who are running Sanitoriums to entertain your men. You might lecture to them; that is entertainment; but don’t have them twice a week or three times a week. Once in a great while the men are interested in the study of their disease. Don’t speak to them in scientific terms, let them understand the disease. They say in the curing of tuberculosis it depends more upon what a man has from his neck up than what he has from the neck down. Impress upon them that they have got to live a careful life. Keep people out who want to entertain them. Your men will be just as well and better satisfied with little entertainment if you keep them busy all day long.

DR. SMITH, U.S.P.H.S.: I wanted to discuss this afternoon a matter which is of great concern to all branches of the service, and that is Order 59 as applied to transfers from hospital to hospital. Order 59 is going to be watched rather carefully by the Veterans’ Bureau. Order 59 lists hospitals and gives a certain number of hospitals to each district. A district manager in New York may take a tuberculous patient and send him to a local hospital or he may send him away to a certain designated hospital to which he has blanket authority to send him, Oteen or Fitzsimmons; but according to Order 59, once they send a man to a local hospital, the district manager may not remove the man from that hospital and send the man to Fitzsimmons Hospital in Denver. In other words, it is worth watching to see whether Order 59 will not rather tempt the district managers to make a snap diagnosis on the ground and send away to the hospital to which he has blanket authorization to make transfers, on the one hand, a man whose disease is so far advanced, that it might be unwise to send him; or, on the other hand, men with questionable diagnosis. It will be worth watching. I am sure the Veterans’ Bureau will desire information on the subject as to whether you who are out in the tuberculous hospitals will receive classes of patients who are unsuitable in the usual sense of the word for transfer.

Here is another thing we shall all need to watch and concerning which the Veterans’ Bureau will I know desire information. Will the practice of sending patients to the local general hospitals result in a piling up of patients who need to be transferred and whose transfers will be delayed. We all know that a transfer is indicated not only for the purpose of providing a climatic change and we all know that in certain sections of the country there are provided beds for tuberculous patients and it is necessary to keep these beds filled.

According to the present practice and strict interpretation of order 59, if the medical officer in charge of the Naval Hospital in New York has a tuberculous patient and wants to effect his discharge to Fitzsimmons, he first asks the district manager for permission to transfer the patient. The district manager in turn asks the Director of the Veterans’ Bureau; the Director of the Veterans’ Bureau advises the district manager, who in turn advises the officer in charge of the Navy Hospital. Now it will be necessary to watch and see whether this effects an undesirable delay in making the transfers. The Veterans’ Bureau will desire to be informed if such is the case.

There is another thing. A patient under treatment at Fort Bayard, New Mexico, and fit for discharge cannot, according to a strict interpretation of Order 59 be discharged without invoking the same authorities who sent him there. In other words, he must take it up with the district manager, who then advises the man in charge of the hospital.

Order 59 is magnificent in this, if it works out: that no man will be transferred from one hospital to another except upon the recommendation of the medical officer in charge, and you who have had experience in this matter will know what that means. It means that it is not the man with the longest and strongest pull who will be transferred but the man whose transfer is recommended by the officer in charge of the hospital. We are prepared to assist in every possible way in carrying out that order but it is necessary for us to watch the effect from the field and get advices from all hospitals concerned, as to whether this order will not need modification.

SURGEON F. H. MCKEON, USPHS: Some have stated that they were in ignorance of the existence of G. O. 27. At Hospital # 64, upon the receipt of that order we immediately had about one hundred copies made and the entire hospital personnel was supplied therewith. After that every man upon admission was furnished with a copy, together with a copy of the rules of the hospital, for which he signed a receipt. I offer that as a suggestion.

On Tuesday the statement was made here that a man who is able to take five or six hours prevocational training at a hospital has no place in a hospital and should be in training. I think that statement should be qualified somewhat. It may easily happen that a man who can safely take five or six hours prevocational training in a hospital would soon break down under vocational training, for the reason that while he is in hospital his entire life is supervised; he must take a rest hour; he must turn in at a given time at night; he is assured of three or possibly more proper meals a day. Those conditions do not obtain when that man becomes a trainee and I sincerely hope that the follow-up nursing system which the Veterans’ Bureau is putting into effect now will result in a more careful supervision of the trainee’s life, so that when it is found he is living not wisely but too well he may be given proper advice and be returned to the hospital before the breakdown occurs.

This afternoon the subject of hospitalizing the tuberculous veteran in n. p. hospitals was discussed. I rather think it a somewhat sweeping assertion to say that every tuberculous individual with mental symptoms should be hospitalized in a t. b. sanitorium. We will all grant that men with signs and symptoms of an active tuberculosis disease should be hospitalized in an institution for the treatment of tuberculous. But to my mind that does not hold where the disability is clearly a mental disorder; that man is ambulant. The other man gives no trouble whatever because he is bed-ridden. I have no doubt that every t. b. hospital commander here today has had such cases. Your ambulant case, with few if any indications of active tuberculosis but who notwithstanding is tubercular, when he develops mental symptoms is not only a source of annoyance in the tuberculosis hospital but is destructive of morale. His place is clearly in a hospital for the treatment of mental cases.

DR. M. C. GUTHRIE, U. S. VETERANS’ BUREAU: This matter affects us administratively from a different angle. Many of the general hospitals have wards for the cure of tuberculosis. We presume that the turn-over must be fairly rapid. When men have accumulated in sufficient number and their disposition is determined as to whether they should go to a tuberculous institution, and they refuse to go, shall we turn them out or shall we let them stay?

SURGEON L. M. WILBUR, USPHS: If the transfer is suggested in the interest of the physical welfare of the patient and he refuses to accept that transfer, he is interfering with treatment. The regulations provide for that.

SENIOR SURGEON T. R. PAYNE, USPHS: I don’t agree with some of the t. b. men. I think a man can make a fight if he is dissatisfied and does not want to go and I think you will do harm in transferring him. If a man is home-sick and will not improve, I think he will do very much better to stay just where he is and you ought not force that man to go somewhere where he will not be satisfied. A sanatorium is a school to teach men how to live. In a general hospital you will have trouble in enforcing a rest hour because there are a great many other men in the institution who are not compelled to do so. The pass privilege is another thing. Some patients have but one pass a week and other patients get passes frequently. It serves to dissatisfy the t. b. men as they felt they were not on an equal footing. That is the only objection I can see.

SENIOR SURGEON J. E. DEDMAN, USPHS (R): There are several things that occur to me. In the first place there is the question of food. Of course that is the vital thing in every hospital. In our hospital, as I said before, we have a large number of negroes and what you give to the white boys in the north is not satisfactory to the colored patient. I think it is an important thing to try to give the men what they want in the way of food.

When I went to Greenville it was the custom to give the men breakfast at about seven o’clock; luncheon at 10:30; noon meal at 12 o’clock; at noon the men were not hungry and were generally dissatisfied with the food; at 3 o’clock, after the rest hour, they would have another nourishment; supper was served at five o’clock and as a rule they did not care much for that. Then we would send over to the wards large quantities of milk and eggs and bread and butter. They did not need any base balls. They played ball with apples.

It occurred to me that that was a bad system. We omitted the morning nourishment and the afternoon nourishment and I substituted an evening cafeteria luncheon thinking that it was a long gap from the supper at five o’clock to breakfast at 7. We thereby saved a great deal of money and since we did that we find the patients think the food is fine. We also find that they sleep better by taking this light luncheon just before they retire. I mention that for what it is worth.

The rest hour is important in tuberculosis. That is why hospitalization is so essential, because men will not take proper rest. We have a morning rest from 9 to 10, afternoon rest from 1 to 3 and evening rest from 6 to 6:45. The last period is not universal, and we wonder how you can get an accurate record of a man’s condition when you do not get his evening temperature. We find that it has been a great help to us. When I instituted this rest period from 6 to 6:45 I told the men it was for their good and although they objected at first, it appealed to their reason, after they were told why it was done, and we have had no trouble.

Another thing we have inaugurated along this line. I talked with Dr. Smith last spring. He agreed to send to our hospital a school for chiefs. I think this was a most helpful thing, because we had chiefs of medical staffs come to us and take a course that would tend to make for uniformity in administrative medical work in our tuberculous hospitals. I have talked since that time with several of the men who came down to take that course and I believe every one of them expressed the opinion that it was very helpful to him to have an opportunity to exchange ideas and to have the same methods for carrying of medical staff work which required tact and executive ability.

There is one thing I could not pass by because it is of such great importance to the Federal Employees Compensation Commission. We have sometimes employees engaged along various lines, and shortly after I arrived at the station I found one or two who said they had tuberculosis. I think it is most essential to see that not only one man but a board of medical officers examine every employee when he comes into a tuberculous hospital to make sure that he does not show activity in tuberculosis so that later he will not have a claim against the Federal Employees Compensation Commission by saying that he was working in a tuberculosis hospital and contracted tuberculosis while in the hospital.

There are many things I would like to speak of. I was very much impressed with what the doctor said about entertainment. I believe it helps the morale and is the most wonderful thing in the world. We can spend sleepless nights building up morale in a hospital and one man can disturb the entire morale.

In closing I want to say, after all is said and done, the big thing with us is the backing we get from the heads of our department and from the Surgeon General. I have known times I felt like throwing up the sponge. All of us have gone through these moments. The main and only thing that keeps us up is the encouragement we get from the heads of the department and I want to take this opportunity to express my appreciation.

GEN. SAWYER: This meeting was called for the week of the 20th, with the understanding of the Budget Director, General Dawes, that on tomorrow the Chiefs of the various Departments of the Government were to hold their semi-annual session and we thought that you would enjoy that occasion. It has been found impossible in the compilation of the facts and figures necessary to hold that meeting tomorrow. Therefore it becomes necessary for us to change our program and I am happy to announce to you that I feel sure you will have quite as interesting a program as you would have otherwise, for tomorrow we will have as the first speaker of the morning, Congressman Madden, the head of the Appropriations Committee. If you have not heard him I am sure you will be very much interested both in what he has to say and in the way he says it. We are then to have as the next speaker of the morning, General Dawes. General Dawes is remaining over tomorrow that he may have the pleasure of meeting you personally, and I predict that you will agree, after you have heard General Dawes, that if you have had no other excuse or no other compensation in coming to this meeting, you will have it in hearing General Dawes. For the balance of the program of tomorrow forenoon, it comes to my mind that possibly it would be most interesting to you all if we were to take up some of the questions that come to your mind that have not been presented in this program. This was suggested to me by one of the gentlemen here who I noticed does not talk much but who evidently thinks a lot, that it would be to the interest of a good many if they might bring up some subject that they are particularly interested in. So we are going to have in the morning a question box, and if any of you have questions in which you are particularly interested and will present them at the desk of the Secretary, we shall try to have them taken up for discussion at this round-table hour tomorrow forenoon.

President Harding will not be here in the morning. When I spoke to President Harding to come over and address this meeting, he said to me, “General, you know Mrs. Harding and I are to receive this body tomorrow evening.” I am sure that you are going to have in that reception, in the personal contact with the President and Mrs. Harding, a joy such as you have not contemplated.

_Seventh Session_ Friday, January 20, 1922.

GENERAL SAWYER: Fellows of the conference, as I told you yesterday we had expected this morning to be here with the Chiefs of the Bureaus. I explained to you why that program was changed. I told you also that you would not be disappointed in today’s program, and now I am going to prove it.

America produces many things. It is wonderful in agriculture, in industry, in commerce, but one of the greatest products of America is its men, and, strange as it may seem if you will stop to study it from that aspect, you will find that each State of the Union has its record for producing certain kinds of men. For instance, from Wyoming we get our stock men; from Iowa, our farmers; from Indiana, our authors, particularly our fiction writers; from Ohio, of course, we get our presidents; from Illinois, a thousand miles from Wall Street, we get the greatest of financiers. It is true that Illinois has produced more financiers than any other State, and men who have been at the head of the greatest banking institutions of the United States have come from this great corn-raising, middle-western State.

I should like to remind you, before I introduce this speaker, that this Federal Board of Hospitalization represented last year an expenditure, in all of their various lines of work, of $750,000,000.00. We have in our employ this morning something like 42,000 individuals, for which it is costing us something like $42,000,000. Today we are providing 132,000 meals for the people in the government hospitals and the employees that are necessary to take care of them. Tonight, if this northern blizzard continues, it will require 132,000 blankets to cover them; and in the most economical way in which we can provide for the needs of these sick men it will cost us—it does cost us—in round numbers, a hundred thousand dollars each day, with institutions operated as economically as they can be.

I only relate this that all of you may know and may carry this message to the country—that Uncle Sam is certainly not stingy; that Uncle Sam is really putting forth every energy he possibly can to carry out the idea of the best treatment of the World War Veteran.

This is my story in brief.

I have pleasure now in introducing to you Congressman Madden, Chairman of the Appropriations Committee of the House.

CONGRESSMAN MADDEN:—

“Mr. Chairman, ladies and gentlemen:

The most sacred obligation we have today imposed upon the Government is the proper care of the men who came back from the War less physically fit than they were when they went away. Provision is being made for their care to the extent that it is possible to make it. I think it may be safe to say that no country in all the world has been so generous in its care of its wounded soldiers, as America.

Hospitalization is one thing that we must provide, and we must provide every necessary comfort for those who gave to the country in its hour of direct need. We must not be foolish, however, in what we do. We must have a care as weal of other things as of the men themselves. I think the American people would be willing to make any sacrifice for the comfort of the men who served the nation either in the late war or any other war; and the best evidence of their willingness to do that and of the willingness of the Congress to cooperate is the fact that we are spending out of the public treasury for the allotments, allowances, hospitalization, vocational training, insurance, and other things for the comfort of these men, 489 million dollars a year; and it is growing and, as far as I can see, it will continue to grow.

Now we may be doing some things in connection with this expenditure that are not for the best interests of the men, and I sometimes have doubt as to whether we are wise or unwise. I sometimes have doubt as to whether we are managing this expenditure as it ought to be managed,—whether we are giving the proper care to the moral situation surrounding the hospitals where these men are being treated. We have evidence before my committee in the record testified to by those in charge of hospitals in which these men are being cared for, to show the most demoralizing situation as the result of the extravagance and expenditure of money by the men being hospitalized at the expense of the Government.

I have a suggestion to make in this connection. I have no desire whatsoever to take away from any man anything that ought to be given to him in the way of service or care by the Government. On the contrary, no man will go as far as I will to see that proper care and proper attention is given to every man that served the nation; but I believe that in the payments we make to these men who are being hospitalized, we ought to have some control over where that money goes, while they are in the hospital. (APPLAUSE).

I would suggest two thoughts, either the thought that while they are in the hospital they must deposit their money with those in charge, and be allowed to expend only a limited sum, and thereby prevent the assemblage in the neighborhood of the institution which the Government of the United States is maintaining for the care of its patriotic men, from becoming the nest of demoralization or prostitution. You can’t make it too strong. The facts disclose the situation. Now, we have an obligation greater than the obligation to care for the man, and that is to see that while we are caring for them we do not destroy them. (APPLAUSE). We have got to have the courage to adopt a plan.

Up to the present moment most men connected with the government service have been afraid to express an opinion in connection with the ex-service men, lest somebody might become offended at his attitude. (APPLAUSE) Now I am not one of these men. I believe the time has come when the man in public office has got to have the courage of his convictions; there is nobody in the world that people hate so much as the man in high public place who has not the courage of his convictions. The man in high public place has got to have sufficient courage to protect the rank and file of those who are being protected by the Government from the folly of their own deeds; and that applies as well to the Legion and all other organizations connected with the ex-service men, as well as anybody else, for it can.

Now we have a two-fold obligation,—I may say three-fold. We have the obligation to the men, to give them proper care. We have the obligation to the Treasury to see that that care is not conducted at an outrageous expense; and we have the obligation to the Nation to see that the moral standpoint of the communities in which these men are being cared for, is not degraded as a result of our attempt to help the men; and the only way you can stop that is to prevent the men while in the care of the Government, from having unlimited right to spend the money allotted to them out of the Treasury of the United States. It would be far better for them, far better for the community, for the nation, far better for the future of all if we could arbitrarily take the money away from them while they are in our control; place it on deposit, and see that it is applied for some useful purpose for their families after they leave our care. We can do it. We have the power. Have we the courage? I think we have, and if you will join me, we will do it! (APPLAUSE)

I think the men themselves will be happier. Their organizations will be more pleased. You will have some grumbling, but you will have it anyhow. Far better to have the grumbling when the men are sober than otherwise. Far better to have the grumbling when men are likely to be contented than when they are discontented; and I don’t know of any individual more happy than he who knows that when we get through with the treatment we are giving him he can look forward to having a bank account somewhere.

You know we are liable to destroy the usefulness of this man. The citizenship of the future may depend upon our actions, and we must be careful. The obligation is ours today; it must be somebody else’s tomorrow; but the transfer of obligation from one man to another ought not to make any difference. Any man afraid of the obligation to do this work ought to be transferred, because he is not fit for his job. Public office is just an opportunity to serve; that is all. The man who is in public office, who trims his sails to meet every passing wind is not fit for the job. He must have courage, integrity, purpose in life; and the man who cannot do the things that are dictated by conscience and right in a great public office ought not to be returned to it. The man that cannot feel the consciousness of his own rectitude, but rather the political bee buzzing, is not fit for a public office; and the men who are in the great service in which you men are employed have obligations, wonderful obligations, wonderful opportunities.

We depend upon you for the outline of the plan that we must follow in our treatment of this great army of patriotic men that have come back, eyeless, legless, armless, and sick in many other ways; but we must also depend upon you to cooperate with us in an effort to prevent the looting of the public Treasury and the reduction of the moral standpoint of the nation.

You need not be afraid to suggest. We should like to have your suggestions. We invite them; we welcome then. You need not be afraid to criticize; we are glad to have that. But we want you not only to remember that money is a factor as well as a help, but we want you to learn how to spend money. Most doctors do not know how, especially Army doctors. I have discovered that. I don’t blame them. Their minds run along other lines, but somebody has to watch this side of the case.

Now one thing we ought to remember is that the estimates for the expenses of the Government of the United States for the fiscal year, 1923, sent to the Congress amount to 167 million dollars more than we have got; and since these estimates came, 50, 60, 70 million dollars more have come, adding that much more to that which we have not got. I just want to say to you, gentlemen, right here that it does not make any difference how many estimates come, there won’t be a bit appropriated beyond the revenue, and I don’t care from whom the estimates come.