ffiA:<'AlZZ:AA.'At?M%
AAAAJP\&AJrt><mi 
*'.
Heolth Service    *>    Beihesdo, Md.    "  U.S. Deportment ol   *>  Health,  Educoi.on   °?  and  Welfare. Public  *>    Heolth Service    ■*     Btthesdo.  Md.    ™  U S. Deportment of  *  Health.  Education.  J  ond Welfare. Public
Heolth Service
NLM000782576 
NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINf
3Ni3ia3w jo  .-jvaan ivnoiivn    jnidiosw do ^:v;ian tvnoiivn    snidichw jo Aavaan tvnoiivn    3noio3w jo Aavaan tvnoiivn






NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE
                                                                                                 o  V
3NOI03W jo  Aavaan ivnoiivn    3nidiq3w jo a ■.. v.-ian ivnoiivn    3nioio3'/.' do Aavaan tvnoiivn     3nidio3w jo Aavaan tvnoiivn
NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY  OF MEDICINE     NATIONAL LIBRARY OF MEDICINE
3NiDia3w jo Aavaan tvnouvn    3nidiq3w jo Aavaan tvnoiivn    3NOiaaw jo Aavaan tvnoiivn     3nidiq3.v jo Aavaan tvnoiivn
NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE
3NOIQ3W jo Aavaan tvnouvn    snidiqsw jo Aavaan ivnoiivn    snidiqsw jo Aavaan ivncuvn     3nidio3w jo Aavaan tvnouvn
NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE

aNoiasw jo Aavaan tvnouvn    3nidio3w iG Vivian iv;-j< uvn    snoiosw jo Aavaan tvnouvn    snoicisw jo Aavaan ivnoiivn






NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE
Vs*
id:03.-/ jo Aavaan tvnouvn    snidiosw jo Aavaan tvnouvn    snidiosw jo Aavaan tvnouvn    3NiDia3w jo Aavaan tvnouvi>
                       I   £0
r^u
lM-\  i/^hlMAl
& 
 
 
 
IKk1;kk;5K«aaRRRRKRRRRRRRRRRRRKSRR»KR

                     UWARY
               U. S. PUBLIC HEALTH SFRVICf
                  WASHINGTON. L. C.
CONFERENCE OF OFFICERS
IN CHARGE OF
GOVERNMENT HOSPITALS
SERVING
R
R
R
R
R.
R
R
R
R
R
R
R
VETERANS OF THE WORLD WAR
R
>N
★ ★★



&

R
R
R
R
R
R
R
R
R
R
R
           HELD IN


AUDITORIUM, DEPARTMENT OF THE INTERIOR




       WASHINGTON, D.C.

JANUARY 17-21, 1922, INCLUSIVE

IRRRRRRRRRRRRRRRRRRRRKRRRKRRRR^
 
 
CONFERENCE OF OFFICERS IN CHARGE OF
GOVERNMENT HOSPITALS SERVING
 VETERANS OF THE T70RID T7AR
          WASHINGTON, D.C
    JANUARY 17-21, 1923, INCLUSIVE

AUDITORIUM DEPARTMENT OF THE INTERIOR
         UNDER THE AUSPICES OF THE
U.S. FEDERAL BOARD OF HOSPITALIZATION
Brig. Gen» Charles E. Sawyer,  Chairman,

Col* Chas, R# Forbes, Vice-Chairman.

Dr, F« A. White, Secretary.

Maj«. Gen, Merritte W. Ireland,

Rear Admiral E. E. Stitt,

Brig* Gen, H. S. Cumming-

General George H. Wood.

Hon, Charles M* Burke.
Chief Coordinator,

Director, VeteransT Bureau.

Supt.,  St. Elizabeths Hospital.

Surgeon General,  U.S,A-

Surgeon General,  U#S.N*

Surgeon General,  U.S»P.H»S,

President, N.H.D.V.S.

Commissioner of Indian Affairs, 
H-
  LLH.
  H 70
   A

i. Fax
(LA
NATIONAL LIBRARY OF MEDICINE
    ' WASHINGTON, j). fi. 
Page 1.
PROCEEDINGS OF CONFERENCE OF OFFICERS IN CHARGE OF GOVERNMENT

        HOSPITALS SERVING VETERANS OF THE WORID WAR
22£S ASS  Session  (Tuesday, January 17,  1922).
          At 10:OQA.IL the meeting was called to order by Brigadier-
General Charles E. Sawyer.
The roll was called by Dr*  W.  A.  White.
          General Sawyer delivered the following address  on the
subject,  "The Present Status of Federal Hospitalization from the
Standpoint of the Federal Board."

"Commanding Officers:

          You are here,  as your program indicates,  by in-
vitation of the Federal Board of Hospitalization*  That
you may know your host,  the following facts are submitted:

          The Federal Board of Hospitalisation was created
by an Executive Order of President Harding.  The purpose
of the Board is expressed in the Order creating it, which
is as follows:

                            "Circular No. 44.

                    TREASURY DEPARTMENT,
                   Bureau of the Budget
                        WASHINGTON

                                      November  1,  1921.

    FEDERAL BOAHD OF HOSPITALIZATION.

    TO THE HEAPS OF DEPARTMENTS AND ESTABLISHMENTS:

         1.   For the purpose of coordinating the
    separate hospitalization activities  of the
    Medical Department of the Army, the Bureau  of
    Medicine and Surgery of the Navy, the Public 
 
Page 2.
                                         Tuesday,  January 22, 1922.

SAWYER:(Cont.) Health Service, St. Elizabeths1 Hospital,  the
               National Home for Disabled Volunteer Soldiers,
               the Office of the Commissioner of Indian Af-
               fairs, and the United States Veterans* Bureau,
               there is hereby organized a Federal Board of
               Hospitalization.

                    2.   The Board shall be composed of the
               following officials:  An official to be desig-
               nated by the President, who shall be known as
               Chief Coordinator and who shall be President
               of the Board;  the Surgeon General of the Army;
               the Surgeon General of the Navy; the Surgeon
               General of the Public Kealth Service; the
               Superintendent of St. Elizabeths1 Hospital;
               the President, Board of Managers, National
               Home  for Disabled Volunteer Soldiers; the
               Commissioner  of Indian Affairs; and the
               Director of the United States Veterans1
               Bureau.

                     3.   It  shall be the duty of the Board:

                         (a)   To consider all questions
               relative to the coordination of hospitaliza-
               tion  of the departments represented.

                         (b)   To standardize requirements,
               to expedite the interdepartment use of exist-
               ing Government facilities, to eliminate dup-
               lication in the purchase of supplies and the
               erection of buildings.

                         (c)   To formulate plans designed
               to knit together  in proper coordination the
               activities of the  several departments and  es-
               tablishments,  with a view to safeguarding  the
               interests of  the Government and  to increasing
               the usefulness and efficiency  of the  several
               organizations, and to  report to  the President
               thereon.

                     4.   The Chief Coordinator  of the Board  of
               Hospitalization shall  preside  over the Board  and
               be responsible for its efficiency and for  devel-
               oping its activities along practical  lines.   After
               a full discussion of any  question by  the Board,
               the decision  of  the Chief Coordinator will be final
               as to any action  to be taken or  any  policy to be
               pursued, but  any  member may appeal  from the de- 
 
Page 3.
                                        Tuesday,  January 22,  1922.

SAWYER (Cont,)  cision to his own immediate superior.

                          By direction of the President:

                                       CHARLES G. DAWES,
                                        Director of the
                                      Bureau of the Budget."

       From this you will readily see that the extent of the  work
       under the administration of this Board is very far-reaching
       and is an innovation in Federal Hospitalization activities, for
       beside being interested in behalf of reasonable econom-
       ies in administration, the Federal Board of Hospitaliza-
       tion is particularly and especially interested in carry-
       ing out the highest ideals of modern hospitalization for
       the World-War Veteran.

                 The President and his administrative family  have
       in mind, as the basic principle of all hospital service,
       the very best that can be supplied,  measured by real end-
       results.

                 The Board of Hospitalization represents all  of
       the Departments of the Government directing and controlling
       the Federal Hospitals Of the United States.  Each of the
       Chiefs of these Departments will speak of his particular re-
       lation to the subject of Hospitalization as it refers  to the
       World War Veteran, as the program proceeds.

                 In order that each of you nay understand the magni-
       tude of the entire subject of Hospitalization of the World
       War Veteran, I wish to present the following facts;

                 To-day  there are being hospitalized under Government
       control, in Federal Hospitals, 22,440 World War Veterans, who
       are distributed among the various Departments as follows:

            U. S. Public Health Service        16,373
            U. S. Arny Hospitals                 1,681
            U. S. Navy     n-                     1,059
            Soldiers Home  "                    2,500
            Dept. of the Interior Hospitals       827

                            A total of......   22,440

                 This does not take into account patients in contract hos-
       pitals which now number 9,066.  This enumeration demonstrates
       something of the  scope and nature of the work for which  the
       members of the Board  of Hospitalization are responsible.
It may interest you to know that there are now 
 
Page 4.
                                       Tuesday, January 22, 1922.

SAWYER (Cont.)

      under contruction 7,592 new beds, which will be ready
      for occupancy within the next few months and that the Gov-
      erniient is at present contemplating at least 2,500 more
      beds under the new Lang ley Bill, so ultimately the Govern-
      ment will have under its direct administration hospital
      capacity for a minimum of 32,000 patients,  which is esti-
      mated to bo  the peak load.

                 Heretofore there has been no coordinate plan of
      operation of these various institutions*  Under the Board
      of Hospitalization all of this has been changed and to-dayi
      you, whether from the Army, Navy, Public Health Service^  Na-
      tional Home for Disabled Volunteer Soldiers or the Department
      of  the Interior are all members of one big professional family,
      each engaged in the same service, under the same regulations,
      for the care and treatment of the World War Veteran.

                 The Hospitals engaged in this service number at pres-
      ent 107, distributed as follows:

        77 Hospitals controlled and operated by the Public Health Service,
          6    n          "       n       w   h   ii  t^j. Department,
        14    h          n       u       ii   «   it  Navy   "
          9    "          "       «       "   "   "  Soldiers Homes,
          1    "          »       "       nun  interior Department.

      These  institutions are located  in all sections of the United States
      from the Atlantic to the Pacific and constitute one of the greatest
      hospitalization propositions within the history of any country.

                The personnel engaged represents an Army of almost as
      many more persons*  In other words, Uncle Sam, within himself,  is
      to-day keeping in operation a hospitalization program incomparable
      with anything with which former experiences are familiar.

                With this representation of the subject and its magnitude,
      I wish to remind you that each  one of you personally and individual^
      is  a part of this great machine; and upon you rests  the responsi-
      bility of the carrying out of such policies as are adopted by the
      Central Administration.

                In order that there might be perfect coordination and co-
      operation in all of these hospitals and  that all institutions serv-
      ing the World War Veteran might be operated upon a standarized basis,
      the Board of Hospitalization recently adopted the following regula-
      tion as to personnel: 

■Tw."    „
-    «4. 
Page 5.
SAWYER tCont.)                       Tuesday,  January 22,  0922*

    Doctors,  ............................ 1 to every 20 patients
    Nurses,..........................w x  "   "   io   "
    Occupational Therapists,............ 1  "   »   50   "
    Social Workers,..................... i  »   «   50   "
    Vocational and Prevocation-
       al trainers and assistants.........14 "   " hospital of 200 patients
    Other hospital employees.............130

Making a total of 182 employees to every 200 patients,  or almost one at-
tendant and assistant to each patient.

          This arrangement provides that all patients will have ea^ual care
and attention of such a similar type as to guarantee to all classes of pa-
tients the best of professional,  nurse and domiciliary attention that
can be given, no matter in what De^rtment they are being treated,

          All of the Departments constituting the Board of Hospitali-
zation are now meeting in joint sessions, wherein they take up in de-
tail all of the matters pertaining to the welfare of the Veteran Hos-
pitalization subject*  Out of this consideration there is developing
a much better understanding,  a more complete system of operation, better
conduct and much better end-results.

          One of the objects of this conference is that you the better
understand by personal contact with each other and with the different
phases of the work, what the business of caring for these veterans in
its entirety means*  We know of course that you each have your special
problems, you e^ch have certain affairs within yourselves that keep your
attention very nuch engaged in the things with which you come personally
in contact, but we thought it would give you a better impression of the
magnitude and importance of the subject if we were to have you here where
those who are responsible for the direction of the affairs of Hospitaliza-
tion could meet you individually.

          We want you to know that .we are greatly interested in you and
the service you are rendering.  We wish you to feel assured that your in-
terests are our interests.  We wish to impress upon ycm that the conduct
of the affairs under your administration means the reputation and the his-
torical record of  the Government's treatment of the World War veteran.

          We are anxious indeed that you should get from this meeting
inspiration for better work and encouragement in  the efforts that you
are putting forth, new ideas with which  to meet the great and ever-
changing propositions which are before you, closer  touch with those who,
like yourselves, are interested in the World War defenders.  This ac-
complished and each of us will have benefitted and  the  expense  of time
and money  in your  coming here will be  justified. 
C't 
Page 6.
                                     Tuesday, January 22, 1922.

SAWYER (Cont.)

                Your contact here should make you bigger and broader men.
      If you will take cut of the great opportunities that are presented
      in the privileges of tnis meeting,  the effects which may be ob-
      tained,  we are sure that you wj 11 go back to your respective fields
      of service better satisfied,  more capable and certainly more de-
      termined than ever to render the best service there is within you
      under all circumstances and conditions.

                It seems pertinent that I should impress upon you at this
      time that no matter what kind of institutions the Government may
      possess,  how -well equipped with  apparatus*  or how pleasing  in loca-
      tion,  without your interest,  without the scientific care  and atten-
      tion which you can provide, without your determination and your  loy-
      al support and action in all  of  the affairs  pertaining to the  conduct
      of these  institutions,  they will fail.

                On the  other hand,  if  you will give them the  best  within
      you, if you will  keep yourselves  professionally and administratively
      in the vanguard of such affairs,  if you will go whole-heartedly,
      persistently and  determinedly  forward  to the  carrying  out of the
      highest ideals  your  constructive  visions  can  invent, the World
      War  Veteran will  realize  that  in his Government he has  the care and
      appreciation of the  best  Government under the  sun*

               Ax low me  to again admonish you that upon you  individually
      and  personally  rests i4ich of whatever  is  to  come  to the present
      Administration, either in the  form  of  complaint or  of eulogy. To the
      end  that  it  may be eulogy,  let ther ever  abide with you the assur-
      ance that the President of  the United  States and all of his adminis-
      trative assistants will be with you heart and soul in everything
      that promotes the  interest  of the rehabilitation of the World War
      Veteran.  Remember that you owe to your country and to yourselves
      that you practice economy,  that you deal fairly,  that you act square-
      ly with all  of  the propositions which come to you.  Do not forget
      that you should be loyal to the Departments to which you belong,
     ever obedient to  the  orders of your Chiefs; that you be faithful,
     earnest and sincere, honest, conscientious and ever active in behalf
     of the highest principles connected with the maintenance of the
     institution with which you are connected ana finally that you be
     ever able to register and substantiate yourselves as American
     citizens,  full of an American spirit,  loyal to country and to flag.

               If you will do these things,  you will have the everlasting
     gratitude of the President of the United States,  you will be entitled
     toand will receive the econiums of our dear doughboys and above all
     you will have the  satisfying consciousness of a noble duty truly
     done. 
•JC" 
Page 7.
                                       Tuesday, January 22, 1922.

SAWYER (Cont.)

                 In order that the business of the conference may be trans-
      acted expeditiously and effectively, the following rules will be en-
      forced by the presiding officer of each session:

           1.    Those having addresses upon specified subjects are
                    expected to present a typewritten Cojy to the
                    Secretary that it may be kept for reference in
                    the office of the Board of Hospitalization.

           2#    All addresses will be limited to 15 minutes.  All
                    special subjects will be limited in presentation
                    to ten minutes.  General discussions will be lim-
                    ited to five minutes.

           3.    Each session will begin promptly on time.

           4.    Roll call of the attendants will be taken at the begin-
                     ning of each meeting, .

           5.    Reports of all proceedings of sufficient importance
                     will be recorded by the expert stenographers in
                     attendance.

           6.    This is a business affair and should be so considered
                     by all present.  We are here to develop plans.
                     We are here to receive suggestions and get in line
                     for the execution of orders which will lead to the
                     development of the highest order of hospital care
                     and treatment.  With these suggestions we will pro-
                     ceed to the carrying out of the program.  "

      "I have pleasure at this time in introducing to you Colonel
      Charles R, Forbes,  who will speak to you on the 'Relation of
      the Veterans1 Bureau to all Hospitalization activities1. "

      COLONEL FORBES:  Addressed the conference as follows:

             "Upon the signing of the armistice on November li,  1918,  there
      was immediately commenced the demobilization of the armed military
      and naval forces of the United States,  comprising approximately
      4, 000, 000 men and women.  As an aftermath of war service from the
      result of battle wounds,  gassing,  injuries and disease it was anti-
      cipated that there would be a large number of men and women who
      would be jhysicially disabled,  either temporarily or permanently,
      partially or totally.   While it was know with a reasonable degree
      of accuracy how many there were who has been discharged from the
      several services on Surgeons1  Certificate of Disability and the
      number discharged with  disability  noted at the time of discharge,
      it was not possible  to  foretell the magnitude of that considerable 
 
Page 8.
FORBES,, (Cont.)                         Tuesday, January 22,  1922,

  body of men and w^men who though discharged from the service
  apparently in good health would subsequently develop a disability
  tracaable to military service.  Even at  the present time, more  than
  thi^ee years after the A^istice it  is not possible to state the exact
  magnitude of the medical problem confronting the United Veterans'
  Bureau, since new claims for compensation because of disability are
  being filed at the rate of approximately 541 per day.  As an index
  however to the magnitude of this problem, gentlemen,  let me tell you
  that, to date have been filed ziot* than ^62*000 claims for compensation
  for disability and death incurred in military or naval service* While
  this total nuuber of jlaims have not ail been allowed, this number
  does constitute  the present potential load for the united States
  Veterans- Bureau.

           By the  original ^ar Risk j^ct and subsequent acts amendatory
  thereto.- the United States Government recognized its very great
  obligation to the ex-service men and women who had become disabled
  through service, and by these Acts  provided not only financial aid
  to the disabled  veterans but also all reasonable medical and surgical
  treatment and care, whether in a hospital, out-patient office,  or at
  home.

           The problem of hospitalization  itself soon became of para-
  mount importance-  It was initially recognized that,  in spite of the
  meagre governmental hospital facilities  then available for the care
  of beneficiaries8 of the gnited States Veterans' Bureau,  it was essen-
  tial for the best administrative control of veteran patients and for
  the best professional control over  their treatment to place the
  beneficiaries of the United States Veterans1 Bureau under government
  supervision in government owned or operated institutions.  The carry-
  ing out of this  policy has been proceeding steadily at a rate commen-
  surate with the  rate at which additional government hospital beds have
  been made available.  At no time however has it been possible to dis-
  continue the use to a considerable degree of contract civil institutions.
  Even at the present time the United States Veterans'  Bureau is utilizing
  approximately 757 civil institutions for the care of approximately 8,924
  of its beneficiaries,  and has contracts  with a total of 1,524 civil
  institutions for such care.   It is however significant to note  while
  in July 1920 more than fifty percent of Veterans1  Bureau patients  were
  in contract hospitals,  on January 1, 1922,  but 30 percent of patients
  were in contract hospitals.   Furthermore the number of hospitals being
  utilized at any time had dropped from approximately 1200 to  757.

          The curtailment in the use of private facilities was of course
  the  direct result of increased facilities in government  operated
  hospitals.   The  United States Government had originally  stipulated
  that  the hospitalization of  veterans of the Worl War should  be  pro-
  vided  for  the  the United  States  Public Health Service  through its
  Marine hospitals  and  such  other hospitals as  it had been authorized to 
 
Page S *
                                       Tuesday, January 22, 1922,

FORBES (Cent.)

    acquire.  When however it was discovered that the immediate facilities
    offered by these hospitals were insufficient to meet the demand for
    hospitalization, the hospital services of the United states A*W>  the
    United States Navy and the National HomesT for Volunteer Disabled
    Soldiers were to a certain extent made available to the United States
    Veterans' Bureau.

             In l.Iarch, 1919, the United States Public Health Service was
    operating but 21 small Iverine Hospitals.  In order to meet the demand
    made upon it by the then Bureau of War Risk Insurance,  additional
    hospital facilities were rapidly acquired, so that by November. 1919
    there were in operation a total of 38 hospitals with a total bed
    capacity of approximately 7,625.  A year later namely on November 1,
    1920 there had been made available a total of 52 hospitals represent-
    ing 13374 hospital beds* At the present time,  January,  1922,  there
    are available 65 United States Public Health Service Hospitals repre-
    senting approximately 18,200 hospital beds*  It is true that due to th^
    necessity of securing with the least possible delay adequate hospital
    beds, it was necessary to make use of certain Army cantonment hospitals
    of temporary structure.  Hospitals of this type are admittedly unsatis-
    factory, and it is my earnest desire to close such hospitals just  as
    soon as properly located hospitals of permanent construction are
    available to take their place.

             Although prior to July, 1920,  there had been a limited use
    made of the facilities of the Army,  Navy and National Soldiers Homes
    in the case of Veterans' Bureau patients,  it was not until that date
    and in accordance with provisions of the Sundry Civil Act of the 66th
    Congress that a systematic and more  extensive use of these facilities
    was proposed.  It.was perceived that with the general reduction in the
    Army and Navy personnel a number of large and well equipped government
    hospitals were not being utilized to their full capacity.   The utiliza-
    tion of these facilities would have  a two fold result,  first,  the
    placing of a larger number of patients under airect government medical
    supervision,  and second, a more pronounced curtailment in the use  of
    contract civil facilities.

             In June,  1920,  under plans  agreed upon by the representatives
    of the  then Bureau of War Risk Insurance and of the several govern-
    ment services there were immediately made available 4181 hospital  beds,
    not including those in operation by  the United States Public Health
    Service divided among the services as follows: Navy Department Hospi*-
    tals,  1760;  War Department Hospitals.  1510; National Soxdiers:  Homs-s,
    911.  Additional plans contemplated  increased  facilities by all those
    services.  At the  present time,  January 1922,  in accordance with these
    plans the following number of beds have been made available by these
    three services:  Navy Department,  5396;  War Department,  2917;  National
    Soldiers1 Homes, 3317;  Total,  9630. 
 
Page 10.
                                       Tuesday, January 22, 1922.

FORBES (Cont.)

           I have briefly outlined the growth to the present time in
    government hospital facilities available to the United States Veterans1
    Bureau*  Combining the figures I have enumerated it is seen that the
    total number of available government hospital beds has increased during
    a period of a little more than two years and a half from a few thousand
    beds in 21 Marine hospitals to a total of 28655 beds in 94 government
    hospitals*

           Let me now outline briefly the growth in our hospital popula-
    tion over this period.   In September* 1919 there were recorded a total
    of 6003 patients of  the  Bureau of -ar Risk Insurance, which total had
    increased by January 1920 to  10907, and by July 1920 to 19,489, aver-
    aging  over this period a monthly increase  in hospital patients of
    approximately 1225.  From July 1920 to January 1922 the hospital  ■
    population increased from 19, 489 to 29,263.


            These 29,263  patients  are hospitalized  to  the following extent
     in the several  classes of facilities: United States Public Health
     Service,  13,874; United States Army,  1530; United  States Navy  1473;
     National Soldiers Homes', 2637;  St. Elizabeths Hospital, Interior
    Department,  825;  Contract  Civil Hospitals, 8924.   By general class
     of disease,  these  patients are divided  as  follows: Tuberculosis,
     11,822;  Neuro-psychiatric,  8,414;  General  Medical and  Surgical, 9027.

            Of the  total number of 28,655 government hospital beds-avail-
     able,  20,339 are occupied at the present time,  leaving a balance  of
     8,316 unoccupied hospital beds.

            As previously stated,  it is the policy  of this  Bureau wherever
     practicable,  to remove beneficiaries of the  Bureau from contract
     institutions and place  them in hospitals operated by the governmental
     medical services.   If it were possible at the  present  time  to  fill
     every vacant government bed by patients in contract  hospitals  we
     would still be obliged  to continue 608 cases in contract institutions.

            An analysis of the vacant government  beds shows that they  fall
     under the following category:

            For tuberculosis   ............
            For neuro-psychiatric..........
            For general medical & Surgical.
                              Total

            An analysis  of the patients in contract hospitals shows they
     are classified as follows:
2,292
  748
5,276
8,316 
 
Ptae 11.
FORBES: (Cont.)                           Tuesday, January 22, 1922.

            Tuberculosis  ....................2, 930
            Neuro-psychiatric ................4,004
            General medical & Surgical.......1.990
                               Total          8,924

            A review of  these two  sets of figures shows  that althou^
     there are apparently ample facilities for the care of general medical
    and surgical cases,  there is a real and serious shortage of.government
    beds for the care  of tuberculosis and neuro-psychiatric cases.

            In considering  the use of government hospital beds at present
     reported vacant, it  is  of course entirely impracticable to attempt to
    accomplish the  complete filling up of all government hospitals,^ As
    you all realise, this is due to a number of reasons, chief of which.
    are (l) the administrative necessity at all hospitals of maintaining
    a  surplus of beds  amounting to from ten to fifteen percent of capacity
     to a^low  flexibility in case  of epidemic or sudden  emergency;  and to
     permit unhampered  the routine  admission ana discharge of patients,
     (2) the location of  vacant beds away from the points of greatest de-
     mand, and (3)  the  fact  that the vacant beds available are not of the
     type  required  at points where  the Bureau needs  them.

            From an analysis of  this whole situation  it  is believed that
     we have sufficient beds available for  the care  of general cases with
     the  exeception of  two or three areas of  the country, such as memphis,
     Tennessee, and in  the metropolitan district of  New York.  Some  pro-
     vision  must be made  to  care  for cases  of  a  general nature because
     facilities at  these  points are totally inadequate.   In New York,  the
     existing facilities  must be  given up by June  1932,

            However,  the number  of general meaical  and surgical cases
     requiring  treatment  will steadily diminish  and  contract hospitals
     in "many instances  would ultimately be  able  to care for  their needs.
     On the  other hand,  the  Bureau  must make  provision for  the  care of
     tuberculosis and neuro-psychiatric cases  for  many years  to come.

             The general meaical and surgical cases are  a  type which
     justify the use of contract  institutions  more  than  the  other classes
     referred to, by reason  of  the  comparatively short length  of time
     that  treatment is  indicated: emergency conditions which  require
     immediate hospitalization  ./here the patient may be;  and  the disinclin-
     ation on the part  of ciai.-ants to be far  from home,  especially  when  a
     surgical procedure is  incicated.

             The hospital program  of the Veterans'  Bure.iu  is  meant  to pro-
     vide  approximately 20,500"'permanent beds  for  the  treatment  of  tuber-
     culosis and mental c.ses.   It  is estimated  that between the present
     time  and the end of  1S23 th„ Veterans' Bureau will  lose  the use of
     approximately  5, 4CC  beds because the hospitals  will  have  to be
    abandoned oy reason  of  expiration  of  lease, temporary nature  of the
     structure, or  for  other cogent reason.

             The hospitals  being constructed  out  of the  Langloy Bill (Act
     of 1  ijuab. J.??l) and appropriations  for  the Public Health Service 
 
Page 12,
                                       Tuesday,. January 22, 1922.

FORBES: (Contf)

    made either by the Secretary of the Treasury or the United States
    Veterans* Bureau which will become available during the two years
    ending with the calendar year of 1923, will only provide 7, 198 beds,
    while during the same period of the time the Bureau will lose 5,397
    beds for the reasons already indicated.  The ultimate loss of beds
    by reason of expiration of lease, temporary nature of the structure,
    etc., will be approximately 4,875 greater than the beds which will
    be provided as result of construction now going on under existing
    appropriati ons•

          From careful studies that have been made,  it is evident the
    Bureau will require additional hospital facilities at the f ollowing
    points:
               500 beds for tuberculosis patients in the
                      State of California:
               500 beds for insane in California;
               200 beds in Chicago to enable the Edward
                      Hynes Jr. Hospital to be converted
                      into a hospital for mental cases;
               150 beds for general medical and surgical
                      cases in the vicinity of L'bmpbis;
               600 beds for general medical and surgical
                      cases in the metropolitan area of
                      New York;
               250 beds for general medical and surgical
               ___    cases at the Walter Reed Hospital
             2,200

           It has recently become apparent that the neuro-psychiatric
    hospital at Marion, Indiana, operated by the National Home for
    Volunteer Disabled Soldiers, can only care for nervous and mild
    mental cases,  and is not prepared to handle definitely insane.
    Development in the future may make it necessary,  therefore,  to. ask
    for further provision for insane at that or some  other point in the
    country east of the Mississippi River.

           Estimating that we will have approximately 2,000 or 2,500 cases
    in contract institutions for many years,  the Bureau is endeavoring
    to provide for a maximum load of about 32,000 cases,  the peak prob-
    ably being reached in 1922,  It is estimated that the general medi-
    cal and surgical cases will diminish rapidly,  but that permanent beds
    for the  treatment of approximately 13,000 tuberculosis,and 9,500
    neuro-psychiatric cases must be available.

           Gentlemen,  I have attempted briefly  to outline the  growth
    and the  magnitude of our hospitalization program,  and have told you
    roughly  what the  expectation and needs of the United States  Veterans'
    Bureau in regard  to  hospitalization facilities  are.   It is all 
jr..    ,.   s 
Page 13.
 FORBES (Cont.)                       Tuesday, January 22, 1922.

    summed up in our earnest endeavor of the United States Government to
    provide every ex-soldier, sailor, marine or nurse who becomes a
    beneficiary is the United States veterans' Bureau with the best medical
    treatment available under the bust conditions possible.  Eut in spite
    of our needs for additional governmental hospital facilities,  I want
    to assure you all that to my best knowledge there is not a single
    veteran of the-World rjar, eligible for treatment and who has applied
    for hospital treatment,  for whom hospital facilities have not been
    found or who has not oeen offered hospitalization."

GENERAL SAWYER:

    Allow me to suggest just one thing.   You will notice that on the
    program there is a time for general discussion of all these subjects,
    and I wish you would make pencil notes of the things that appeal to
    you as being of importance enough to be called up during the dis-
    cussion.  We are here really to get  out of this all -we can,  and we
    want you to feel free to call for any further consideration of these
    subjects when we get to that hour of a is cuss ion.

         I have pleasure in introducing  major Wlerritte W,  Ireland,  who
    will address you upon the subject of 'The Army's  Relation to the
    hospitalization of the World War Veteran',"

GENERAL IRELAND:

         The treatment provided in our military hospitals  for World War
    soldiers may be summarized in instructions approved by the Secretary
    of War,  which were about as follows:  That nc member of the military
    service disabled in line of duty even though not  expected to return
    to duty,  wouid be discharged from the service until he had attained
    complete recovery or as  complete recovery as could be  expected he
    would attain when the nature of his  disability was considered.   It
    was laid down,  further,  that physical reconstruction consisted  in the
    completest form of medical and surgical treatment  carried to the  point
    where maximum functional restoration,  mental and physical, had  \>een
    secured.   To secure this result the  use of work, mental ana  manual,
    was required during the  convalescent period.   This therapeutic  meas-
    ure,  in addition to aiding greatly in shortening the convalescent
    period,  retains  or arouses mental activities,  prevents the state  of
    mind  acquired by chronic hospital patients,  and enabies the  patient
    to be  returned  to service or to civil life  with the  fullest  realisa-
    tion  that he  can work in his handicapped  state and with habits  of
    industry  much encouraged,  if not newly  formed.  Early  in  1918,  the
    Secretary  of  War also authorized the  Medical Department to proceed
    "with  the  scheme  for reconstruction of officers and enlisted  men of
    the Amy alone -without consideration of the  other  bureaus  of the
    government involved*  This  reconstruction  it was clearly understood
   would end at  the  point where the  medical reconstruction ceased  .,.nd
    the future reconstruction  of such cases was  to be  complete^  by  other
    agencies of the Government after the  individuals had been discharged
    from the Army. 
 
Pa-e 14.
IRELAND:(Cont.)                       Tuesday, January 22, 1922.

             Patients then were cared for in military hospitals up to
   the point of maximum functional restoration, both mental and physical*
   In the case of patients who were ultimately to be discharged from
   military service, arrangements were made whereby the Federal Board
   for Vocational Training might have access to these men as soon as it
   was known that they were to be discharged and the educational officers
   of the liedical Department were directed to cooperate with the repre-
   sentatives of the Federal Board to the fullest possible extent,  in
   order that the patients concerned might have ail the advantages
   assured them by  the Federal Government.

             It was recognized that in order to make this program
   successful for the attainment of the ::aximum physical and omental
   condition through complete medical and surgical treatment, it would
   require the establishmmnt of a policy of extended publicity*  This
   embraced the necessity to educate the public to the need of this
   physical reconstraction for the disabled men before their return to
   civil life; to educate the family of the soldier with regard to the
   need of continued treatment that they might be satisfied to have them
   reimoin in hospital, and finally, to educate the soldier himself by
   placing in his hands at the earliest possible moment after his disa-
   bility had been  incurred the necessary literature which would inform
   him of his status as a soldier and of the privileges,  which were to he
   his as a disabled man, from the Medical Department of the Army,  the
   Federal Board for Vocational Education, the Bureau of War Risk Insur-
   ance, and also to place in his hands such literature as would inform
   him of facts concerning various trades from 'which he might choose a
   vocation,  together with all the information in regard to the need for
   men in the various industries of the country.

             As above outlined this policy of treatment was carried out.
   At the approved  time for the discharge of the patients from the mili-
   tary service,  they at once became beneficiaries of the Bureau of War
   Risk Insurance ana subject to further physical reconstruction or edu-
   cation,  if such were necessary,  under the direction of the Federal
   Board,  Public Health Service or the Bureau of War Risk Insurance.

             Such facilities as were in our hospitals and were not re-
   quired for the care of the sick of the active list of our army were
   placed at the disposal of the discharged veterans of the World War.
   This was done mainly in two ways: first,  by turning over to the Public
   Health Service which was charged with the medical wcrk of the Federal
   Board,  many complete hospitals and second, by caring for many of the
   veterans in our own hospitals after their proper discharge from the
   service.

                   HOSPITALS RELEASED FOR CARE OF VETERANS

             By virtue of Act of Congress in Larch,  1919, every military 
 
                            Page  15.

IRELAND (Cont.)                            Tuesday,  January 22,  1922,


    hospital, including  its supplies,  no longer required for the proper
    care of  the sick  in  the military  service was to be turned over tc the
    Public Health  Service  if  the  latter service so desired.  A detailed
    classified list of hospitals  approximating 2,460 beds turned over
    under this law follows:

               General Hospitals  at permanent military stations
               which  were  transferred to Public Health Service*

        Name                               Bed capacity-Date transferred

    Fort Bayard, New  Ifeocico                   1000     June 15, 1920

    Fort  I.lcHenry,  Maryland                    200      June 15, 1920

    Whipple  Barracks, Arizona                 600      Feb. 15, 1920
         Total                            3600

          Hospitals on Leased Properties  transferred
                 to Public Health Service,

    Name                              Bed capacity   Date  transferred

**0»Reilly Gen. Hosp., Oteen, 1\LC.          1300      Oct.  15,  1920
**Hoff Gen* Hosp,,  Staten Island, N.Y.      1468      Oct.  15,  1S20
  Gen, Hosp. #10, Boston, Mass.             700      July  1,  1919
  Gen. Hosp. #12, Biltmore,  N, C.           450      Sept,  1,  19 IS
  Gen* Hosp. #13, Dansville, N.Y.           288      April 2,  IS 19
  Gen. Hosp. #15, Corpus Chris ti, Texas     262      I lay   31,  1919
  Gen. Hosp. #16, New Haven, Conn.          500      Sept.  1,  1919
 *Gen. Hosp. #17, Markleton, Pa.            187      I.ar.  27,  1919
  Gen. Hosp. #24, Parkview,  Pa.             700      July  30,  1919
  Gen. Hosp, #32, Chicago,  111.             550      Ifey  15,  1919
  Gen. Hosp. #34, East Norfolk, lass.       34C      June  24,  1919
  Gen. Hosp. #40, St, Louis, Mo.            530      June  12,  1919
  Smb. Hosp. #4, (polyclinic) IT, Y.         374      Aug.  15,  ISIS
  Norwegian Lutheran and Deaconess Home,
        Brooklyn, N. Y.                     250      may   15,  1919
  Post Hosp., Q.Ih Terminal, Sewel 1's PointVa250      I&y   27,  1919
  Nitrate Plant, Perryville, Md. (approx)    150      Oct.   1,  1919
Total                         8299 
 
Page 16.
IRELAND (Cont.)                          Tuesday, January 22, 1922.
Camps and Cantonments	taken	over	by Public Health			Service*
Name		Bed	. capac:	ity	Date	transferred
Camp Beauregard, Louisiana			2144		Liar*	18, 1919
Camp Cody, New Kexico			1289		Apr.	14, 1919
Camp Hancock, Georgia			1604		I/Sar.	27, 1919
Camp Josejh. E* Johnston, Fl<	arida		816		July	17, 1919
Camp Logan, Texas			1156		Liar*	12, IS 19
Camp Sevier, S» Carolina			1396		Apr.	5> IS 19
Camp Fremont, California			1156		Ito*	20, 1919
            Total                       9561
                                              » Total 21,460

*  General Hospital No. 17 was closed as an Army hospital on
   I larch 27,  1919,  the Public Health Service having stated
   that it did not desire this hospital.  Later on,  however,
   this hospital was taken over ^oy the Public Health Service.
** Indicates buildings constructed by the Army on leased ground*

   Hospitals abandoned by the Medical Department,  U. S.  Army,
   and available to the Public Health Service,  but not occu-
   pied by that Service because they were not located where
   additional hospitalization was needed.
General Hospitals	Capacity	Abandoned	
GH #1, New York City	1258	Oct, 15,	1919
GH #3, Co Ionia, New Jersey	1650	Oct. 15,	1919
GH #8, Otisville, N.Y.(tuberculosis)	1000	Nov. 15,	1919
GH #9, Iakewood, New Jersey	986	may 31,	1919
GH #11, Cape May, New Jersey	750	July 20,	1919
GH #18, Waynesville, IT. C. (tuberculos	is) 600	June 30,	1919
(31 #22, Philadelphia, Pa.	450	June lO,	1919
GH #23, Hot Springs, N. C.	600	Liar* 15,	1919
GH #35, West Baden, Ind,	800	June 30,	ISIS
GH #36, Detroit, Michigan	900	Aug* 10,	ISIS
GH #38, East View, New York	850	July 15,	1919
GH #39, Long Beach, L. I.	550	May 21,	1919
Total
10394 
«?.
,  ■  ■ • I. I
x-  V■•".'■ 
Page 17
IRELAND (Cont.)

         Base (Camp) Hospitals

   BH Camp Wadsworth, S.C. (GH #42)
   BH Camp Bowie, Texas
   BH Camp Custer, Michigan
   BH Camp Gordon, Ga.
   BH Camp Greene, North Carolina
   BH Camp McArthur, Texas
   BE Camp McClellan, Alabama
   BH Camp Shelby, Mississippi
   BH Camp Sheridan, Alabama
   BH Camp Taylor, Kentucky
   BH Camp Upton, L.I,, N»Y.
   BH Camp Wheeler,  Georgia

             Total
Tuesday,  January 22, 1922.
Capacity

   1000
   1000
   1500
   1500
   1000
   1000
   1000
   1000
   1000
   1500
   1500
   1000
       Abandoned

October 10,  1919
Subsequent to Mar* 3, 19.1
    ti
    n
    n
    n
    ii
    n
    n
    n
    n
    n
11	11	3, 19 lc-
II	11	3, 191S
11	11	3,1919
11	II	3, 1919
11	II	3, 1919
II	II	3, 1919
11	II	3,1919
II	II	3,1919
II	11	3,1919
II	n	3,1919
14000
       Port Hospitals

       (St. Marys) Hoboken, N.J.
       (Gre enhut B ldg.) New Y o rk C i ty
       (Grand Central Palace)N.Y,C.
BH Camp Merritt, New Jersey
BH Camp Mills, LeI. N. Y.
BH Camp Stuart, Newport News, Va.

           Total
EH #1,
DH #3,
DH #5,
opacity 500	Abandoned Oct. 31, 1919
3100	July 15, 1919
2700	June 30, 1919
2000	Dec. 15, 1919
2000	Sept., 18,1919
2000	Sent.10, 1919
12300
Total
36694
     In addition to the foregoing the following permanent military
     pests have been recently acquired by the Public Health Service
     from the Army:

         Post                              Size °f Pos,t
Boise Barracks, Idaho        4 troops cavalry
Ft. W.H. Harrison, Montana   4 companies infantry and hdqrs. 1892
Ft. Walla Walla, Washington  4 troops cavalry and hdqrs.     1859
Ft. McKenzie, Sheridan, Wyom.8 companies infantry & hd^rs.   1898
Ft. Logan H. Roots, Arkansas 4 companies infantry            1892
VETERANS* BUREAU CASES TREATED IN MILITARY HOSPITALS
     Now, with  reference  to assistance rendered within our own hospitals,
in an interview with the  Director of the War Risk Insurance in 1919,  I
heard the former  Secretary  of War say that he considered it an obliga-
tion on the Amy  to  assist  in caring for the discharged World War
veterans and  that any vacant bed in Amy hospitals was always available
for the treatment of these  men.   To carry out this policy,  the Bureau
of rrar Risk and later the Veterans*  Bureau was  from time to time
advised by the Medical Department of the number of available beds in
our hospitals in which we could  accept for treatment veterans of  the 
 
Page 18.
IRELAND (Cont.)                             January 22,  1922.

   World War.  The number of beds thus offered has  varied slightly from
   time to time,  but has always been on the increase,  particularly since
   last July,  Last Lay 1450 beds were available to the Veterans1  Bureau;
   In October 1752 beds were available,  and by November 24th 2200  beds
   were available.  The following brief table gives the exact  status on
   January 5, 1922;
	Beas as signed to B.V.B, (D	Patients in Hospital			TOTAL Cases Under treat-ment.	
Hospital		T. B. (3)	Neu-P. (3)	Gai'L,u: S.: (4)		Vacant Beds 3-VJB.
Army & Navy	150	0	2	85	87	72
Beaumont	200	43	5	18	66	134
Fitzsimons	600'	787	0	74	861	338
Letterman	250	7	7	58	72	237
Ft.Sam Houston	300	139	11	63	213	87
Walter Reed	750	26	24	334	384	366
TOTAL	2250	L002	49	632	1683	123^
    Within, a  few days we expect  to open up several hundred beds at
Fitzsimmons General Hospital  for veterans suffering from tuberculosis.
This  last large increase has  been made possible by funds transferred
by  the  Veterans1 Bureau to  the War Department for the specific- purpose
of  enlarging  this hospital.   When the construction and alteration made
possible by these funds has been completed (and the completion is
expected almost daily) 700 adaitional beds for the tuberculosis will
have been provided in permanent  structures for a little over $1000 per
bed.

     In addition to the buildings turned over to the Public Health,
which have already been enumerated,   the :;edical Department has turned
over to that  Service supplies approximating a value of $12,336,000.00.
It has  been a source of gratification to the Medical Department,  and
I am sure to  the War Department,  that the Amy was in a position to
assist  in rendering aid to the American soldier disabled in the World
War.

     The total number of all  cases treated in our general hospitals
during  the last year was approximately 30,000; of these 10,000 were locaj
cases and 20,000 were general cases,  and of the latter 15,700 were our
own and 4300 pertained to the Veterans1 Bureau. 
 
Page 19.
 IRELAND (Cont.)                             Tuesday,  January 22, 1922.

         A brief summary of the Veterans1 Bureau cases treated in our
    hospitals may be of interest.  Of the 4,300 cases treated during the
    year (October 1, 1920,  to October 1, 1921) 180, or about 4$,  were
    suffering from either nervous or mental conditions;  2195 or about 51$
    with tuberculosis;  770,  or about 18$ with diseases or injuries of the
    osseous system;  75,  or  nearly 2$ with heart or vascular diseases,  and
    the remaining 25$ was made up of all other conditions combined.

         In addition to this work, much assistance has been rendered in
    making jhysical examinations for that Bureau to determine the right
    to compensation or the  necessity for hospitalization.  Over 2,000 of
    these examinations  were made during the year,  many of which necessi-
    tated admission to  hospital for varying periods to permit a thorough
    survey in order that correct diagnosis or physical condition might be
    established."

GENERAL SAWYER: "I am sure  it must be gratifying to you to obtain
    a more intimate knowledge of the conduct of these affairs.
    I have pleasure in introducing to you Rear Admiral Edward R4  Stitt,
    Surgeon General of the United States Navy,  who will inform you as
    to ,The Navy's Part in the Hospitalization of the World War Veterans*."

ADMIRAL STITT:

    "The Medical Department of the Navy has been able to work with
    the Veterans* Bureau along the following lines:

    First:  the turning over to the Public Health Service for the care
    of the Veterans of the World rar of the Naval hospitals at Hiiladel-
    phia, Pa., Cape May, N.J., Gulf port, Miss., and New Orleans,  La*
    and quite recently to the Veterans1 Bureau itself of the hospital at
    Fort Lyon, Colo, used for tuberculosis patients*  These institutions
    were completely equipped when transferred,  so that no additional
    expense was involved.  The hospital for tuberculous patients
    at Port Iyon has been operated by naval personnel since November
    first, but this institution will be taken over by the Public Health
    Service on Liarch 1st.  With the great reduction in naval personnel
    and the discharge from the service of large numbers of the tuber-
    culous, the needs of the Navy did not seem to justify the maintenance
    by the Navy of  so large a hospital, there being at present 735 beds
    with possibilities of expansion*  Upon his return from a recent in-
    spection the Surgeon General  of the Public Health Service expressed
    to me his admiration for the  institution.  We should not have
    been able to turn over this hospital had it not been for  the
    generous offer  of the Surgeon General of the Army to take care
    of the naval tuberculous at the Fitzsimmons General Hospital .at
    Denver.  The bed capacity of  these five hospitals totaled 2229,

      Second:  The  caring for the veteran patients  in the same hospitals
    in which the sick of the Navy are being treated.  In assigning
    accommodations  to the patients of  the Veterans1 Bureau  there are 
:•■■■<•   I ■'  ■'■"'
:  r
:. ;  •. -......'f  t-j
C>.  ''
"■■'•   '    » 
Page 20
STITT (Cont.)                               Tuesday, January 22, 1922,

   many problems which complicate this matter.  Manifestly it is
   necessary for the Navy to be prepared to receive the patients from
   its own personnel, and -when it is considered that the fleet may
   at one time be in the port of New York and sending its sick
   to the New York Hospital during such time and then sail away
   for another port to then transfer its sick to another hospital
   the difficulties are apparent.  If v/e could, divide the ships between
   different ports and their sick betwen different hospitals the
   matter would be easy of adjustment.
   Again we have only a limited number of beds in our three hospitals
   on the Pacific Coast and at the present time a large fleet is based
   on this station so that we are unable to offer accommodations in
   those hospitals to the Veterans1 Bureau and at the same time make
   adequate provision for the naval sick*
   As a general rule we are only able to provide hospital facilities
   for general medical and surgical cases, but much of our work is in
   studying cases of suspected tuberculosis and where a positive diag-
   nosis is made the determination of the extent of the process*
   At Great Lakes, 111.  owing to the urgent needs of this section of
   the country, we have agreed to care for approximately 300 neuro-
   psychiatric  patients, this in addition to 300 beds for general patients,
   In order  to  obtain medical personnel trained in  the supervision of
   such  cases  it was necessary to withdraw cur psychiatric specialists
   from  various stations where their  services were needed, but  it was
   felt  that  this was a greater need.  To provide for additional men
    trained  in this specialty we no# have a number of young medical
    officers under  training  at St. Elizabeths Hospital.

         The Navy  is  not  only  indebted to Doctor White  for this  service
   but  it  owes  him obligations for his many years of instruction  tc
    the classes  at  our Naval Medical  School.  At  the present  time  there
   are under consideration plans  for the  establishment under Doctor
    White of a school for the  training of  psychiatric personnel for
    other services  caring for veterans,  talcing advantage  of the abundant
    clinical material at  St. Elizabeths,

         At  our hospital at Chelsea,  Lass, we  have been able  to offer
    539 beds to the Veterans*  Bureau and  from the letters I receive,
   as well as from a personal inspection,  I  can attest the care that
    is  there being  given our veterans.

         The Navy is  particularly proud of its good  food  and I think cur
   hospitals  lead  the Navy in this  important service*  which not only
   makes for contentment but aids convalescence.   We have just agreed
    to  receive the  patients  from the  Polyclinic Hospital of New York
    and  expect in a short time to be caring for approximately 350
   patients  in the naval hospital located in Brooklyn.  We are very
   proud of the physio-therapy installation at this hospital,  which
   has been pronounced by experts as one of the most complete equip-
   ments in the country. 
 
Page 21.
STITT (Cont.)                              Tuesday, January 22, 1922*

      In our hospital in Washington we are offering 250 beds*  In this
    institution we are peculiarly well equipped for the diagnosis and
    treatment of obscure cases by reason of its association with the
    laboratories of the Naval Medical School.  These naval hospitals are
    geographically so situated that large numbers of patients can be
    treated near their homes.  Although most of our hospitals in our
    island possessions are small yet we can take care of a limited
    number of veterans who might be in such localities.

      The mental environment at these hospitals is admirable from a
    standpoint of cheerfulness, amusement and when indicated occupational
    recreation, our rule has Qeen so far as possible to treat veterans
    and sailors alike.  To the Red Cross we owe much of the measures for
    contentment among the patients, although we also owe obligations to the
    morale division of the Navy Department for assistance along the lines
    of recreational and educational opportunities, especially as regards
    well conducted libraries.  The number of beds now available in our
    hospitals approximates 2900.  Aaiing tne 2229 Deds transferred to the
    Public Health service makes approximately 5172.

      THIRD  In the transfer to other agencies caring for veterans of
    hospital supplies and equipment.  As noted previously we have turned
    over not only the beds of  five hospitals but in addition surgical,
    X-Ray,  laboratory and other facilities as well as store rooms full
    of varied  supplies.  In addition we have from time to time given
    various  medical and  surgical  supplies,  I may state that we are
    now  turning over  to  the Public Health Service $1,375.00 worth
    of stock from our Supply Depot and stand ready to transfer another
    million  dollars wofcth of medical stores when called for.

    FOURTH   On board  ship and  at  our various stations medical officers
    have examined claimants by the thousands, assisted them in making
     their applications and aided  them with advice.

        In  the Bureau  of  Medicine  and Surgery one  of our most important
    activities  is  in  supplying data  to the Veterans1 Bureau for use in
     the  adjudication  of  claims for compensation.  The reports at present
    are  more comprehensive then  formerly made, and include in addition
     to  the  name,  rar.k  or rate  and  claim number, the date and place of
    birth,  enlistment, discharge  or  release  to inactive duty, together
    with a detailed medical history.  The maximum number of reports^
    sent out by the Bureau has been 250 in a day with an average daily
    completion  of about  100 cases.  At present we are up to date in
    answering  claims.  Notwithstanding the reduction of the clerical
    force in some divisions to the point of extinction of the activity
    in the  effort  to  make  the  furnishing  of  records to the VeteransT
    Bureau  our  first  consideration we should have been far behind in
    furnishing  records had it  not ^)Qen for the hearty and willing coop-
    eration  of  the Veterans' Bureau  in assigning  clerks from their own 
 
                             Page 22.
STITT (Cont.)                              Tuesday,  January 22, 1922.

   forces to assist in this most important and imperative work*

     Where by reason of law or otherwise v/e have been unable adequately
   to provide for the veterans either in personnel or material Colonel
   Forbes has ever stood by to give us hearty cooperation and assistance.
   I am also indebted to General Sawyer,  the Chief Coordinator of the
   Hospitalization Board for en courage merit and advice whenever asked of
   him.

     In reciting the activities of the Navy in providing hospital
   care for veterans, I trust it has become apparent that I have the
   honor to represent an organization,  equipped to aid the Veterans*
   Bureau in fulfilling the pledges of our government to its veterans,
   disabled in the Great War,  and manned by a personnel actuated in
   all ranks by an earnest desire to contribute in the discharge of
   our .obligations."

GENERAL SAWYER: "I do not know exactly what impression you get from
   this information that is given out here by the heads of these great
   departments,  but to me it seems that here is a spirit,  a whole-
   souled determination to put everything at the command of the
   Government at your service to help you,  that we may help the World
   War Veteran to the best that can be given.  The recitation of these
   things by this Adi.ural and this Major General shows how much really
   comes through a closer affiliation.  - how much we get that is worth
   the while from a better understanding; and that is what we really
   believe we have in this new Board of Hospitalization.
          We have with us this morning the man who has been personally
   responsible for the largest number of these patients; in fact,  he is
   responsible for more of these patients than all of the rest of the
   departments together; and if you do not know himj,  I should like to
   introduce to you a man whom I have found,  by close contact and
   personal observation during the months I have been in Washington,
   to be a man who is giving everything within him to make of the
   Public Health Service of the United States of America the best
   Public Health Service in the world and to give to the World War
   veteran the best hospitalization service that can be rendered.
          I have pleasure in introducing to you Surgeon General Hugh
   S, Cumming,  of the United States Public Health Service,  who will
   speak oh the subject of "The Service Rendered World War Veterans
   by the Public Health Service1."

GSWERAL CUMMING:

   In presenting even a brief outline of the services which have
   been rendered,  and are being rendered, to disabled veterans of the
   World War by the Public Health Service,  it is necessary,  for a
   proper comprehension of the subject,  to state,  at least in general
   terms,  the genesis of the relationships which the Public Health
   Service has sustained,  and now sustains,  to this -very important
   responsibility.

        The Congress, before the close of the war, had given considera-
   tion to a comprehensive plan for the care of disabled veterans 
 
Page 23.
CUI.2.HNG (Total)                            Tuesday, January 22,  1922.

    totally unlike the previously existing pension  systems, and had
    passed legislation putting into effect this program.

          In doing so, use was made of  existing agencies  rather  than  the
    creation of new cues.,  Arrng these  existing agencies was  the U. S.
    Public Health Service*  This Service., on March  3,  1919, was given
    authority to furnish medical care and treatment to veterans, acting
    in this capacity as an agency of the war Risk Insurance Bureau.
    The Director of that Bureau was charged with the  real  responsibility,
    but was permitted, under  the legislation,  to make use  of  the Public
    Health Service in discharging his responsibility  -with  regard to
    medical care and treatment.

          Peace having come unexpectedly and demobilization following
    shortly thereafter, the problem of  the care for the disabled veteran
    became at once very pressing.  The  Public Health  Service had
    under its control only a  few hospitals, with a  total bed  capacity
    of about 1,500.  The Director of the war Risk Insurance Bureau
    looked to the Public Health Service to supply him with the neces-
    sary medical services, and the Public Health Service,  therefore,
    found itself faced with the task of supplying,  in a short space
    of time, an extensive system of medical relief*

          It undertook this problem and, under the  legislation, sought
    to meet the responsibility in several ways.  By the transfer to
    its jurisdiction of facilities used by the Army and Navy  during
    the war, by the purchase  of such facilities as  were available and
    within the moderate appropriation,  by the  leasing of fairly suit<*
    able places and their conversion to hospital purposes, and by mak-
    ing contracts with civilian hospitals all  over  the United States^
    for the care of veterans, this Service was able to furnish facilities
    with rapidity.  These facilities were by no means always  desirable,
    but at least it may be said that the Public Health Service was
    enabled to keep pace With the demand and to supply to  all veterans
    who applied some form of  hospital care and treatment.

          The administrative  organization, which had  been  formed under
    the law, for the care of  veterans,  included three bureas, namely;
    the Bureau of War Risk Insurance, the Federal Board for Vocational
    Education, and the Public Health Service.  This organization, while
    it was the best that could he formed under the  circumstances,  left
    a good deal to be desired, and was  the cause of much  criticism and
    no little dissatisfaction.

          Latters became so urgent finally that, under the Presidents
    direction, certain changes were made, and  later,  by act  of  Congress,
    even more radical changes were made, all with  the ultimate  tendency
    of concentrating  in one  organization  the entire responsibility for
    all matters affecting veterans of the World War.   This culminated
    in the passage of legislation creating the U» s«  Veterans' Bureau 
 
                              Page 24
CUI2.IING (Cont*)                          Tuesday, January 22, 1922.

   and charging that Bureau with the full responsibility for all
   matters affecting veterans,   (Aug. 19,  1921.)

        In the legislation creating this Bureau, however, the
   Director of the Newly created Bureau was authorized, in giving
   hospital care and treatment to his beneficiaries, to make use of
   certain official agencies, and among these the Public Health Serv-
   ice, which at that time was carrying most of  the medical work for
   veterans,  and in fact this Service is still supplying by far the
   largest number of hospital beds for their care.

        Under this new  legislation, adjustments were made as rapidly
   as possible, and are still going on, with the result that the
   present situation of the Public Health Service; in this responsi-
   bility is fairly clearly defined for the first time since it has
   undertaken this work*

        The U. S. Veterans' Bureau has now  taken over, or will shortly
   talce over, from the  Public Health Service all of the responsibility
   and all of the work  involved, with the exception of the operation
   of hospitals.  The work taken over by  the U.  S. Veterans1 Bureau
   includes the entire  responsibility for the operation of all out-
   patient departments  for the care of veterans.  Thus the Public
   Health Service is now left simply as a hospitalizing agency for
   the use of the Director of the Veterans' Bureau.

        The Public Health Service, therefore, stands in the same
   relationship to this work as other official agencies, namely; the
   National Homes for Volunteer Soldiers, the Army, the Navy, and St.
   Elizabeth's Hospital of the Interior Department,  That is to say;
   it  operates independently a system of hospitals for the use of
   the Director of the  Veterans' Bureau in  the care of his benefi-
   ciaries.  It has no. responsibility with  regard to meeting the
   demands for hospital facilities and it has no responsibility with
   regard to the distribution of patients to these hospitals.  Its
   responsibility is limited simply tn theJoperationhof such hospi-
   tals as the Director desires, ana to the admission of such patients
   as he may desire to  send  to the same.

        When the Public Health Service was  suddenly charged with the
   large and important  responsibility for supplying medical care and
   treatment to veterans of  the World War,  it proceeded at once to
   organize,  on a commensurate scale,  to meet a  problem the character
   of which was unknown and the magnitude of which could only be
   surmised.

        The first and greatest problem faced by  the Public Health
   Service was,  of course,  to determine .as  soon  as possible the
   character and the magnitude of this problem.  In conjunction with
   the War Risk Insurance Bureau,  there was compiled and finally
   published a public document (^31 of the  56th  Congress, December 5,
   1919).  In this document,  this entire problem was analyzed, and
   certain very definite conclusions v/e re stated as to the need for
   medical and surgical facilities for the  proper care ana treatment 
 
Page 25.
GUMMING (Cont.)                             Tuesday,  January 22,  1922.

    of discharged disabled veterans.

         It is unnecessary at this time to attempt any analysis of
    this document,  but it is worthy of some comment.   It indicated
    that within two years from the date of its publication there
    would be needed for patients of the War Risk Insurance Bureau
    7,2CG beds for general medical and surgical cases,  12,400 beds
    for tuberculous cases, and 11,060 for neuropsychiatric cases,
    making a total of 30,560 beds.

         Recommendations in this document were made for the expendi-
    ture of a marge sum of money for necessary construction,  and  a
    draft of a bill was offered which would appropriate the money for
    this purpose.  The bill contemplated that this money should be
    expended in annual installments,  extending over a period ending
    June 30, 1923.  This document also indicated that the peak of the
    load, at least for neuropsychiatric ana tuberculous disorders,
    would not be reached for some years.

         The conclusions reached in this document were the subjects
    of a good deal of criticism.  It was rather generally felt that
    the facilities which had been provided during the war for the
    medical care and treatment of soldiers and sailors could be made
    use of very readily and very satisfactorily in the care of dis-
    charged disabled soldiers and sailors at the termination of the
    war.

         jt was not clearly appreciated that the war program for  the
    care ■ of sick and disabled could,  by no means,  be  converted into an
    adequate and satisfactory system of hospitals for the care of
    sick and disabled persons under peace conditions.   At all events,
    no money was appropriated for purposes of constructing hospital
    facilities until March 4,  1921.

         It is highly significant at the present time to note that
    the needs foreshadowed in this public document have,  since the
    date of its publication,  been more or less verified by subsequent
    experiences.

         Making due allowances for discrepancies,  which might have
    been expected,  and for developments,  which could  not have been
    readily foreseen,  it may  be  truthfully said that  this document
    indicted  quite clearly and  more  or less  accurately the hospital
    needs for  the care of sick and disabled ex-service  men and -women,
    if these patients  were to receive  the character of medical service
    v/hich,  in  the judgment of the best medical minds,  was necessary
    for their  restoration to  health and which could not be satisfactorily
    given in other  than suitably constructed  institutions.

         Leaving  aside  these  considerations,  it was apparent that,
    when the Bib lie Health Service  was charged with responsibility, 
 
                              Page 26,

CUMMING (flont.)                            Tuesday, January 22,  1922.

    it was immediately necessary to meet the urgent demands suddenly
    created by the termination of the war.

         The Public Health Service,  in the manner indicated above,
    attempted,  therefore, to formulate and .put into execution a
    temporaiy program for the purpos,   of meeting immediate needs,
    leaving a permanent program to be developed in accordance with
    the appropriations and legislation..

         Without going into any more detail,  it will suffice to state
    in very general terms the work which the Public Health Service has
    done in this connection and 'which it is still doing.

         Since the inception of the work,  it has created a hospital
    system of considerable magnitude,  and is now operating some 68
    hospitals,  -with a total bed capacity of over 21,000, and expects,
    'within the more or less n^ar future,  to open additional hospitals
    and increase present facilities by something less than 5,000
    additional beds.

         This Service now has under its care about 13, 5C0'veterans
    of the World War in its hospitals.  In addition to this,  it is
    also caring for 5,000 to 4,000 Federal beneficiaries,  with whose
    care and treatment it has long been charged,  making a total of
    nearly 17,000 hospital patients under its care at the present time.

         In the development of this hospital system,  the Public Health
    Service has divided its hospitals into three large groups,  namely;
    hospitals for general medica,l and surgical cases,  for cases of
    tuberculosis,  and for cases of neuropsychiatry.   It has been un-
    able to develop this system of hospitals  with the uniformity
    desirable under the circumstances,  and has,  therefore,  found diffi-
    culty in meeting the needs of those suffering from neuropsychiatric
    and tuberculous disorders.  This demand,  however,  has of late Deen far
    more adequately met,  especially -with regard to tuberculosis.

         In addition to the development of its hospital syotem,  the
    Public Health Service,  soon after assuming its responsibilities in
    this work,  created wheat was designated as the District Supervisors'
    organization.   The united States was divided into fourteen districts
    and,  in some marge center of population in each of these districts,
    there was established a district headquarters,  with a subdistrict
    organization reaching out even to the individual counties.

         This organisation constituted a decentralizing agency,  and,
    as  such,  served a most useful and  important function,  not only in
    the work of the Public Health Service,  but also in the work of
    the War Risk Insurance Bureau.   This entire organization,  which
    had grown enormously,  was transferred  to  the Bureau of 'War Risk 
 
                               Page 27

CUl-vXNG (Cont.)                           Tuesday, January 22,  1922.

   Insurance in April, 1921, with its complete personnel.  It  is
   now operated by the u. S. Veterans' Bureau as its decentralizing
   agency and is still performing a necessary and important function
   in the work of that Bureau,

        It -was also necessary to create a greatly extended purveying
   service for supplying the necessary equipment, etc., to the hospi-
   tal system which had been inaugurated.  The Pruveying Service has
   grown enormously an±t  at the present time, is not only;purveying
   to the hospitals of this Service, but is also rendering assistance
   to the Tj. S. Veterans' Bureau in purveying for its offices and its
   medical facilities.

        The creation of an Inspection Service also became a necessity,
   in order that the hospitals of this Service might be kept under
   constant surveillance, and that all complaints might be  carefully
   investigated.  This Inspection Service has now been reduced some-
   what,  but still is functioning satisfactorily and has also render-
   ed a great deal of assistance to the U.  S. Veterans'. Bureau in
   mailing certain inspections for that Bureau.

        In addition to these matters,  the Public Health Service also
   began the creation of a large system of out-patient dispensaries
   for the care of veterans of the World War and developed  this work
   considerably.,   Up to recently,  it had in operation some  58  of
   these  dispensaries,  many cf them equipped and staffed for all
   forms  of out-patient diagnosis  and  treatment.

        The development of this  dispensary  system was & matter of
   supreme importance in furnishing the  medical  examinations- of
   veterans required for  the  purpose of  establishing  their  compensa-
   tion ratings.   This entire  service, as  stated,  is  about  to be
   turned  over  to  the  U,  S.  Veterans' Bureau  and  will,  in mature, be
   operated 'ay  them.

       In carrying  out all  of this  work,  the  Public  Health  Service
  has, of necessity, been  obliged  to assemble a  large personnel.
  The personnel at  the present  time is  somewhat  less  than it has
  been previously, by reason of the transfer  of  certain activities
  to the U. S, Veterans' Bureau, but,  with the anticipated opening
  of many new hospitals and the increase of its  facilities, this
  personnel must, of necessity,  slowly increase.

       At the present time, the Public Health Service has in this
  work about 1,700 medical officers, not including attending
  specialists.   Of these, about 950 are officers of  the Reserve
  Corps,   A Dental Corps has been created and numbers, at the
  present time,  about 180 dental officers.   A corps of female nurses
  has been assembled and numbers,  at the present time, about 1,800. 
 
Page 28
CUMMING (Confc.)                             Tuesday, January 22, 1922*

   A Reconstruction Service has been formed and numbers, at the
   present time, about 580 reconstruction aides.  A Dietetic Service
   has teen organized and numbers about 165 trained dietitians*
   These figures will give some idea of the large personnel neces-
   sary in the performance of this work.

        It is difficult to draw distinctions between the various
   classes of personnel,  bui, it may perhaps be said in general
   terms,  at the present time,  that the most difficult qualified
   personnel to secure is the medical officer.  The Public Health
   Service was peculiarly fortunate in assembling a large Reserve
   Corps.   At the close of the war,  many medical men -who had been in
   the military forces were demoolized.  Finding themselves somewhat
   adrift,  and having broken completely old associations,  they  v/ere
   inclined,  if opportunity offered,  to continue in the Government
   service.  A special appeal was made to these men by the Public
   Health  Service and inducements were offered to them to accept
   service in the care of disabled discharged  veterans.  As a result,
   the Public Health Service was able to assemble a much larger
   number  of reserve officers than could have  been done under any
   other circumstances.

        It has been a matter of great difficulty to maintain among
   these officers the necessary morale,  by reason of the difficult
   circumstances and conditions under which they are employed.
   Having  only a limited and somewhat uncertain tenure of office,
   with many uncertainties as to their future,  it is worthy of  note
   that they,  nevertheless,  have, given to the  Government a service
   which could not easily have been secured from any other source.
   They have shown a fine spirit in the performance of this duty,
   and,  as much as any set of men assembled under such conditions
   and circumstances,  have delivered a service the quality of which
   is comparatively high.   The retention of their services seems to
   me a matter of importance.

        From the inception of this work up to  date (Jan. IS,  1922),
   there have been cared for in hospital by this Service 'about
   245,000 veterans,  who have been furnished a total of about
   12,831, 000 hospital relief days.   Also,  about 1,945,000 out-
   patient treatments have been given and a total of over 1,427,000
   medical examinations have been made.  Many  special services  of
   various kinds have been rendered.  For example; about 17a,000
   jatients have been given dental treatment.   Several thousand
   patients are being given occupational therapy and several
   thousand patients given physiotherapy every week.  Prosthetic
   appliances of various kinds have been furnished to thousands of
   patients.

        The important matter of medical social service in its hospi-
   tals has not been neglected by the Public Health Service.  In
   cooperation with th. American Red Cross,  there has been organized
   an efficient medical social service,  which  has administered to
   the needs of the discharged disabled soldiers and sailors.   These 
 
Page 29.
CUM UNO (Cont.)                              Tuesday, January -1?, 1922.

   activities of the American Red Cross have been supplanted by many
   other agencies,  including the American Legion^ Knights of Columbus,
   Jewish Welfare Society, and others.  All of these agencies have
   rendered valuable assistance in the prosecution of this important
   phase of the work.

        The Public Health Service accepted a share in the responsi-
   bility for the care of discharged and disabled ex-service men,
   with a full comprehension of the privilege which had been con-
   ferred.  It has taken a pride in attempting to give to disabled
   ex-service men the very best service possible*  While its ideals
   have not always been realized,  it has,  nevertheless,  I believe,
   always treated the ex-service man with consideration and given
   him good professional service.   It is xsy endeavor that the charac-
   ter of this service shall continue to improve, and i believe that
   it does improve constantly.  No effort will be spared to render
   the very best service possible under the circumstances and condi-
   tions imposed,

        Just what the future will hold for the Public Health Service
   in this work, it is now impossible to say.  It appears,  however,
   that the Public Health Service for sometime to come will be one
   of the designated agencies for furnishing hospital care and
   treatment to beneficiaries of the U. S. Veterans1  Bureau.   This
   responsibility of supplying hospital facilities,  with all that is
   implied,  will be as adequately  met as possible*   The Public
   Health Service at the present time is operating a number of
   hospitals which,  from many standpoints,  are not suitable to the
   purpose to which they have been put.  To attempt to operate hospi-
   tals in unsuitable buildings, unsuitably located,  subjects the
   Public Health Service to unmerited criticism,  but,  since these
   facilities are needed for a time,  it will be necessary to  continue
   such places in operation.  It is not possible., under such  circum-
   stances,  to render the hijhest  type of service,  but every  effort
   will be made to render the best service possible.

        With the construction which is now going on,  under appropria-
   tions which have teen made available by Congress,  it is anticipated
   that,, in the more or less near  future,  it may be possible  for the
   Public Health Service to close  some of its unsuitable plants and
   open others of a far more satisfactory character.   This will re-
   lieve the present situation a great deal and will do much  to
   obviate the criticism which .has been made against the National
   Government because it has not supplied suitable  hospital facilities
   for the care  of  men who have 0iven so much to their country.

        In conclusion,  it seems appropriate to say  that the Public
  Health  Service,  in all of this  work,  has realized  fully the
  necessity for the  most complete and cordial cooperation with
  other governmental agencies  engaged in  it.   It has  been a  firm 
i
i 
Page 30,
  CUMMING (Cont.)                           Tuesday,  January 17,  1922.

     policy  of the  Public Health Service to stimulate an attitude of
     cooperation on the part of all of its employees.  It is a matter
     of  peculiar. satisfaction at this time to say that the Public
     Health  Service feels that, in the present Director of the
     Veterans'  Bureau,  it is receiving from him a most cordial sup-
     port in this policy of cooperation and the relationships which
     exist between  these two Bureaus daily grow better,  as they  must
     if  the  work is to  be properly accomplished.

          It is also to be noted in this connection that the recent
     creation of the Federal Board .of Hospitalization has added  to
     the administrative machinery a piece of cooperating mechanism,
     which will, undoubtedly,  do much to stabilize and coordinate,  as
     well as standardise,  many necessary things,  which,  up to this
     time, haye been carried on more or less independently.   A govern-
     ing body of this character,  which can lay down broad policies,
     influencing all of the official agencies engaged in this work,
     must of necessity  be in a position to subserve a very useful
     purpose.   The  sympathetic consideration and  support of  this  body
     should  have a  fine moral effect.

 GENERAL SAWYER:  "Representing General Wood we have Colonel  Mattison."

 COLONEL MATTISQiT read  the folio-wing article prepared by General  Wood:
     relative to the N.E,D.V.S. and its Relation  to  the  World War Veteran:

          "Of all the various agencies utilised by the Federal Govern-
 ment in carin0 for disabled men of the World War,  the National Home
 for  D.  V. S.  is probably the oldest in this line of work, dating back
 over fifty  years in its care for disabled soldiers.   Immediately after
 the  close of the Civil War,  the necessity for some  organization  of the
 government  to care for the many thousand disabled soldiers  of that war
 became  apparent, and in 1865,  by act of Congress,  the Nationa- Heme
 for  Disabled Volunteer Soldiers came into existence with a  Board of
 Managers selected  by Congress to carry cat the purposes of  this  Act.
 Prior to this,  several of the states,  civic and  benevolent  organizations
 had  talien up the work  locally in many parts of the  country,  but  the
 creation af a National Board superseded the local work  and  for quite
 a number of years  prior to the time that State homes were established
 by various  States  the  burden of caring for disabled veterans of  the
 Civil War fell on  the  National Military Home.

          The  first Home established was located  at  Dayton,  Ohio
 and was  knovm as the Central Branch,  but as the  necessities of
 the  question developeu,  other branch  Homes were  established by
 Congress until at  present there are ten different institutions
under the control  of the  Board  of Managers,  scattered from  Maine
 to California.  But  as  the  Civil War  was practicably a  war  between
sections  of the country,  all the  Homes,  with the exception  of the  one
at Johnson City, Tennessee,  are located either in the North or  on 
 
Page  31
GUT. WOOD (Cont.)                       Tuesday, January  17,  1922,

   the extreme Northern border of the South.  For example the Home
   at Hampton,  Virginia.

           Llembership in the Home was originally confined to dis-
   abled soldiers of the Civil war,  but gradually as the need de-
   veloped,  this privilege was extended to soldiers of the Mexican
   War of 1846,  the Indian campaigns,  the Spanish American War,  and
   the Philippine service,  so that by the yeafr 1917 when the World
   War occurred,  practically all disabled soldiers who had served
   in any of the wars of the Republic,  were eligible to membership
   in the H0Ke.   ^ne high tide of membership in the Home was in 1906
   when over twenty one thousand  disabled soldiers were members of
   the various Branches.  After the peak of the load had been reached
   there was quite a decided downward curve in membership owinm. to
   the advancing years and heavy death rate among the soldiers of
   the Civil .Tar,  so that by 1917 the membership had decreased to
   about thirteen thousand men,  and there v/ere in the various branch
   Homes many thousand vacant beds,  both in barracks and in hospitals.

           In this connection,  attention is called to the fact
   that the  Home functioned in a two fold capacity.   It furnished
   hospital service to the man who actually needed such attention
   and it also furnished domiciliary service to men who were dis-
   abled and prevented from tailing care of themselves in the ac-
   tive competition of life but who  v/ere net actually patients.
   This latter service is called our domiciliary service and is  a
   service that  probably will increase  very materially in its scope
   with the  passage of time,  as men  who have served  in the  World
   War,  owing to disability will find themselves unable to  meet
   the active competition of the world  outside and will therefore
   need this domiciliary service in  a very acute way.

          By the Act of October 6,  1917,  eligibility in the
   Soldiers1  Home was given to men who  had served in the World War,
   on exactly the  same terms and conditions as it had been  given
   to the veterans of the other wars, and therefore  today the dis-
   abled soldiers  of the World War stand in exactly  the same po-
   sition in their rights to care and treatment in the National
   Home as does  the soldiers of the  Civil,  or Spanish American
   Wars.   But few i^en of the World Wrar  had taken advantage  of this
   privilege prior to the year 1920  when the Sundry  Civil Bill for
   the F.  Y.  1921 gave authority to  the Director of  the Bureau of
   War Risk  Insurance,  now  the  Director of the U. S. Veterans'  Bur-
   eau,  to make allotments  to the Board of Lhnagers  of the  National
   Military Home  for alterations  and improvements of existing facil-
   ities  to  meet  the demand of hospitalisation from the Bureau of
   "War Risk  Insurance.   Such changes were thought necessary as a
   large  amount of spece  available was  barrack space which  while
   satisfactory for domiciliary service,  was not satisfactory for
  hospital  service. 
 
Page 32
GEN. WOOD (Cont.)                       Tuesday, January 17, 1922.

              Acting in accordance with the desires of Congress,
    as shown in this bill, the Board of I.fenagers at once entered
    upon an energetic campaign of construction  to prepare their
    plants for this work.  Conferences were held with the Director
    of the Bureau of War Risk Insurance,  and the statment made
    by him that the greatest need of the Bureau of war Risk In-
    surance at that time was for tuberculosis and neuro-psychiatric
    beds.  To meet this need, and to grant to the fullest the wish
    of segregation on the part of the World War men, two branch Homes
    were set aside and their domiciliary and hospital population moved
    to other branch Homes, and acting under the advice of the most
    competent experts, the Board could find,  the branch at Johnson
    City, Tennessee was changed into a tuberculosis sanatorium,  and
    the branch at Marion, Indiana was changed into a neuro-psychiatric
    sanatorium.

              In addition to the complete change of two branch
    Homes,  numerous and extensive improvements and alterations
    were made at a majority of the other Homes so that the fullest
    cooperation might be given to the Bureau of War Risk Insurance
    in its great work, and today outside of the Home at Hampton,
    Virginia,  and the one at Danville,  Illinois, which have been
    practically set aside for the older class of veterans,  adequate
    facilities have been prepared for the hospitalization of such
    soldiers of the T.'orld War as may be assigned to them for hos-
    pitalization.

              But in this connection especial attention must be
    called to one very peculiar and unique feature
    of the service furnished by the National Military Home,  cdia
    that is the fact that under the law,  the Home must care for the
    victims of peace as well as the victims of war and furthermore,
    that the gates of any branch Home are open to any disabled
    soldier of the World War and that for admission,  it is not ne-
    cessary that the disabled soldier be sent there by the U. S.
    Veterans'  Bureau or any other organization.  If he presents
    himself with his honorable discharge and the medical examina-
    tion shows disability, under the lav/ the Hone must talce care
    of him as  long as such disability exists,  this whether the dis-
    ability be one of war or one of peace.  To give a concrete ex-
    ample,  if a World War soldier presents himself at any branch
    Home with a leg or arm amputated,  under the law,  the Home mist
    take care of him whether he lost the limb in the Argonne or in
    v. Maw mill,  and this feature is one that I  think should be care-
    fully considered because it leads up to the question spoken of
    above,  of domiciliary care.   Now a man with a leg g°ne is nat-
    urally  crippled in the battle of life and cannot compete on equal
    terms in almost all professions or trades,  but still when the
    operation  is  completed and the wound healed, he does not require
    hospital treatment but comes under the domiciliary class, and I 
 
Page 33,
 GEN.  WOOD (Cont.)                          'Tuesday,  January 17,  1922.

    cannot help but feel that there are probably many hundred of
    cases along this line of disability which if transferred from
    the active hospitals of other branches of the service to the
    National Military Home for domiciliary care, will lighten the load
    very materially of hospitals where active curative work is being
    done,  and increase the number of beds available for active hospi-
    tal work,  and at the same time give the domiciliary case the  best
    of care and attention.

              This brief summary of the relation of the National
    Military Home to disabled soldiers of the World War,  leads
    one to the inevitable conclusion that the work of the Home
    in caring for these disabled soldiers is one that will increase
    from year to year and if the results of the Civil Wrar can be  re-
    lied upon,  the peak in caring for these men will  not be reached
    for twenty years,  possibly thirty would be a more correct esti-
    mate of the time.   Tn other words while it is probable that the
    hospital peak will be reached by 1923 or 1924,  and then fall  off,
    the domiciliary load is one that will grow from year to year  and
    become more and more important as time goes by.

              In conclusion,  speaking for the National Military Home,
    I  wish to state that the relations existing between the former
    head of the Bureau of War Risk Insurance,  Col.  R.  G.  Choline ley-
    Jones,  and  the present Director of the U.  S.  Veterans*  Bureau,
    Col.  C.  R,  Forbes,  have in every way been, most  pleasant and co-
    operative and  every request made by the Home  for  allotments and
    assistance  in  this  work has been most generously  and  promptly met.

GENERAL SAWYER:  "I have  pleasure  in introducing Dr.  W. A.  White, Secretary
    of  the Board  of Hospitalization,  who will address  you on the  subject
  ^  off the Neuro-Psychiatric Case  and How to  Meet  its  Requirements".  "

DR.  WHITE:

             The neuropsychiatric  problem which  the World  War  created and
   presented to the medical  personnel of the  various  branches  of the Govern-
   ment for solution, may be advantageously  considered in  three parts.

             The first part  of  the  problem consisted  of dealing with the
   conditions which developed in our armies during the war, more particu-
   larly those conditions  which developed as a result of  the  stresses of
   actual service, particularly, of-actual fighting.   This  large,  .md as
  you well know,  very heterogenous group, in some mysterious way came to
  be  labelled with the diagnosis of "shell-shock", a term which neuro-
  psychiatrically was most unfortunate, and which continues its vexatious
  existence.

             This  group of cases,  while a very heterogenous one,  consisted
  largely and  perhaps most characteristically, of a multiplicity of types 
 
                              Page 34.

DR. WHITE (Cont.)                           Tuesday,  January  17,  1922.

   of conversion hysteria, but aside  from any  attempt  to  diagnose  in detail
   the various  forms  that  "shell  shock"  took,  it  :s  sufficient  to  say  that
   this group as a whole was a group  of  acute  psychoses developed under  the
   severest  of  stresses  of service conditions  and that when  these  stresses
   were relieved, awl  particularly after the signing of the  Armistice, these
   patients  got well and to all intents  and purposes this  group as a whole
   ceased to exist and so  is rmt  today one of  our problerasu

             The second  group is  the  ^roup of  what I shall call the  ordinary
   State hospital type of  psychosis.  This includes  the type  of individual
   that we ordinarily  find in State hospitals,  that  has always  been  recogni-
   zed, that is usually  called "insane",  and that for the  most  part  was
   discovered by the army  rather  than created  by  war conditions, although
   it must be recognized that a certain  number in this group  might,  under
   the ordinary circumstances of  life, have remained stable,  at least much
   longer than  they did.   However, there, is nothing  unusual or  extraordin-
   ary or unfara: liar in  this group to the average physician of  State hospi-
   tal experience.

             With regard to the treatment of this group, however, it should
   be said that the .preat  stimulus which came  to  psychiatry because  of the
   ■war came  because the  country discovered, and was  astounded by the
   discovery, that it  had  distributed throughout  the length and breadth
   of its population a vastly greater proportion  of  defective and mentally
   ill individuals than  it had the remotest dream of.  Because  of this
   stimulus  which psychiatry received, the  matter of treatment has received
   very much more intensive thought -.with the net  result that  there are to-
   day more  well recognized agencies  for dealing  with this class of  patients
   than ever before.   Very briefly these agencies  may be considered under
   the following heads,  some of which of course are  not only  well known, and
   well recognized,  but have been used for many years,  whereas  others that
   are perhaps  equally well recognized have only  received wide application
   recently.

             The first of  these agencies,  perhaps, is the application of
   the general  principles  of medicine and surgery to the treatment of the
   sick individual.  In  other words,   the patient's general health becomes
   a problem for inquiry and appropriate consideration,  irrespective of his
   mental state, on the general theory that physical health is _t least the
   best condition precedent for undertaking a  restoration to mental  eqiii-
   brium.

             The sec ond of these agencies  is the  complement of  the first,
   and is best designated under the general term  of  psychotherapy and con-
   sists in  the  recognition of the mental disease  as such irrespective of
   whether there can be found any physical  foundation for  it  or not,  and
   on the basis  of such recognition endeavors  to deal with it as a thing
   in itself.  In passing  I may say that  theoretically the best results
   would  come if these two agencies could work hand  in hand each with
   sufficient understanding of the other. 
 
Page 35
WHITE (Cont.)                        Tuesday, January 17, 1922.

         The third agency, which has been very much broadened in its
activities in recent years, I may designate as the social agency.  It
recognizes implicitly at  least, if not consciously, that mental disease
at any rate the kind of mental disease included in the seond group,
the so-called "insane" is a disorder of the individual as a member of
the social group and that  it manifests itself largely by disturbances
of his relation to his fellows, and therefore  it becomes a legitimate
therapeutic endeavor to attempt a readjustment of these relationships.
To this end the social agency has been developed in many directions.
In the first place, we have amusements.  The simpler amusements may be
called, speaking from the  point of view of the patient, the passive
variety,- the type  of amusement that is brought to the patient, such
as theatrical performances, moving pictures, and the like, whereas
the second type of  amusement, which is more advanced and more valuable,
is the type in which the  patient himself takes part,  such for example
as theatrical performances in which he is a performer, musical programs,
in which he plays  or sings.  Then there is the group which is not after
all very widely separated from the amusement group and yet is somewhat
different, and that is the group which we might term athletic activi-
ties and which demand upon the part of the patient some initiative.
These range all the way from the simplest activities, which'are imi-
tative in nature, such as  calisthenics under the instruction of the
athletic director,  to mass games, where a large group of patients are
all engaged together in a common purpose, such as push ball,  to games
of contest requiring not  only  initiative but a relatively high degree
of efficiency, such as the tug»of-war and the various types of races
and stunts, boxing  and wrestling, and which are from time to time
advantageously staged on  a field day and receive the added stimulus
of an audience,  In addition to such activities as the above there are
also many minor ones of a similar nature, the principle of which,
however, is the same, - the social give-and-take of patient between
ward and ward, the  instruction in such things as folk dances,  and the
like.

          The fourth agency,  which has been very largely developed
recently, but which has always been used, is the agency of work. This
has been applied in approximately three ways.  The first of these is
known as diversional occupation and comprises practically the whole
field of what is thought  of by many as occupational therapy.  The
activities in this  field  consist of such work as basket weaving, leath-
er tooling, bead stringing, rug weaving, and a thousand other similar
activities.  The object of this activity is to assist in the re-direc-
tion of the patient's interests, to turn them away from  infantile and
regressive objects, and to project them again into the outer world of
reality.  Then there is the indistrial type of work therapy in which
the patient is carried still further along the line of personal  ini-
tiative and given an opportunity to do creative work which is at the
same time useful and which helps him to keep in form pending the time
of his ultimate discharge from the hospital.  And finally, there is
the vocational education  work,  which undertakes definitely and system-
atically to give a  man training in some specific direction which he  can 
 
Page 36.
DR. WHITE (Cent.)                       Tuesday, January  17,  1922.

   utilize, after he leaves the  institution, and which will have a definite
   economic value.  For this  latter v/ork of vocational training there is
   needed such psychological  advice and assistance which will at least
   prevent the wastage of  time and effort upon unprofitable or impossible
   tasks.  Whereas the vocational psychologist cannot by any rule-of-thumb-
   tests tell that a man will make a success in this or that direction,
   he can tell within reasonable limits that a certain patient cannot
   profitably undertake a  certain type of training, that his capacities do
   not measure up to the minimum requirements that would make success
   possible.  In this way  the v/ork of vocational education for the neuro-
   psychiatric case can be narrowed down so that it can be applied more
   intensively and more effectively to selected groups that can be reason-
   ably assumed to be good risks.

             The fifth agency, which can be advantageously brought to bear
   upon the neuropsychiatric  case,  is the agency for extra-mural social ad-
   justment,  and the personnel consists of the psychiatric social worker.
   With her help the patient discharged from the hospital can have the
   maximum amount of assistance for relating him again with the problem of
   self-support and self-sufficiency.  She,  through her study of his
   family situtation,  his economic status,  his industrial placement and
   socal contacts can assist  to these ends.

             The third group  of neuropsychiatric cases is like the second,-
   a group that has always been with us,  but unlike the second it is  a
   group that never before has been systematically hospitalized.   It  is  the
   group of what might broadly be termed borderland states,  comprising all
   sorts of types of defective,  delinquent,  psychopathic,  neurotic, c.nd
   mildly psychotic individuals.  Whereas they perhaps present no new
   problems when one is speaking from the platform of neuropsychiatry,  they
   do present a distinctly new group of problems from the standpoint  of
   hospitalization.  Here all the agencies which have been described  in
   connection with the second group need to be brought into action, but
   beyond them there needs to be a definite intensive study of methods for
   the new hospital problems involved.   I mention only one aspect of  the
   problem because it is one which, has  forced itself repeatedly upon  the
   attention of hospital authorities  and that is the need for an intelli-
   gent,  and J may say,  a therapeutic utilization of discipline in dealing
   with these cases,   jn this group there very probably are contained a
   reasonable number of individuals of  unsual equipment,  who,  if ear
   ingenuity  and our breadth of vision  are  great enough,  may perhaps  be
   saved  for  some  work of more than ordinary usefulness.

             One of the  medical agencies which it is contemplated to  bring
   to  bear upon this  third group of neuropsychiatric cases is  the dispen-
   sary because  it  is  recognized that there  is actual danger in hospitali-
   zing a certain  proportion of this  group,  and therefore it is much  better
   to  deal with  them as  ambulent cases.   They can be dealt with in the
   dispensaries  which  are  equipped  not  only  to take care of them,  but for
   all other  medical and  surgical conditions,  and so will get the very 
 
Page 37
DR. WHITE (Cont.)                            Tuesday,  January 17M,  1922.

   best possible attention.   There  should, however, be  connected  with  these
   dispensaries, especially  the  larger one3  in the  more densely populated
   districts, a psychiatrist with psychotherapeutic training who  should
   have a psychiatric  social worker to help  him*  If  there are enough
   patients  to warrant it  perhaps additional assistance might be  needed.

             And finally,  I  would emphasize  that  in this great scheme,
   which contemplates  the  hospitalization  of from ten to fifteen  thousand
   neuropsychiatric  cases  of the general type  above referred to there
   should be included  all  of the armamentarium for  scientific research
   and all of  the  opportunity for individual endeavor and intiative which
   is calculated to  bring  the brighter professional minds to bear upon
   the subject and to  illuminate it with the light  of their genius.  In
   order that such results may be effected as  promptly  as may be,  and with
   the highest possible efficiency,  I  believe  there should be established
   a training center for neuro-psychiatrists where  our younger men, who
   are recently graduated  from our  medical colleges,  and who have the
   inclination to  specialize in  this branch  of medicine, can fit themselves
   in a minimum period of  time to take it up as their life work.  And that
   this result may be  accomplished  I think it  important  that in extending
   an invitation to  the younger medical  men  to enter  this branch of the
   service that it should  be possible  to give  them  some assurance of
   permanency in their respective jobs,

 GENERAL SAWYER: "The subject with which  Dr.  White has dealt is so
   important that  it will  have more consideration later in the pro-
   gram, as  you will notice.

              It is  quite  necessary in the operation  of all affairs
   with which Americans or even any of the human family deal,  to have
   somebody  who knows  something of  the legislative  procedure that is
   necessary to the  conduct  of their affairs.

              Honorable Charles H.  Burke was added  to the Hospital-
   ization Board for two reasons:   first, because he  does represent
   in his great family many  hospitals, the services of  many doctors,
   likewise  of many  nurses.   He  therefore comes to us,  being a Congress-
   man of long experience, as a man who  can  deal with the subject partly
   from a professional aspect or view  of the matter,  and again with a
   thorough  and complete understanding of  the  legal side of the affairs
   v/ith which we are dealing.

              So I have great and special  pleasure  this morning in
   presenting to you the Honorable   Charles  H.  Burke, Commissioner  of
   Indian Affairs, who will  address you  briefly on  the  statutory  regu-
   lations affecting the hospitalization of  the World War Veteran."

BURKE:        Mr.  Chairman,  fellow  members,  ladies  and  gentlemen:

              I think  in the introduction  of General  Sawyer I  learned  for
   the first time  how  it happened that I was accorded the honor and the
   privilege of being  a member of an organization made  up of  such a dis-
   tinguished membership as  is this Board, barring  your humble  servant. 
 
                             Page 38

BURKE: (Cont.)                            Tuesday, January  17,  1922.

             It would hardly be  expected,  after  listening  to  these dis-
   cussions by these eminent experts  in their  particular lines,  that  I
   would undertake  to say  anything  along the scientific side  of this  prop-
   osition, and I am going to  be rather general  in what I  state in the
   short time I shall talk to  you.

            Government  activities can only exist by  reason of the law,
   and so  it will be proper to consider perhaps  or discuss  briefly the
   application of the law  with reference to the  activities  that are being
   conducted, of which  you,  each of you,  are a part.

            The responsibility for  whatever the  Government  may do in  this
   or any  other matter  rests largely  upon the  Congress.  I  have hastily
   gone through the legislation  that  has been  enacted in the  last few  .a/.
   years with reference to taking care  of and  providing for the ex-service
   men, and during  the  war for their  dependents,  and for those who might be-
   come incapacitated or disabled from  any cause.  There has been much
   legislation,  demonstrating  that  the  Congress  is keenly alive to the
   importance of the situation.  There  has been  one act after another,
   and hardly an act but what  has been  amended within a very short time
   after its enactment.

            The recent  law is  what  is known as the Sweet Bili, the lav/
   under which we a.re now  operating,  Within the memory of many who  are
   here present the appropriations  for  all purposes of the  Government were
   under a billion dollars, and  there is being and is appropriated at the
   present time nearly half of that amount for the purpose  of caring  for
   the hospitalization,  etc. of  these ex-service men.  Am I correct,
   Colonel Forbes, in the  amount of money  that is being appropriated!  It
   is a vast and large  sum of  money, and  it is the duty of  those charged
   with the responsibility of  expending  that money to see  that we get a
   hundred cents1  value  for every dollar  that has been appropriated.   This
   requires economy and efficiency,  and  traU gathering and  this organization,
   of which General Sawyer is  the chairman, was created for the purpose
   of getting better results from the moneys that are appropriated by the
   Congress; and you,  each and every one  of you,  have been brought here,
   as I understand,  for the purpose of  coming in closer contact with  those
   who are charged with the responsibility, in the first instance,  of
   administering the expenditure of this  large sum of money; and you ewe
   to this responsibility  exactly the same responsibility  as does Colonel
   Forbes or anyone else occupying a higher station than you may occupy.

            Therefore,   I am confident and  I am certain that when this con-
   ference shall have concluded,  every  person that has come here will go
   back to his  respective place where his duty requires himf with a better
   understanding and with a more determined disposition to  try and render
   better service ana get really more for  the money that is being expended
   for the purpose for which it is being expended.

            Speaking of  legislation, we shall undoubtedly  require con-
   siderably more  legislation because, as  I have stated,  in the short time
   since  this subject was first taken up by Congress think  of the progress
   that has been made. 
 
BURKE; (Cont.)
Tuesday,  January 17,  1922.
           As I understand,  in  1919  the Public Health Service were hos-
 pitalizing something  like  two  thousand persons.  General  Sawyer stated
 here today that we are now caring for twenty-two thousand; and I think
 it has been stated -  and it is  generally considered -  that the maximim
 will soon be thirty-two thousand.   So you see that it  is  more than
 likely that we are going to have to have additional legislation and
 more appropriation; and I  may  say to you generally that I have that
 confidence in the American people - I have that confidence in the Con-
 gress of the United States - to know that there need be no uncertainty
 nor hesitation  on  any one's part with reference to what may be done
 to provide for caring properly  for  these dependents and these ex-service
 men who are entitled  to every  consideration.

           I believe,  as the result  possibly of this conference,  it may
 be brought to the attention of  this Board that there is some legisla-
 tion amending the so-called Sweet Bill-  I think Colonel Forbes,  as the
 head of the Veterans* Bureau, has already discovered and suggested some
 very necessary amendments  to the lav/, and I have no doubt that he will
 be able to secure those additions to the law.  It looks now as if we
 may have to provide for additional  hospitals by the enactment of fur-
 ther appropriations of money.  It will not be done unless it is  neces-
 sary,  but I am sure if it  is necessary that adequate provision will be
 made and made promptly by  the Congress.

           One of the  policies of this administration is coordination
 and cooperation,  and  endeavor to avoid duplication in administrative
 matters;  and if there is a bureau charged with a certain responsi-
 bility and with certain duties to perform,  if it may be possible  for
 them to do what may be under the jurisdiction of another bureau,  to
 centralize and have this work done by one rather than  two; and so
 in the work of coordination in the administration of this particular
 activity there has been a great saving.   The Public Health Service,
 I  believe,  makes certain provision and takes care of certain persons
 at the request of the war VeteransT  Bureau and  vice versa.  I think it
 has been  said,  - if it is true it ought to be corrected,  - that when the
 Veterans' Bureau takes care of patients for the Public  Health Service,
 there  has been no provision made for reimbursing the Veterans' Bureau*
 That will undoubtedly be taken care  of by Congress,  either by increas-
 ing the appropriation for the Veterans' Bureau,  or  providing  that when
 they render service  for the Public Health Service,  the  Public Health will
 reimburse  them for such moneys  as they may expend.

          Now  one of the  things that I want  to  particularly bring to
 your attention,  and  to perhaps  admonish you,  in the two or three min-
 utes I have  left,  is  to  remember, as I  stated at  the outset,  that
 governmental activities  exist only by  authority  of  the  law,  and  that
 we  must keep within  the  law; and remember,  if  there are some  things
 in  connection with your duties  that  are not  operating just as  you would
have them,  that they  cannot be  changed without  changing existing  law.
The responsibility for the  law  is upon  the Congress of  the United States.
The responsibility for this great undertaking is upon the  Congress  of
the United States, and if you have not sufficient money to properly  take
care of these men, the responsibility  is not yours;  the responsibility
is  upon the Congress. 
 
Page 40
BUPJLE: (Cont*)                              Tuesday, January 17, 1922,

             It is your duty^ - it  is  our duty  to bring  to  the  attention
   of the Congress the money  that is necessary  in order  to  properly handle
   this subject.  Then it  is  for the Congress to say whether or not that
   amount will be appropriated*  Under this present administration, those
   of us who are in Bureau positions have been  admonished that  we must
   keep our expenditures within the appropriations, and v/e have had brought
   to our attention the statutes upon  this subject*  I am going to read them
   to you for your information, and _  want to say to you who may have
   charge of an institution and have had a certain allotment Of funds for
   a given period, that it is up to you to see  that your expenditures do
   not exceed that allotment.  If you  have not  sufficient money to do what
   you feel you ought to do, you must  reduce your expenditures  for the time
   being, regardless of its effect upon the service, because under the law
   you have no right to create a deficiency or  incur any liability on the
   part of the Government  in advance of an authorization and an appropria-
   tion therefor.

             I want to call your attention to the statutes  on this subject
   because they are being  brought to our attention not only by  the Presi-
   dent and the head of the Bureau  of  the Budget, but by the Congress;
   and so I want you people to understand that  v/e are expected  to follow
   the law,

             Mr. Burke read extracts from: Section 3679
                                           Act  of March 3,  1905.
                                           Section 5503.

             That, ladies  and gentlemen, is the law; and so I want to im-
   press upon you that you so conduct  your institutions that you will keep
   within the limit of the allotment that lias been made for your insti-
   tution; and if you have not sufficient money, then bring it  to the
   attention of the head of the Veterans'  Bureau or someone else connected
   with the administration.  They will consider it,  and if  it shall seem
   that more money is necessary they will not only recommend it, but I
   think I can say for the Congress that the Congress will generously re-
   spond.

             I congratulate this conference upon its start.  I hope that
   there may be a general discussion,   - that those who have come from long
   distances will tell their experiences and make suggestions with reference
   to anything that will improve this  service; and I am very certain that
   when the conference shall conclude  on its last day it will adjourn with
   a feeling that the time has been v/e 11 spent,  and that in the future v/e
   are going to profit,  and profit materially, as to the result of what
   may be done  in this  conference and  by it," 
,   ,1. 
                             Page 41.          Tuesday, January  17,  1922,

GENERAL SAWYER:   "Fellow workers, I certainly hope  that  this intro-
   duction this morning has given you  tv/o  things;  first,  that it has
   given you the impression that the men engaged at  the head of  the
   affairs of this Government  in this  subject are capable, worthy men,
   I hope it will have given you the same  inspiration  that I carry
   away this morning, - to go  on with  this conference  and with your
   work after you leave here more earnestly if possible, more sin-
   cerely if you may, and certainly with more determination to bring
   about the results we all have in mind.

      This morning you have heard the  various members  of  the Board of
   Hospitalization make their  addresses, brief of course as they have
   been and in many  instances  not entirely fair to them, considering
   the subjects they have to handle; but they have done as well as
   time will admit*

      This afternoon this conference,  under the chairmanship of  Col-
   onel Forbes will  take up a  special  subject or-two,  and will then
   go into the matter of  the general discussion of the affairs as
   they have been presented today.  We want  you to  feel  that we are
   here to listen as you have  listened this morning; and  so we are
   going to ask each one  of you to participate in the  discussions.
   We v/ant this to be an active meeting, of men in motion, so that
   when this conference does close v/e  may have the satisfaction  that
   has been expressed here by  the Commissioner of Indian Affair3»  "
General Sawyer asked that,  upon adjournment,  the members of the Con-
   ference assemble outside the building in order that a group photo-
   graph might be made.
The meeting adjourned at 12:15 P.M. 
 
!L ®. £. .° H ^  Session.
(Tuesday, January 17, 1922).
                          Pago 42.


          At  2:00 P.M.  the meeting was called to order by Colonel
 C.  R. Forbes.

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

 COLONEL FORBES:

     The first paper of  the afternoon was to have been read by Colonel
 Patterson,  Medical Director of the Veterans' Bureau; but in his absence,
 Dr.  Rawls,  of the Public Health Service, will deal with the subject of
 'Operation  of Dispensary and Dental Clinics'. "

 DR.  RAWLS:

    ,rI regret  very much  that Colonel Patterson cannot be here today,
 because he  had some very definite statements to  make about the dispen-
 sary problem  of the Veterans' Bureau.  It was only last night that his
 physical condition warranted his telephoning to  the Bureau his impossi-
 bility  to come.  In his absence I shall attempt  to give you briefly a
 plan of the dispensary  service of the U. S. Veterans *  Bureau.

    The  Veterans1  Bureau plans to establish  a chain of dispensaries
 throughout  the United States, located in the fourteen District Offices
 and  in  the  hundred and  twenty six sub-offices.

    This is  a  new idea but is the logical result  of past experience in
 furnishing  service to the patients of the Veterans1 Bureau and in pro-
 viding  adequate medical facilities.   It may not  be r.miss to trace the
 development of this idea from the time when the  Veterans1  Bureau "*as in
 its  infancy as the Bureau of War risk Insurance  and when the problem of
 securing examination reports on claimants for compensation and providing
 treatment to  patients amounted'to a grave emergency.

   No ready made  medical service existed to which the  Bureau could turn
 for  its needs.   The problems of demobilization confronted  the  Army and
 Navy. The Public  Health Service  was  presented with the neods of the
 Bureau  of War  Risk Insurance and undertook  the difficult task  of forming
 a medical organization  throughout the Country to meet  these needs.  The
 United  States was then  divided into fourteen districts with the District
 Headquarters  and.  a medical officer of the Public Health Service in charpe,
 called  a "District Supervisor",  who was directly responsible for the or-
 ganization  of  a medical staff throughout his District.  The first plan
 for medical service was the  appointment of  physicians  as de-sirn'vted medi-
 cal examiners  on  a foe  basis wherever there were claimants of  this  Bureau
 to be examined  and treated,  the  ultimate object  beinp;  to have  at least
 one designated  examiner in every county of  the United  States,   By January
 of 1920  this  object had beer, attained and designated medical examiners
had been appointed  '■.-. j-  '■• -  ci+" and town and in almost every  village of
 tv><= "*nii*~,try •

  iue District supervisors so°n  iJ^J  ohiS  a  n0St  cxPonsivo  method  of
              tho work.   The Bureau  concurrently found it  increasingly 
 
Second  Session
(Tuesday, January 17, 1922).
                              Page  43.


DR. RAWLS:  (Continued.)

unsatisfactory  in its result - an  army of physicians  widely  scattered,
whose work  was  difficult to control  and well nigh impossible to  standard-
ize.  1?he requirements of the Bureau were very  definite.  As a result,  the
Eublic  Health Service developed the  medical unit plan of  organization,
which,  in brief, was the formation of groups of physicians  in the  larger
communities to make complete general and special examinations and  to  give
careful study to cases requiring treatment.  The results  were so far
superior to any previously obtained  that the Bureau of War Risk  Insurance
urged the District Supervisors to  complete the  organization  of their
Districts along these lines and to use the designated medical examiners
as little as possible.

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

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

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

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

   Under the terms  of the  Veterans*  Bureau Act,  the Director  is  charged vrith
the responsibility  for proper examination,  medical  care,  treatment, hospit-
alization,   dispensary  and  convalescent care,  necessary and reasonable after
care, welfare of  and nursing service  to beneficiaries of  the  Veterans1
Bureau,  and  since he  is  so charged, the manner  in which dispensary and 
 
§L £ £. £ £ Si  £ £ £ £ 1 £ n                 (Tuesday,  January  17,  1922.)
                             Page 44


DR.  RAWLSs (Continued.)

reasonable necessary after care can be afforded is a matter of immediate
importance.  It is therefore proposed to establish in each District Office
and  sub-district office  a dispensary of standard type which will vary only
in size  according to the amount of v/ork in the city and surrounding
territory which it serve's.  It is proposed to establish a type of dispen-
sary to  be used as a standard which will provide facilities for a medical
clinic,a tuberculosis clinic, a neuro-psychiatric clinic, a surgical clinic
and  an eye, ear, nose and throat clinic.  In addition, there will be a
dental unit, primarily for the purpose of making accurate dental examina-
tions, and secondarily for the purpose of furnishing dental treatment.  It
is proposed to establish an X-ray laboratory and a small clinical lab orator'.
and  pharmacy.  These are the facilities of the standard type of dispensary
proposed.

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

   The initial expense involved in establishing dispensaries will necessar-
ily  be large, but once established, will not only furnish medical service
of the highest type to patients of this Bureau^ out will, it is believed,
result in an actual economy when compared with the present method of
providing similar medical service practiaally on a contrast basis.   X-ray
service  alone costs the  Government large sums annually v/hich, with the
establishment of the dispensary, can be practically eliminated.  Laboratory
service  is also an expensive item of out-patient service when performed
by contract, which can also be eliminated.  Dental treatment to which
patients of the Veterans1 Bureau are entitled under the law, is a matter of
grave concern as it is handled at the present time on account of the great
expenditure involved. This expense can be very materially reduced  if the
Bureau establishes its cam dental dispensaries where careful examinations
can  be made and definite determination of the dental disability can be made
by trained examiners. Treatment to v/hich the patient is entitled can then
be furnished either by the dispensary or performed by contract under close
supervision.

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

   It  is  believed  that the  dispensary vvith its trained  professional staff
to render medical  treatment and  to provide medical follow-up and after care
during that period when  the  patient is  undergoing the final stage of his 
IX
V
'.:•  ■   te  j
.t.'
• .i * . «, .i
■ / 
.5 £ £ £ £ 1  §. £ £ * i £ £*                 (Tuesday, January  17,  1922.)


                              Page 45


 DR. RAWLS:(Continued.)

 physical recovery and is  making his  social and vocational recovery  to  a
 life of usefulness in the community, will  meet a  long  felt  need.  It is
 believed that the period  of hospitalization can be materially shortened
 if the patient  can be discharged directly  to a woll  organized out-patient
 dispensary where  his  treatment will be  continued  and his social and in-
 dustrial rehabilitation made under the  careful surveillance  of trained
 medical groups.   The  effects of hospitalization,  prolonged  after  the
 maximum benefit has been  received, are  injurious  to  the average patient
 and if continued, soon  makes of these patients domiciliary  charges upon
 the Government*   This is  to be deplored and prevented.

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

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

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

    The establishing of  dispensary service  by the  W.  S. Veterans'  Bureau is
 therefore the logical outcome  of past experience  in  the examination and
 treatment of its  patients.   The Director is  also  enjoined by the  Veterans'
 Bureau Act to furnish adequate  medical  care  including dispensary  sorvice,
 follow-up and after care to  claimants of this ^ureau.  The matter has been
 given and is being given careful consideration in this Bureau and it is
 hoped that in the  near  future the dispensary service of tho  U. S. Veterans'
 Bureau will  extend throughout the united States,  for the convenience of all
 disabled  veterans  of the 'World War and  for  the betterment of the  treatment
 which this  Bureau  is endeavoring to give." 
.<T   •">   -',   rf 
 (Tuesday, P.M.)                               January 17, 1922.


                           Page 46


 COL. FORBES:  stated that H was believed that the dispensary was the
    type that could do everything but put the man to bed; that it was
    decided that it would require an appropriation of seven million dollars
    to put over the dispensary program; that tho Bureau has a dental bill
    of 435 thousand dollars; that the dental work is one of the big items,
    as is the x*&y service under the present contract system; that hereto-
    fore tho examiner was the workman; that the patient would go for exam-
    ination, and the examiner would say: "You have two teeth out on this
    side, and it is no use to put one in on this side unless you have the
    other two put in also; that the Bureau has had bills come in for dental
    service for one mouth in the amount of $350.00; that that service has
    been abused; that Xrray bills for one mouth have ranged from 015 up; that
    •,.>3,50 was decided upon as a general figure.

     We shall now have a half hour's discussion of the topics presented in
    today's program so far."

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

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

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

 GENERAL SAWYER:   stated  that the cofrection would be made,

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

 COLONEL FORBES:    stated that  they  do.

 SURGEON 3AHRANBURG:   stated  that he  thought  there must be  an error  in the
    figures  as given;  that at St,  Louis  they  have a 660 bed hospital, with
    an  average of  600  patients;  and that with the use of  aides  in greater
    proportion than here  mentioned, they cannot do as much work as  is  re-
    quired of them  in  that line,

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

SURGEON BAHRANBURG:   suggested  12 as  the number  of physio-therapy aides;
   and the same number for occupational-aides.   He addod a fow works
   concerning the clinic  at  St, Louis,  stating  that  they had 162  cases
   last month; that they  have an x-ray laboratory, etc., and  that  the
   cost of operation of the  dental clinic was a  little over #8000 a month. 
;   <r
"jr.  ■-•' \■.-C--V."-.
a;  ',•   •!".
;.. i W
-,■ ••■.-   •; .vr
, .  ; .   j ...  .  . .  ,.
.   •**
■.•'■ J
.1 . .  '  :   w  +
 
(Tuesday,  P.M*)                               January 17, 1922.

                          P*se 47
 SURGEON YOUNG:  inquired as to the basis on which were derived the figures
    for total per diem cost.

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

 BR. SJSNFORD:   stated that he was interested in the dental clinic in
 ~_ Denver, and remarked that the dental clinic was the hardest to handle.
    He added that their dental bill for one month vas C3760, but that their
    expenses in that connection were much less now; that they have a
    personnel of eight full-time doctors - three men in the laboratory; and
    that the clinic there is a complete one.

 COL, FORBES:  "There is no question but what the fee basis is costly. Out
    own clinics are the most economical,

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

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

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

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

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

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

COL. EVANS:  answered that that was  the provision  made, 
 
(Tuesday, P.M.)
Page 48
January 17, 1922.
 COL. FORBES:  said that he believed that the rehabilitation proposition
    is much more of a medical problem than an educational one; that
    there must be a closer medical  observation of the men and not quite
    so much education; that if the  physical disability can be removed
    first, then the man is better equipped for vocational work; that
    the man should have the maximum of hospital  treatment before he is
    put into vocational work; that  the problem is 90$ medical and 10$
    educational.

 SURGEON DEDMAN (Greenville):  stated that his place had adopted the system
    of sending a copy of the physical report of  the Board of Medical
    Officers to the social welfare  part of the Red Cross, and one copy
    to the educational department of the Veterans1 Bureau so that the
    Bureau might be in constant touch with the man's physical condition.
    He recommended that there be in the sub-offices experts on T.B., etc.,
    and thereby eliminate the sending of men to  hospitals when they have
    no trace of such disease.
    He expressed appreciation of the work of the Red Cross in his community.

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

 SURGEON STITES:  stated that the educational director at the Alexandria
    hospital is kept in constant touch with every patient there, particular-
    ly those approaching discharge.  He also stated that he was particularly-
    impressed with what was contained in General Tfood's paper with reference
    to the care and treatment of disabled veterans whoe© disability is in
    no way connected with the service; that there are veterans in his com-
    munity who need treatment, but whose disability is not connected \7ith
    service.

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

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

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

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

 SURGEON MILLER:    said he  had a  telegram saying that admittance was refUSQc
    to active  T.B.-  Dementia Fr^c*x cases.

 COL.  FORBES:  recommended  that hj?^take_jtjiis_ujj^        Surgeon General. 
1  r  '.- "• *'
' '--"WW
■ x- 
(Tuesday,  P.M.)                              Januafy 17, 1922.
                        Page 49
SURGEON 1/ILBOR:  spoke concerning the patients at Gulfport, and stated
   that many of these men lack confidence in themselves as regards train-
   ing and have to be encouraged.  He recommended that the men be given
   a partial course of training in the hospital, after discharge, in order
   to give them sufficient confidence.

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

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

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

COL. FORBES:  "Would you say that in all cases of medical doubt, a man
   should be xray'd?"

CAPTAIN BLACKTOOD:  "Yes/"

CAPTAIN BLACKWOOD:  stated, in addition, that he considered the matter
   of dispensaries a very good one.
   He also recommended that the amount of paper work for medical officers
   be reduced, as it seemed that the work they are trying to do in a
   medical way will be subservient to the clerical vrork. He stated  that
   he had reference to both Navy and Veterans' Bureau papers,

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

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

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

              represented Colonel Kennedy.

              inquired as to the number of patients at Letterman Hospital,
COL. HANIIER

COL. FORBES

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

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

                     NATIONAL LIBRARY OF MEDICINE
                         WASHINGTON, D. C 
 
(Tuesday,  P.M.)                              January 17, 1922.
                        Paae 50
COL. HANNER:  replied that the men  had been taken in and that some of
   them had been hospitalized and some not - pending authority from the
   District Manager to discharge them from the hospital.

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

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

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

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

SURGEON QUICK:  stated that he was connected with a Marina Hospital,
   which did not take T.B. or N.P, cases; that the patients were bene-
   ficiaries of the Veterans' Bureau and were mostly of the surgical
   type; and that he felt there was very little he could add to what
   had already been brought to the attention of the gentlemen present.
   He stated that he believed the large percentage of medical men would
   agree that rehabilitation was more of a medical matter than an educa-
   tional one.
   He also expressed himself os being in favor of the dispensary plan for
   the Districts; but added that he felt there must be a great deal of co-
   operation between the District Managers and the Medical Officers in
   hospitals; also, that medical officers in dispensaries should use a
   great deal of judgment in referring cases to the attending specialists.

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

COL. BRATTON:  stating that he had charge of the Army and Navy.Gen-
   eral Hospital at Hot Springs, spoke concerning the discharging of
   patients from government hospitals by reason of disorderly conduct.
   He stated that when such men were discharged they were not granted
   transportation to their homes, and therefore became nuisances to
   the  community there. 
■'■  .'"      -  i' r:
•'•  *'■'  <.,: 'i
WM 
(Tuesday, P,M.)
Page 51
January  17, 1922.
COL.  FORBES:   stated  that  there  is  a  General Order providing for the
   payment  of  such transportation.

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

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

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

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

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

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

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

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

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

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

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

COL.  FORBES:   asked Captain  Blackwood if  everyone in his hospital had  a
   disability. 
If -■   '•
-    .r>."'* +
'•'.Z  .V'"   ' 
(Tuesday,  P.M.)                               January 17, 1922.
CAPT. BLACKWOOD:  answered  in the negative; and added that at his hos-
   pital they get diagnosis varying anywhere from baldness to flat feet;
   that the man clairaa the  disability, and when the hospital cannot find
   it, the man is discharged.  He cited  one instance where a man came
   to the hospital claiming that he was  suffering from "Compensation",

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

CAPTAIN DUNBAR:  said that he came prepared to offer statistics on the
   Legaue Island Hospital,  and added that he thought that that hospital
   had been doing as  much work for the Veterans1 Bureau as any of the
   naval hospitals; that out of so many  sick days, one third of them
   had been devoted to the  patients of the Veterans' Bureau.
   Remarked that during the past year it had not been necessary to dis-
   charge a patient for disciplinary action, but that so far this year
   tv/o had been discharged  for peddling  drugs.
   He also brought up the subject of treating patients for disabilities
   other than those mentioned in the diagnoses upon admission to the
   hospital, and gave as example a case  diagnosed as "chronic gastric
   catarrh", but found to be an "ulcer"  case.  He said that in emergency
   cases they went ahead and operated.

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

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

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

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

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

COL. FORBES:  replied that transportation would be to the legal resi-
   dence or to place  hospitalized.

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

DR. GUTHRIE:  said he had been inclined to listen because he felt that
   the reactions from the field had been more than the Bureau*s,
   He informed the doctors that Col. Patterson had doomed it necessary
   to place a Bureau  representative in each hospital - the larger ones-
   in order to take care of the very things that the doctors had been
   bringing up in the conference.
   He added that many such matters would be discussed later in the
   conference in addresses. 
 
(Tuesday) P.M.)
January li, 1922.
                        Page 53


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

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

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

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

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

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

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

                  'That a  committee of five, representing each of the
                    departments, be selected to take under advisement
MOTION         the matter  of  the paper work  of the various de-
                    partments and  to make such suggestions and recom-
                    mendations  as  they: nay deem advisable; this, re-
                    garding  hospitals'.

Motion was seconded by Surgeon General Cumming.
Motion   carried. 
 
(Tuesday, P.M.)
January 17, 1922.
                          Page  54


SURGEON KOLB:   offered a resolution:

                    'That there be  established  a special  hospital  of
                    100 beds for treatment of beneficiaries  of  the
                    Veterans' Bureau who are  pronounced psychopaths
                    or drug addicts*f

Then followed  a general discussion by  Dr. Klautz, Dr. Cobb,and others
    regarding"drug addicts who  have T.B., regarding  the manner  of  re-
    taining «uch patients in hospital contemplated.

DR.  GUTHRIE:   stated that the  Bureau is investigating such a matter and
   rinvit&ii;;.6Uggestions from the doctors.

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

    Motion   carried.

DR.  FOSTERi  suggested the cutting of  the man's compensation as a means
    or help toward keeping him  in the hospital.

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

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

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

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

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

DR. WHITE:   explained  that a  man  in the  service - Army, Navy, etc. -
   could be sent  by the Secretary  of War,  02* the Navy, to St. Elizabeths
   as well as  anywhere  else; but that the  courts in the District state
   that as soon as the  man changed to civilian  status his commitment ends,
   and he is illegally  detained.

COL. FORBES:   -Jsuggested  that the question be  referred to the Legal
   Division of the Veterans' Bureau. 
n  ;-, .>♦■.,..*.-  ,<
 
(Tuesday,  P.M.)
January 17, 1922.
                     Page 55


COL. FORBES:  "The conclusion of this session precludes me from any
   further activity here.  There is a little lack of enthusiasm here.
   I v/ant you to remember that we have asked you gentlemen here by
   and under proper authority, and that it cost a good deal of money
   to bring you here, which money is coming out of my appropriation.
   Now you have got to come through with everything that is in your
   systems; you have got to give us resolutions, a dvice, e tc., and as
   long as I am coming to these meetings I want to see lots of interest
   and enthusiasm shown, especially by you gentlemen who are commanding
   large institutions.  Surely you have known lots of improvements you
   could suggest.  I want you to make such suggestions.
      During tomorrow's session v/hen we are having motions and resolu-
   tions, have something to offer.  We are here to serve the Government
   and the ex-service men,  I want you to help me, because in helping
   me in my work you are doing what the law has provided for the ex-
   service mea.,
      I have been in your hospitals, most of them and I am wonderfully
   well satisfied with the work you are doing.  I am wonderfully happy
   because of the spirit shown and the accomplishment you have made.
   You have worked against odds many times, and I know there has been
   lack of appreciation.  What moneys you need for medical service
   it is my duty to see you are allotted.  I want you to know that
   we are not opposing any of the medical activities, because as I said,
   I believe and I am aatisfied that our greatest problem in this work
   is one of a medical nature.  Of course the Veterans1 Bureau must prop-
   erly operate through its doctors, and those of-you who are handling
   this big medical problem must help me, and I must do what you decide
   is best to be done in the interests of the men,"
MEETING  ADJOURNED    -    4:30 P.M., Jan. 17,1922, 
.■   i
.?•'.";.«    ■.■;.
/ '> :*'..: 'r
:'.  •     .{■■•■*..
'J5 
Tkird  Session
(Wednesday,  Jan.  18,  1922.)
                          Page 1.


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

         * The roll was called by Dr.. ¥. A. White.

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

                        Committee on Resolutions.

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

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

                        Committee on Forms:

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


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

        General  Sawyer introduced Major General Merritte W. Ireland,
     who presided over the morning session. 
K                                iv
■.         -                           1             •' 
Third  Session
(Wednesday,Jani  18,1922.)
                               Page 2.


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

COL. P. S. &&LLORAN:   read a paper on the subject of "U.S.Veterans'
     Bureau Inspections, U, S. Veterans' Hospitals", as follows:

      The inspections of the U, S. Veterans' Bureau hospitals were former-
ly made by the General Inspection Service of the U. S. Public Health Ser-
vice.

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

     In carrying out Section 6 of the Sweet Bill which authorized the de-
centralization of the Veterans' Bureau, the Inspection Section was organ-
ized to consist of the Chief and several assistants located in the Central
Office, and an* Inspection Section in each District Office.

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

     The Chief of the Inspection Section directs and co-ordinates the
duties of all personnel assigned to Inspection Section including thos* -*"
temporarily assigned to it for special duty, for example, various
specialists at the Central Office are available to investigate mattera
pertaining to their specialty, and. for this purpose, are temporarily        V
assigned to the Inspection Section and work ur-dei*' the direction of the
Chief of the Section to whom their report is sabmit/ted.

     Ordinarily the District Inspectors mrke ail inspections -and investi-
gations v/ithin their respective districts when directed by the District
Manager or the Director of the U.S,Veterans' Bureau. Only special cases
are investigated by the Central Office„

     In general, the duties cf the Inspection Section are to make such in-
spections ..and investigations as may be necessary in order to standardize
the character of examinations, medical care, treatment, hospitalization,
dispensary, and convalescent care, nursing, vocational training, and such
other services as may be necessary for the welfare of beneficiaries of the
U. S. Veterans'  Bureau. 
 
I £ i £ 1  £ £ £ £ i £ £               Wednesday, January 18,  1922.)
                           Page 3.


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

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

     See General Order No. 28 - U. S. Veterans'  Bureau.

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

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

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

   (2)      Preparation and shipment of remains of deceased; - - - casket
         too small, shabby lining; no flag furnished;  shipping-box broken,
         due to lack of reinforcements; shroud of cheap material,
            Investigation usually shows gross exaggeration. In some in-
         stances  specifications for the casket, shroud and shipping-box
         have  been such that cheap material is provided.  Due to this fact
         the contract price  has been too low.  The Director rs willing to
         provide  sufficient  amount and desires that presentable casket and
         substantial  shipping box be furnished.
            Investigation  has  also shown that record is not always kept  that
         the remains  have  been inspected by a medical  officer,  before ship-
         ment,

   (3)       Poor-food,  especially  weak coffee, and food cold when served.
         Investigation  usually  shows fares  as a rule,  are good, the com-
         plainant usually being tired of institutional menus. 
;; t-:y:A:A.
 ; . •.    ;,•••.•■' >•>*'

';     .  '   't '

,V".'U   '. t! v
.••■ilh  :i'
... •"' ,";'*a  '= i.    *■;;••»:;-:    ^M":
  '•*".'" .  C. ":. ' .' :.'"•■;  ":..'XC •  • ■  Wi' '  V
-■  ■•' *   '\ ■■-.'"   f?    ■""■  "*   ■''.^ • "* "■   C
- '.< J7.W"V' .'    ;'W*:". '  ^ '  i -' ".'. Y '! '' '.'■"
?-"   ;, /  '/  avo"<

»f
.  ;*-.£■
% , 
T h ird  Session.
(  Wednesday,  January 18,  1922.)
                             Page  4,

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

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

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

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

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

    (9)      Rest periods  not enforced,

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

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

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

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

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

    (15)     Bed linen not changed  sufficiently often.


            In general, the  above  list of  complaints are rarely received
from Governmental  Institutions.  WThen Inspectors have found unfavorable
conditions effecting the welfare  of the beneficiaries of the Bureau in
Governmental Institutions, prompt  remedial measures are usually instituted
to correct the conditions by  the Commanding Officer of the Hospital." 
..   <■„„  .  -.,  f,
•*   *■;;
/  ■  i
f ;
• ' <•
■  ■..•U'v..
.  ■(
i  , JV
■.*>••■.•  i  ;•.
■'*.*'■ a: 
                                                  File No. S9960
UNITED STATES VETERANS* BUREAU.

                                                  September 9, 1921.

                 GEIIR^L  ORDER  N 0. 2S


Subject:  STANDARD OF REQUIREMENTS FOR HOSPITALS.


          The following General Order is hereby promulgated, ef-

fective this date, for the .guidance of all officers and employees

of the Unitad States Veterans' Bureau:

          Minimum requirements have been adopted for all institu-

tions furnishing medical care and treatment for patients of the

United States Veterans' Bureau, including hospitals under contract,

as follows:

                     REQUIREJSiTTS ~0R ALL HOSPITALS

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

2*  There should be an organized medical staff composed of men
    competent in their respective fields of medicine and actively
    meeting their responsibilities for tho direction of the
    professional policies, for the w.adical v/ork of the institu-
    tion and also for the professional care of the patients in
    the hospital.

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

^.  Resident trained nurses - not less than 1 for each 10 or any
    part of 10 bed patients,

5.  There should be facilities and personnel for the proper ad-
    ministration of dietetics. 
 
G. 0.  28 Page 2.
6.  There should be periodic staff nestings to discuss -

      1.  Errors of diagnosis.
      ?   Unsatisfactory results of operative or medical treatment.
      3.  Autophy results.

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

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

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

10.   One hundred square fe^t of floor space for each bed and
      distance between beds    5 feet.

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

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

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

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

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

16.   The systematic  use of occupations for their therapeutic ef-
      fects,  under the direction of workers specially trained for
      this duty. 
 
G.  0, 28 Page 3,
17,  Special attention to recreation and diversion with reference
     to their therapeutic value,

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

19.  No charges to be made for patients absent from hospital  for
     more than 2^ hours.

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

         ADDITIONAL REQUIREMENTS FOR TUBERCULOSIS HOSPITALS

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

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

3.   Suitable rules proscribed for conduct and published rules
     providing for a satisfactory regimen of treatment in tuber-
     culosis hospitals.

U,   Satisfactory treatment conditions, including measures  for
     enforcing suitable discipline and to prevent absence without
     leave and to prevent excessive exercise,  whether  from  aaiuse-
     ment or otherwise.
         ADDITIONAL REQUIREMENTS FOR NEURO-PSYCHIATRIC HOSPITALS

1,   Direction of the administration of the hospital and leader-
     ship in its medical work by physicians trained in the- diag-
     nosis and treatment of mental diseases,

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

3»   Regular and frequent conferences of tho medical staff at which
     the diagnosis, treatment and prognosis of each new case ad-
     mitted arc considered and at which cases about to be discharged
     are presented, training in psychiatry for now members of the
     staff being considered as a special object. 
 
G. 0. 28  Page 4.
4.  The reception of all new cases in a special department or
    in special wards where they way receive careful individual
    study and where those with recoverable psychoses way receive
    continuous individual treatment.

5.  Classification of all patients with reference to their^
    special needs and their clinical condition, such classifi-
    cation being flexible enough to permit frequent changes*

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

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

 3.  The  employment of  female  nurses in  all  reception and  in-
 firmary  wards.

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

 10. Special provision for  the tuberculous.
          If, after written notice has been given, any institution

furnishing medical care and treatment to patients of the United

States Veterans' Bureau fails or refuses to make reasonable effort

to meet the foregoing requirements, such institution v/ill be

deemed to be rendering unsatisfactory service, and if under contract

with the United States Veterans' Bureau, such contract may be can-

colled, and the Director will refuse to make contracts when the

care and treatment offered do not  substantially meet the require-

ments specified herein.
U. S. Veterans'  Eureau. 
 
Third  Session.                (VJednesday, January  18,  1922.)
                           Page 5.


SENIOR SURGEON B. J. LLOYD, (U.S.P.H.S.,(R): presented the second paper,
   entitled "Admissions to, Transfers and Discharges from Hospitals of
   of Beneficiaries of the U. S. Veterans' Bureau, which is given below:

        "I do not often speak in public.   Occasionally I attempt to
   speak extemporan?caely, but today I shall claim your indulgence and
   confine my remarks strictly to v/hat is written in this manuscript,
   for the reason that if taken in a disconnected sense some of the things
   I shall say might sound sensational, whereas if taken in a connected
   sense and in the way I shall say them,  I think you will agree with me
   that there is absolutely nothing sensational in my remarks.

        Attendance at this conference is  indeed both a privilege
   and an opportunity.  To be asked to address this gathering is a
   distinction worthy of the best that can be said on the topic assigned.

        I take it that you are already familiar with the rights and
   benefits to which the disabled ex-service man is entitled; that you are
   familiar with the usual routine of paper v/ork and other procedures in
   admitting, transferring and discharging, and I shall therefore omit
   some of the more or less definitely settled, fixed policies in this
   discussion.

        I fully realize that my subject is an extremely important one
   and that it is in a measure connected with nearly every benefit extended
   to the ex-service man or v/oman, and with every service that is rendered
   in his or her behalf.   On the intelligent administration of the
   functions of admission, transfer and discharge to, or from our hospitals,
   as the case may be, depends,  in great measure, not only the economical
   and efficient administration of our entire hospital program, but in
   equal measure the recovery, the health, the happiness, the future use-
   fulness, even the very lives  of men and women, many of whom have made
   great sacrifices and passed through great agonies.

        When I make these assertions,  do not think for a moment that
   I  am comparing these functions  v/ith the actual volume of work that is
   done in the hospitals, with the relief  that is given therein,  nor with
   the benefits which accrue to  the patient,  but, just as victory in a
   great battle may depend on the  placing' of the right troops in the right
   place at the right time,  so victory, in the struggle of the disabled
   ex-service man for rehabilitation,  for  health, or for life, may depend
   on his  beingreent to the  right  hospital at the right time.  Neither
   must he be discharged  too soon,  nor kept too long, and when he is
   transferred from one hospital to another there should be sound medical
   reasons therefor,  barring those  unfortunate cases, v/here the beneficiary
   may be  transferred  to  a hospital near his home when it is  seen that
   death is  inevitable. 
.. I

,'J." ..'id'-'   '.»■
r t    •..•
- f V
!"."   1
cr"
t :•. i,;.
i 
! £ i I i  i££££££              (Wednesday,  January  i8,  1922.)

                           Page 6.

LLCYD:  (continued)

        Goingtbeek now to the contact which hospitalization makes,
   or should make, with the  other benefits extended to the ex-service man,
   let me picture to you the state of our past, and to a  great extent,
   our present organization, by recalling to your minds the old story of
   the six blind men of Hindustan who went to see the elephant, each trying
   to tell what the elephant was like.  The first man got hold of the
   elephant s ear and said that the animal was very Wlike  a fan; the second
   got hold of his leg and said, "No, I can't agree with  you; this elephant
   is like a young tree."  The third man got hold of the  elephant1s trunk
   and said, "The elephant is like a snake."  The fourth  man grasped a
   tusk and said that the elephant was like a spear; the  fifth fell against
   his side and said he was  like a wall; and the sixth got hold of his tail i
   and said he was like a rope.  Now all were partly right and each was
   mostly wrong, and a somewhat similar condition exists with regard to our
   work.

        This meeting, gentlemen, is an attempt to further co-ordinate
   the efforts of all the agencies that are at work for the ex-service man.
   Ours is a tremendous responsibility, both from the standpoint of our
   duty to the ex-service man and of our duty to the taxpayer as well.

        No man except the man in the field knows better than I do  that
   you have been circularized and regulated and instructed and uninstructed,
   informed and misinformed, ordered and dis-ordered, until I have no doubt
   you have been tempted to  slam your fist down on your desk and say,"well,
   for Heaven's sake, how many bosses have I, anyway, and which lead had I
   better follow,"  And as for reports, no doubt you have wondered, "T7ell,
   what will they v/ant to know next?" And yet there has generally  been a
   fairly good reason for every question you have been asked and a reasonably
   intelligent, honest, and often an enthusiastic, and sometimes an efficient
   man or woman behind the interrogation point.

        In addition to having all these things done to you,  I suspect that
   you and your colleagues in the hospitals,  some of you at least, feel
   that you have been libelled and slandered by newspapers whose editors
   thought they v/ere  telling the truth,  and by newspapers v/hose editors
   probably did not stop to consider v/hether they were telling the truth
   or not.   You probably feel that you have been libelled and slandered,
   unintentionally of course, by men inside of legislative halls,  and also,
   again perhaps unintentionally,  if carelessly,  by men and women  outside  of
   legislative  halls,  and by men and women both inside and outside of well-
   meaning  civic organizations.   And, I  may say that in the Arlington Build-
   ing  in  this  city there are reams of evidence v/hich might be cited in
   support  of your beliefs,  and  at  "C"  Building at 7th and B  Streets,  there
   are  tri-remes  of such evidence,  and these  reams and tri-remes of evidence
   have  cost the Government  of the  United  States  thousands,  tens of
   thousands., yes, hundreds  of thousands of dollars  for investigations,  when
   as a matter  of  fact,  the  majority  of  the complaints that  have been filed
   against hospital administration  need  never  have been investigated by  the 
 
Third  Session
(Wednesday,  January 18, 1922.)
                            Page 7*

LLOYD:   (continued)

   Government at all if the individual who submitted the  complaint  had
   taken the trouble to do a  little honest investigating  on  his  or  her
   own account*

        The fact that these statements have been made with the best in-
   tentions in the world does  not  lessen'the  injustice  contained in many
   of the chargea, nor does it remove the sting which has accompanied these
   charges, and you, gentlemen, have listened to the soft pedal  on  the in-
   side and to jazz on the outside until you  have  probably said, "For the
   love of justice, is there  not some man who has  grit  enough to get up in
   public and  tell the truth  and say what he  thinks?"

        But, gentlemen, it will not always do to talk back.  Actions speak
   louder than words, even though  they do not make as much noise, and
   Solomon v/as right when a few centuries  ago he remarked that "A soft
   answer turneth av/ay wrath." We must  always maintain a courteous,
   gentlemanly,  dignified attitude.  We  must  never for  a moment allow our
   sympathies  for  the deserving unfortunate ex-.service  man to become in the
   least weakened,  and we must continue  to give him the benefit  of  the doubt
   in borderline cases,  and  finally v/e must maintain our  equanimity under
   the  most  trying  circumstances.

        And  now  that we  have  you here, we  are going to  ask you  some more
   questions,  and  I hope you know  the  answers, because  I  don't know the
   answers to  some  of these  questions  myself, nor  do I  intend to answer
   them.

         In passing,  I might  remind you of  the fact that in times past we
   have spent  money very freely  on our hospital  program,  and that while
   v/e still  desire  to give  our beneficiaries  what  is perhaps a  little more
   than reasonable  medical  and surgical  care  and  treatment,  at  the  same
   time we must  be  able to show Congress that we  are operating  economically
   under  present conditions,  and certainly, when not in conflict with the
   patients'  rights or interests,  the  question of economy of administration
   must be  considered in admitting,  transferring  and discharging.  Are we
   giving this question of enenomjp. of administration the  proper  considera-
   tion in  performing these  functions, and if not, vrhat are  the  reasons? T7e
   want to  know.  This I v/ill label "Question No.  1,"  and let you think  it
    over for  a  while.   It is  perhap not the most important question I shall
   ask but  it  is important.

         Nov/,  having delivered myself of  this  question,  and not having
   answered  it,  I suppose you are ready  for Question No.  2.   Well,  I am
   not. I want to talk a little  before 1 sprin| the next question.  Of
   course we  all know that the primary object in placing a man  in a
   hospital  is to  give him a chance to get well,  or as nearly well as
   possible.  This,  however,  is not the only thing to be accomplished in
   the  hospitalization of patients of the Veterans' Bureau, and, if I may 
 
Third  Session
(Wednesday, January 18, 1922.)
                              Page 8.

LLOiD:  (continued)

   speak frankly, I may say that, while theoretically, hospitalization,
   rehabilitation, and the awarding  of compensation ought to dovetail into
   each other without any overlapping or getting in each other's way, as
   a matter of fact they won't do it, - at leafct they haven't done it so
   far^ but, nevertheless, we've got to make the best possible connection
   between these functions.

        Let us hark back to Regulation No. 57 of the old Bureau of War Risk
   Insurance, v/hich gave temporary total disability to the beneficiary whose
   disability showed Service connection, together with compensation at this
   high rate as soon as the man entered the hospital, and which cut down
   this compensation anywhere from $80 per month to nothing at all as soon
   as the beneficiary left the hospital.  Although this Regulation has
   been somewhat modified recently,  it is still a very strong incentive for
   men to seek hospitalization.  It takes an unusually patriotic citizen to
   030 to C>60 a month or less when he can get C>80 a month and board and
   lodging if he can remain inside of a hospital.

        Apropos of this provision, I recall the circumstances of a young
   man who came to me quite some time ago, having left the hospital at Fort
   McHenry,  He presented himself in a courteous, dignified way, was per-
   fectly serious and absolutely frank.  He began the interview by handing
   me the card of a U. S, Seantor.  Then he told me his story, and it was
   a good story.  I shall try to recall it as nearly in his own language
   as possible.  "Doctor", said he, "I have just left your hospital at Fort
   McHenry.  I do not like it.  I realize that the Public Health Service is
   not to blame for conditions which I found, there.  It is not suited for
   a hospital.  It is badly located. There are odors which it seems yjR  .s: j.. .c
   impossible to overcome.  The walls and floors are dingy, and vhile they
   are clean, they cannot be made to look clean,

        "i wqs shot through the stomach by a machine gun.  Here are the
   scars.   If I do not work hard I feel fairly comfortable, and yet I am not
   well.  I receive $30 a month when I am outside the hospital. I receive
   C80 a month and my board and room when I am in the hospital. Personally
   I would much prefer to remain at home, but when I v/ork hard enough to
   make a living I break down.  I have seen so many men in the hospital who
   are receiving their board and lodging and their 080 a month v/ho are not
   as Reserving of this as I am that I do not propose to remain at home and
   work on my present compensation, and * would just like to see you keep
   me out  of a hospital.   And furthermore, I demand to be sent to the
   hospital of my choice.  What are you going to do about it?"

        I  replied, "Young man, you have been unusually frank in *vhat you
   have said.  I shall be equally frank with you.  If I had been wounded
   as you  have,  and if I  had the information which you have gained from your
   stay in different hospitals, I should probably make the same demands.
   You can have  your transportation whenever you want it," 
•:  , Vi   "7.,-r'.   .  •■-■•:v-;
v.f...>   .-»     -a;-W
■ (..*•
? t .-<■■■ •
'."' '   ..i '^
•.;  a a a.-'
   v. ,.  -. 4 ■

"   at W '
*. •.•». er*a'
::-•>.::   <  I

.  A  .
'a r
<cv.»  -v'"'
t    .-iU
i .'.'  W. ■ '■' .'.,
" ■*  w;  " -v  ^

;' :'f '.»•■; 
I.m££<L  £££££££                   (Wednesday,  January 18,1922.)
                             Page 9.


LLOf D:  (continued)

   t saw this young man later at No. 38  in New Ycrk  and  he  told me  that
   he was about to got what he considered a  satisfactory rate  of  compensation,
   and that as coon as he could get it he would  go home.

        Question No. 2,   How '.'.any men are there  in  our  hospitals today who
   would volantarily leave if we did not, by providing total disability
   rating and compensation while in tho  hospital, place  a premium on their
   remaining there?  Her: many of those v/ho v/ould  leave really  ought to leave?
   What can be done to correct the defects in the operation of Regulation
   No, 57, modified as it has been?  Perhaps you  think I am giving you
   several questions in one, but -re will still label  if  "Question No. 2."
   I am not alone  in desiring to know the answer  to that question*

        Before I go any further l.-t me soy that  I regard admissions,
   transfers and discharged as such closely related operations that I shall
   not attempt to  treat them separately,but  shall discuss them in any
   sequence that may be convenient.

        I assume that all of you havo been advised that  under  General
   Order Wo. 59, the allocation, distribution and transfer  of  patients of
   the Veterans' Bureau are functions and prerogatives of that Bureau.
   Theoretically,  none of the Services has anything to say  about  these nat-
   ters.  Practically, if I have not misunderstood the intent  of  this Gen-
   eral Order, it  does not mean that, altogether.  The actual  authority
   for fend the right to refuse transfers certainly is vested in the Veterans'
   Bureau and its  representatives, but the Veterans'Bureau  and the District
   Medical Officers and District Managers depend on you  to  tell then when
   you think transfers ought to be made.  Admission to a given hospital is
   the prerogative of the Veterans' Bureau within certain limits; that is,
   the Service concerned must be able to take and care for  the class of
   patient sent by the Veterans' Bureau.

        With regard to the discharge of  patients fron hospitals,  the Veterans1
   Bureau is continually encroaching, perhaps unavoidably,  on what was once
   the prerogative of the1 Medical Officer in Charge and  the Service which
   operated the hospital.  Blanket authority for field transfers  from one
   district to another has been entirely withdrawn, and  District  Officers
   must either place immediately in an authorized hospital  in an  adjacent
   district, as specified in General Order Ho. 59, or, having  placed for
   observation or diagnosis a patient in a hospital within their  own dis-
   tricts, nust apply to the central office if it is  desired to transfer
   later*  It is, or should be, understood that under the present regime,
   that Medical Officers in charge of hospitals who regard  transfers as
   necessary must request the District Office to make these transfers if
   within the district, and must request the District Offices  to  obtain
   authority from the Central Office if  it is desired to transfer outside
   of the District. 
 
Third  £ £ £ £ 1 ° E                  (Wednesday,  January 18,  1922.)

                             Page  10.


LLOYD:   (c onti nue d)

        Several  questions  suggest  themselves with regard to General
   Order No. 59, and perhaps I  should  label this  series of  questions  "No.  3,"

        (a)   Has  General  Order No.  59 lessened the  number  of ill-
   advised and unnecessary transfers,  which is  one of  the objects, I
   believe, that were intended  to  be accomplished.

        (b)   Has  General  Order No.  59 caused any marked fluctuation'"
   in the patient  personnel of  any of  the  hospitals? I notice,  for
   example, that Public  Health  Service Hospital No.  53, Dwight,  111.,
   ljas recently  dropped  from      occupied beds  to  65 in number,
   giving a surplus  of 165 unoccupied  beds.   Houston, Texas,  has
   dropped from       occupied  beds  to 443 beds,  giving a surplus of 528
   unoccupied beds.  At  No.  32, Mount  Alto, Washington, there  is a ward
   for colored patients which will accomodate 30,  in which  there are
   only 6 colored  patients at the  present  time.   Are these  fluctuations
   coindidences  or are they the effect of  the Veterans1  Bureau having
   assumed the functions under  discussion.  Of  course  if v/e  could be sure
   that these reductions in patient  personnel are  going to  be permanent
   it v/ould not  make any difference.   We could  cut down our v/orktng
   personnel at  a  hospital like Houston, Texas, and v/ith the consent of the
   Veterans' Bureau we could close a hospital like Dwight,  111., but will
   the pendulum  swing in the other direction again, and what advance in-
   formation can the Veterans'  Bureau  give these  fluctuations and of
   their approximate duration?

        (c)    Have you received very many  patients who,  owing to their
   condition or to the nature of your  facilities,   or both,  should
   never have been sent to your hospital?

        (d)    Has General Order No. 59 tended to delay  the turnover
   in those  general hospitals having special wards for  psychoneurotic
   and psychotic  patients,  who are detained for a'short time only until
   they can  be otherwise disposed  of?

        (e)    Should  General Order No.  59 be modified,   and if so,
   in what particulars?

      Having  delivered this third volley of questions,  I shall talk a
   little more.   I  have  no  idea v/hat opportunities you  gentlemen have had
   to become  familiar v/ith  the  facilities at hospitals  other than your ov/n.
   I  have no  idea v/hat information District Managers  and District Medical
   Officers have  of hospitals and conditions in Districts other than their
   ov/n.  General  Order No.  59 of course attempted  to  convey some idea of
   the facilities in  all  of the  hospitals used  by  the Veterans' Bureau,
   but it was  impossible  to incorporate anything like a comprehensive 
 
1. 2l £ £ £  £££££££                   (Wednesday,  January 18,  1922,)


                            Page  11.


LLOYD:  (continued)

   statement with regard  to these facilities.   Quite recently, at  the
   request of Dr. Gutai-'.e, and with the  assistance  of men in both  Bur-
   eaus, I prepared  a  questionnaire for  all the hospitals, asking  v/hat
   your general  conditions and  facilities were  .like.  Moot of the  hos-
   pitals have answered this  questionnaire, and the information obtained
   is exceedingly valuable,   Practically without exception the answers
   have been concise,  complete  and exactly v/hat was asked.  Those  of
   you. who have  not  answered  please do so as soon as you can.  I wish
   it v/ere possible  to print  or mimeograph these reports and distribute
   them.  Certainly  anyone v/ho  is charged with the  responsibility  of
   placement and transfer of  patients  should have access to these  reports.
        While  I  am on  this subject of  facilities, let  me invite attention
   to the fact that  there are narked differences in the  kinds of facilities
   offered by  different hospitals and  by the hospitals of the different
   Services,  Let me also invite  attention to  the fact that we have
   patients who, if  properly  distributed, would fit into these different
   institutions  possibly  in a much more  satisfactory way than at present
   and at a smaller  expense.  Particularly I suspect that there are  many
   patients in Public  Health  Service hospitals that do not need the
   highly specialized  and necessarily  expensive care that these hospitals
   arc giving, and I also suspect that there are many  vacant beds  in our
   Soldiers'Homes whore these patients can be  given all  they need  at a
   much less expense than is  possible  in the highly developed hospitals
   of the Fublic Health Service,  and possibly  those of the Army and  Navy
   bob well.  Why v/ould not this be a good time to arrange for the  prompt
   transfer of such  patients?  Europe  has found the Convalescent Home
   to be an economical institution, being much less expensive than the
   hospital.  Why may  not our Soldier's  Homes  be used  for convalescents  and
   those who need relatively  little medical care and treatment, but  v/ho
   are still not well  enough  to be thrown on their  own resources?  These
   questions I shall not  number.   They .just crept in.

        There  is one class of beneficiary that none of the Services  seems
   to be prepared to handle satisfactorily,  possibly due to the fact that
   legislation is needed  to deal  v/ith  this class.   There may be a  solution
   other than legislation but none of  us  has thought of  it as yet. I
   refer to the  drug addict who is entitled to hospitalization for some
   Service connected disability.   We haven't any place to put such patients
   and we do not know what to do  with  them after we put  them there.  We
   do manage to  take care of  some of them but  at great inconvenience,
   and without being able to  treat them  for their ov/n  best interests.  We
   cannot get them admitted as irresponsibles  by the Courts,  We have no
   such thing as voluntary committment,  and  if one  of  them desires to  walk
   out of the hospital, out he walks if  he is  persistent enough about  it,
   and we cannot stop  it.  This is a good time to say  something about what
   we might to v/ith  these cases. 
1 -
>.:-..-.
> ■ i
 
Third  Session
(Wednesday, January 18, 1922.)
                             Page 12.

LLOf£:  (continued)

         I have said very little about discharges for the reason that
    disciplinary discharges are to be treated by another speaker, and
    Regulations Nos. 26 and 26-A, bearing on this subject are to be
    discussed by Doctor Guthrie, v/ho follows me on the program.  I will
    say, however, that this subject is an important one and I can easily
    understand that from the standpoint of the man in charge of a hos-
    pital present procedures with regard to discharges are unsatisfactory.
    On the other hand^ I can understand that v/hen a man is in a hospital
    it affords an excellent opportunity to settle once and for all his
    claims for the various benefits provided by law, and yet I think
    it is right that the Veterans* Bureau should accomplish these obiects
    before the man is ready to be discharged.  As yet this is not being
    done.

         In conclusion, Gentlemen, I may say that as I see it, those
    of you who are in charge of hospitals are, if you v/ill pardon the
    expression, between the devil and the deep blue sea. You are told
    one minute that if you exceed you allotment you v/ill go to jail,
    and in the next breath you are told to go the limit if it is for
    the ex-service man.  You have been told that there is room for im-
    provement in your hospitals.  No doubt there is, but in my humble
    opinion there is also room for improvement in the laws providing
    these benefitss in the orders, regulations and procedures designed
    to administer these lows, and last but not least, there is a crying
    need for some meaiis of creating a sane public sentiment that  will
    enable the public servant to discriminate between the man who really
    has a serious disability v/hich he got in the Service who deserves
    our help and out sympathy, and to v/hom you and I would give the
    shirts off our backs if need be, and the man who spent a few days or
    a few weeks in camp who is not really disabled but who proposes to
    live at the expense of the tax payer just as long as he can get
    away with it.

         We, Gentlemen, are not responsible for the law, nor is the
    Director, and the Director has men who tell him what the lav/ is and
    he has to obey it and so do we, but it is our duty to point out
    defects in the law and try to get them remedied," 
 
Third  Sessio.n
(Wednesday, January 18, 1922.)
Page 13,
SURGEON M. C. GUTHRIE  (U.S.P.H.S.) had for his subject, "Discussion -
   General Order No. 2o", and spoke as follows:

        "The subject assigned to me for discussion is General Order No. 26.
   This refers to U. S. Veterans1 Bureau General Order No. 26, dated Septem-
   ber 6th, 1921, the  subject of which is: "Admission to and Treatment in
   Hospitals of the U. S. Veterans1 Bureau Beneficiaries."  You are doubtless
   all familiar with the general provisions of this order.

        It goes without saying that any definite order or instruction which
   effects the policies and functions of the U, S. Veteransi Bureau and ~hich
   may be issued to the field is sure of a series of return re-actions from
   various parts of the country, both os to the manner in v/hich such an order
   is applied and as to the c*?nsoquoncesof its application.  These re-
   actions are naturally good, bad, and indifferent; exact and truthful state-
   ments or colored as to the manner in v/hich they affect the various  individ-
   uals in its application, but coming from all parts of the United States
   they afford many valuable and effective criticisms of the order in  question
   and are illuminating as to the original intent of the order and the  amount
   of deviation or variation from its. original purpose brought about by the
   manner in which it is put into effect.

        Hie criticisms  of General Order No.  26 had to do very largely with
   the "Four Days'  Notice"  clause,  and because of the fact that large  num-
   bers of beneficiaries in hospitals  were being  discharged without pro-
   visions having been  made  for  out-patient  care,  dental care,  physiotherapy,
   or other treatment where  such was  indicated and necessary; that patients
   were being  discharged without having  proper arrangements made for voca-
   tional  training where the  patient  in  question was  feasible for  some  kind
   of training  and was  anxious to get  it;  that many  such patients  had to leave
   a  hospital when they were  receiving no  compensation  or where adjustments
   or readjustments  of  matters related to  compensation  needed to be carried
   out here.

       These were the  dominant  and outstanding criticisms which followed
   the  issuance of General Order  No. 2 6,  and as a result of these  criticisms,
   it was considered  advisable to issue a  supplemental  order  correcting the
   defects complained of.  Accordingly General Order No. 26-A came out under
   date of November 17, 1921,

       The re-actions to General Order No.26 were as I have just  stated and
  came largely from the Bureau beneficiaries, from friends, relatives, and
  allied, agencies working in the field.  The criticisms of General Order
  No. 26-A, hov/ever, came largely from the hospitals and the District offices
  the hospitals particularly. There was an apparent contradiction between
  the tv/o orders. No. 26-A seemed to  largely or entirely contradict the
  provisions of the  original Order  No. 2 6.  General Order N0. 26 stated that
  patients not  requiring further hospital treatment should be given four
  days to  complete personal  arrangements and then he discharged. 
 
Third  Session
(Wednesday, January 18,  1922.)
                            Page 14.

GUTHRIE:  (continued)

   General Order No. 26-A requires that before a patient is discharged
   from hospital it should be determined whether or not he is in further
   need of out-patient care; whether or not he is feasible and eligible for
   vocational training and if he wanted training,that this should be ar-
   ranged before he is discharged, and that the necessary adjustments or
   re-adjustments of all matters pertaining to a claimant's compensation
   be entirely completed by the time of his discharge from hospital;
   and further it must be distinctly understood in carrying out all of this
   that no unnecessary delay in discharge of patients would be allowed.  A
   pretty complex and contradictory situation you might say.  However, between
   the time of the issuance of General Order No.  26 and of General Order No.
   26-A — to be exact, on October 14, 1921, a general order  was addressed
   by the Medical  Division of the U. S. Veterans1  Bureau to  the several
   Government services — the Surgeons General of the Army, Navy,  U.  S.
   Public Health Service, the superintendent of the National  Homes for Dis-
   abled Volunteer Soldiers, the Superintendent of St. Elizabeth's Hospital,
   and to the fourteen District I'lanagers.   The essential parts of  this letter
   are as follows:
October 14, 1921.

PSR/jcs L 10-DIIO
District Manager,
District No,  1,
U. S. Veterans' Bureau,
101 Milk Street,
Boston, Mass.

Dear Sir:

        Referring to General Order No. 26 and to Paragraph No. 2,
which reads as follows:

        "All patients now in hospitals in your District, who do not
require further hospital treatment, will be given four days notice
to make their personal arrangements and will then promptly be dis-
charged from hospital.  Each patient discharged under existing
Regulations will be furnished transportation to hio bona fide legal
residence in the United States or to the place from v/hich he was
hospitalized.  Notification of such discharge will be sent immediately
by the Officer in Charge of the Institution caring for beneficiaries
of the If. S. Veterans'Bur -au to the District Manager of the District
in which the institution is located. 
 
itili  i£££l££                   (Wednesday, January 18, 1922.)

                             Page 15.

GUTHRIE:  (continued)
        In complying with these instructions and before author-
izing discharge of patient of the U. S. Veterans1 Bureau from hospital,
District Managers v/ill determine?

        1st.  Whether the patient is in need of out-patient,
              dental, physiotherapy, or other treatment, or
              convalescent care.  If so, District Managers
              will make the necessary arrangements to con-
              tinue the treatment indicated after discharge
              of the patient from the hospital.

        2nd.  Whether the patient desires vocational training:
              If so, his eligibility and feasibility will be
              determined and arrangements made for placing him
              in training promptly upon his discharge from
              the hospital.

        3rd.  Necessary adjustment or re-adjustment of all
              matters pertaining to his compensation will
              also be completed promptly upon his discharge from
              the hospital.

        In order to accomplish the above patients of the U. S.
Veterans' Bureau will not be discharged from hospitals until
District Managers have been notified and the necessary ar-
rangements made by them for the determining of the above factors
upon v/hich the District Managers will approve discharge and
notify the hospital accordingly.

        Instructions contained in this communication do not
apply to the Provisions of General Order No. 27, regarding the
discharge of patients for disciplinary reasons©

                               Very truly yours,
ROBERT U. PATTERSON,
Assistant Director,
U. S. Veterans' Bureau.
     This supplementary letter — perhaps it did not reach you all —
was not as susceptible of misinterpretation as General Order No. 26-A. The
needs of the patients about to be discharged v/ith reference to after-care
out-patient treatment, etc., are not matters which should take long to de-
termine; feasibility for training is also a matter capable of prompt de-
termination; eligibility or the right of a pationt for training is a matter
that can be handled either before or after a patient's discharge has been
effected, and the necessary adjustments or re-adjustments of matters re-
lating to compensation, while necessary of establishment before discharge
from hosnital  do not require that such patients must remain in hospital 
* 'o :  i 
h i r d  Session
(Wednesday, January 18,  1922.)
                           Page 16.

GUTHRIE ?  (continued)

   until actually in receipt of compensation.  It simply means that the
   important steps leading up to this  action should be properly gotten
   under way, and having done this, the completion of the compensation
   status can be as readily carried out after discharge as before.  Not-
   withstanding the supplementary instructions following  General Order
   No. 26 still further conflict regarding the application of the two
   orders in question in the District  offices and in the hospitals v/as
   apparent from reports received in the Central Office, and it v/as decided
   to ins-ert a further explanatory notice in the U. S. Veterans' Bureau
   Field Letter No. 20, of December 24, 1921,  This notice was as follows:

           "Judging from letters that have reached the Bureau, there has
      been some confusion with regard to the exact intent expressed in
      General Orders Nos. 26 and 26-A.
           Rightly interpreted, these  orders are in no wise contradictory.
           The intent of General Order No* 26-A is fivefold, namely:
           (1)  To determine the eligibility of claimants for vocational
                training.
           (2)  To determine their feasibility for training.
           (3)  To arrange for training when eligibility and feasibility
                are established.
           (4)  To accomplish everything necessary to adjudicate claims.
           (5)  Provision for outpatient treatment when required,

           "All of these matters ought to be attended to before the patient
      leaves the hospital, and with close co-operation and efficient admin-
      istration, both in the field and in the Bureau, this can be done,
      and of course must be done without keeping the patient in the hospital
      after his treatment is completed.  Manifestly there is only one way
      to accomplish this, and that is, to anticipate the discharge of the
      patient a sufficient length of time in advance to provide for these
      objects."

           "Feasibility of training is to be determined preferably by the
      Medical Officer in Charge of the hospital, or his assistant, and
      means only that,  in his opinion, the patient is physically and
      mentally fit to receive vocational training."

           "The other requirements must be met by the Bureau or its
      field representatives, but with the co-operation of the hospitals.
      A representative  will shortly be named at each hospital,  v/ho will
      keep himself informed of the status of each patient's claim to the
      benefits  enumerated and v/ho v/ill follow up all cases in which there
      may be  delay."

           "Again reminding all concerned that anticipation is  the key-
      note of the  action desired in these General Orders, the hope is
      expressed  that  the  objects outlined may be obtained, as nearly as
      possible, before  the  patient is  ready  to be discharged." 
 
Third  Session
(Wednesday, January 18,  1922.)
                           Page 17.

GUTHRIE:  (continued)

        Any discussion of the instructions of General Order No. 26 and
   No. 26-A must take into consideration the reasons which led to the
   ieeuaroe  of those orders.  The officials in the U. S. Veterans' Bureau
   had been convinced for sometime that a high percentage of patients were
   being cared for in hospitals, and this applies particularly to contract
   hospitals, v/hose necessity for remaining in hospital was not based upon
   sound medical reason,  and in many instances upon no real medical indica-
   tion at all,  A number of factors were responsible for this situation, —
   the rapid growth and development of the District offices required the
   personnel therein to v/ork at high pressure at all times;  it has been a
   continuous struggle to keep abreast of the volume of incoming correspond-
   ence, v/ith requests for hospitalization, application for compensation,
   claimants crowding the doors, and a thousand and one other subjects. It
   has been a struggle on the part of the District personnel to keep from
   being swamped by the tremendous and ever increasing daily load.  Hospital-
   ization was authorized and carried out both in contract and Government
   institutions in cases  of all character for treatment where the indica-
   tions for such v/ere great and immediate, or were slight or nil, for ail-
   ments, objective and subjective, imaginary and real, for physical exam-
   ination and report, for determination of compensability, and for informa-
   tion concerning the connection with military service of a  claimant's
   disability.  The list grew so rapidly that patients were lost sight of.
   Many claimants were hospitalized for examination and treatment, and
   overlooked after examination and treatment had been completed. Contract
   hospitals particularly, through lack of a proper and direct connection
   in channels of communication between such hospitals and the District
   offices, were carrying patients over long periods of time,  patients
   got into contract hospitals for whom no proper authorization was ever
   provided, and the records of whom were never clearly defined in the
   District offices.  The scattering of patients anywhere from  one to a
   considerable number in several hundred contract institutions in each
   District extended the lines of communication between the Government
   and the District Offices until it v/as practically impossible to keep the
   contact clear.   The Central Office in Washington felt that it v/as time to
   take stock, and stock-taking at almost any time is an enlightening pro-
   cess.   The Director desired to remove claimants from contract hospitals;
   he desired further to utilize as much as possible the existing Government
   facilities which have been provided for this purpose.

        Under date of September 1st, about the time of the issuance
   of General Order No.  26 there 'were 9,592 patients in 862 private
   hospitals; there v/ere 18,698 patients in 92 Government hospitals.
   Today  there are 8924 patients in 757 contract hospitals and 20339 pat-
   ients  in 92 Government hospitals.   From these figures it would appear as
   though the~~clearing out of hospitals, as provided for in General Order
   No.  26,  has not been productive  of results.  This, however, must be viewed
   in the  light  of v/hat  is actually taking place in the field. About the
   time of the issuance  of General  Order No.  26, or a little  before, every 
J 
1 h I £ 1  5. £ £ £i £ £                 (Wednesday, January 18,  1922.)

                           Page 18.

GUTHRIE:  (continued)

   District was putting  into the field a  Clean-up Squad for practically every
   state, the function of which Squad was to make contact with all potential
   beneficiaries of the  U. S. Veterans* Bureau for the purpose of establishing
   claims, of offering hospitalization for examination, for emergency treat-
   ment, and for other situations.  These Clean-up Squads served  to  feed a
   considerably increased number of patients of all types into hospitals.
   Anticipating that  such period of hospitalization would be brief,  they have
   used contract hospitals because of this fact, and because of their loca-
   tion in the near or immediate vicinity of the patients handled. The
   turnover has thus  been largely increased.  The increase of patients in
   Government hospitals  has risen steadily at the rate of approximately 600
   a month until it has  reach the figure  of 20339 patients, as against 18698
   patients in the early part of September.  There has been a slow but gradual
   decline of patients hospitalized in contract institutions, notwithstanding
   the very material  influx into the hospitals by reason of the Clean-up
   Squads just spoken of.  It might appear to you who are actually caring for
   patients in your institutions that notwithstanding the explanation of the
   meaning of General Order No. 26 and 26-A, that the holding of  a patient in
   a hospital until all  of the several matters necessary can be taken care of,
   will result in undue  delay in. discharge.  This doubtless would be true if
   each hospital were required to assemble data called for and make  the other
   necessary provisions  and forward the reports to the District office to
   await return and receive transportation before a patient could be discharged

        In the issuance  of General Order  No. 26-A and the supplementary in-
   structions it was  contemplated in the  Bureau here in Washington that a
   representative of  the District Manager would be necessary in each hospital,
   at least, in those of considerable size, and some distance away from the
   District office, in order that direct  liaison betv/een the District Manager
   and the hospital in question might be  maintained, it being the business
   of this representative to see thort matters of after-traatment, convalescent
   care, feasibility  for training, and necessary adjustments of compensation
   matters v/ill be properly taken care of prior to the time that  it  is ac-
   tually necessary to discharge the patient.  This representative will keep
   contact v/ith the appropriate District  office and handle transportation for
   returning a claimant  home or to point  of hospitalization.  Anticipation on
   the part of the medical officers adtually taking care of claimants in hos-
   pitals, of the needs  of each patient in respect to these necessary details
   would enable the District Manager's representative located in  the hospital
   to carry out the proper adjustments of these important matters and the
   patient made ready for discharge at the proper time without delay.  To make
   effective the services of the Government hospitals in the functions which
   they are carrying  out, a thorough understanding of the problems involved is
   very necessary and a  sympathetic understanding of each other's problems,
   as betv/een the District Managers and Hospitals together with a spirit of
   co-operation and fair play is essential to the desired results, if not
   an absolute prerequisite to the success of the undertaking. 
r  •' ( J
A  :':\     '..
* ■- ■.  ;!
,   1 
Third  Session
(Wednesday, January 18, 1922.)
                             Page 19.

GUTHRIE:  (continued)

        Many features of our v/ork are,  I recognize,  trying and a thousand
   and one annoyances are a part of each day's v/ork.  Keeping before  us  at all
   times the meaning of the v/ork involved  is  a great aid  to the elimination
   of misunderstanding, and personal  conferences  serve to smooth out  and ad-
   just overlappings of authority. One  ex-service man maimed or injured,
   replaced into his particular niche of our  social  fabric should mak& us
   feel appreciative of what our work means,  and  the knowledge that we are
   rebuilding men who have suffered in  the  service of our country, should
   fortify us very strongly against the annoyances and trials which must
   sink into insignificance when compared with the work done.  I know that
   you all realize this and that your every effort and energy is bent
   to the accomplishment of the purpose for which v/e are  all working  together;
   that we are making headway  in the  proper direction is  beyond question;  that
   we are helping to rebuild the disabled  is  becoming more apparent as our
   xTork goes along, and we all, I know, are not only proud that we are
   having a part in this work, but feel privileged that our services  are
   helping to bring about these ends,"

        Upon the conclusion of Dr. Guthrie's  paper,  the subject-matter of
 the several papers read during the morning  session was  thrown open to dis-
 cussion, the presiding officer rer&rking in this  connection that full oppor-
 tunity would be given to all to freely  express themselves.  With reference %q
 the matter of the issuance of so-called conflicting  orders, which had
 been referred to, he stated that the  administration  of  the Veterans'
 Bureau is regulated by certain laws upon which these  orders were  based,
 and that when such laws are changed,  it of  course becomes  necessary to
 revoke certain orders in force at the time*  He added that the matter of
 hospitalization, thrown suddenly upon the Public Health Service  and the
 U. S. Veterans'  Bureau is a tremendous  undertaking and that those who
 carry on this work are entitled to the  sympathy of all  good people.

 COL.  BRATTON: wished to place himself  on record as  saying that there is
   nobody who is in greater sympathy with the wounded soldier, 'whom he would
   like to see receive all that a grateful Government can  give, but that due
   to the very liberality of the Sweet  Bill, cases have crept  in whereby
   compensation  is  being received for disabilities in no way ^connected with
   the service.   He stated that the Sweet Bill does not clearly define what
   the line  of duty shall be  and that he is amazed at the number  of cases
   that are  being carried along and hospitalized;  that he  is of the opinion
   that the  gentlemen in Congress  do not realize how liberal this act is and
   that men would receive  compensation for diseases which existed prior to
   their  coming  into  service.  He offered the following motion amending
   section 300 of the  Sweet Bill,  to be incorporated in a resolution to
   Congress  as coming  from this body,  which resolution v/as adopted: 
■vr
r.;:j.
ia  T
i*  '"'.'••'.*" .',■•.>■•. >' 
'LalLE.1  i££££££               (Wednesday,  January 18,  1922.)

                          Page 20.
                         Mot  i  on:

     ^ RESOLVED,  that  in considering the  question of line
   of duty,  it should be understood that an officer of the
   Army^ or Navy,  or an enlisted  man of the  Army or Wavy, who
   has been  accepted  on his  first physical  examination after
   arrival at a  military station as fit  for service shall  be
   considered to have contracted in line of duty any subse-
   quent determined physical disability, unless such disa-
   bility shall  be shown to  be the result of the patient's
   own carelessness,  misconduct, or vaoious habits at anv
   time, or  to have been contracted while absent from duty
   without permission,  or unless the  history of tho case
   shows unmistakably that the disability existed prior to
   entrance  into the  service.

DR. G. II. YOUNG:  stated, that  it has  frequently fceen a shock to  his
   sensibilities  to see  the  manner in v/hich compensation has been
   av/arded to certain ex-service men v/ho ar.o not in any sense de-
   serving;  that  assuming John Doe had a disability when he  came
   into the  service,  it  is now going  on  four years since his dis-
   charge and if  such disability was  exaggerated in service  he
   should be compensated just  as if he had  been wounded in action;
   that the  question  comes up  as to how  it  can  be  determined as  to
   whether the exaggeration  of his disability arose so.y during six
   weeks, six months  or  eighteen months  of  his  military service
   or in the perioc1 of nearly  four years which  has  since elapsed?
   That he is of  opinion that  this applies  especially to the border
   line psychiatric cases.

DR. COBB:  suggested  that  general  discussion of the other  subjects be
   taken up and  that  this  very important ratter be  brought up later.

DR. BREW:  referred, to the case  of a ran in hospital with  a  fracture
   of the thumb, v/hich was operated upon v/ith the  result that it
   functioned properly and the man v/as not  handicapped in  the least.
   After the operation, which  resulted in his total rehabilitation the
   man v/as av/arded vocational  training and  drew §80 a month.  He referred
   to the case of another  man who  had  been  in every hospital he  could reach,
   obtaining transportation  from the Red Cross  v/hon he could not otherwise
   cb!..ain it; this man was in:"acted into service  at Jefferson Brrracks and
   had a military service  of £.8  days,  of which  £8  days  he was in hospital
   14 days,  and  his  disability v/as amoebic  dysentery, v/hich  he could not
   have  incurred at  Jefferson  Barracks;  this  man v/as  in hospital for 18
   months  and has been drawing W130 r-  month for  training, v/hich  he has
   been  taking for tv/o years.  Dr. Brew  also  referred  to the  case of a
   negro, v/ho had syphilids before he went  into the  service;  that he is
   as well as the average man of his type and is receiving a  compensation
   of CllO a  month; that this man has benefited by  his  military  service be-
   cause he  has  had a  line of treatment that he v/ould  not have received in
   civil life. 
 
Third  Session
(Wednesday,  January 18, 1922.)
                            Page  21.

DR. WHITE:  (Speedway  Hospital)   thought that the matter  of allowing tho
    space of six feet between beds  should  be adjusted, as  this space will
    greatly reduce the  hospital  capacity.  He also referred to the matter
    of rations for absentees  and stated a  man may be  away  a matter of  seven
    days without leave  and  asked whether or  not the hospital shall charge  fo:
    .that patient's rations, as the  dietary service must  prepare  for him
    whether he is there or  not,  and  there  is always tho  possibility of his
    return the next day;  that it also  happens that a  patient on  leave  may
    return two days before  he is expected. He thought that if meals are
    prepared they ought to  be paid  for.

       Dr. White also referred to losses of  clothing  which take  place  and
    thought it was unfortunate that  individual lockers v/ere not  supplied for
    use of patients,  as if  they  v/ere  supplied they could  be rented to pat-
    ients at a nominal  cost,  thereby relieving the institution of the  cus-
    tody of the clothing.

       The  large amount of  paper work  v/as  also mentioned by Dr.  White.  He
    stated that he understands that  v/hen a patient is sent to a  hospital he
    receives a compensation of £80  a month automatically,  in which case he:
    cannot see tho necessity  for making additional physical examinations.

       With reference to  the  matter  of admissions, transfer and  discharges,
    Dr. White expressed the opinion that officers 'should require a patient
    to state whether  or not he is receiving  compensation;  that in the  matter
    of transfers as well  as admissions, officers  should  be required to state
    in v/riting, specifically  and distinctly,  the  reason  v/hy they desire cases
    transferred. He mentioned one instance wherein it was  stated that  a
    patient had a gunshot v/ound  of the left  thigh, and he  simply had a scar
    to show for it. He  thought that  officers  should be required  to  state in
    writing the hospitalization  needed. Dr, White also referred  to  cases
    where it is desired to  discharge a man from a hospital for certain of-
    fenses, stating that if  this  is done, compensation of course, would be
    stopped and the man will  not feel  kindly  toward the  particular  hospital
    which discharges  him. He was  of  opinion that  in such cases a hospital
    should be required  to terminate  its ov/n cases and not  dump them off on
    other institutions  and  stated that at  the  Speedway Hospital  there  is no
    hesitation about  reporting such  cases as  they are found, and  if  officers
    who transfer patients would  give specific  reasons as to why  patients
    need hospital treatment,  there will not be  so many men coming into hos-
    pitals who do not require treatment anywhere.

       In regard to G.  0. 26, Dr. 'Tiite inquired  as to v/ho  is to  decide the
    feasibility and eligibility  of patients who are ready  to be  discharged,
    stating that he had been waiting for a representative  of the-Veterans'
    Bureau to be sent to his  hospital  empowered and. authorized to make awards
    of compensation, as if medical officers are expected to  do it,  their
    number will have to be  increased;  that a man  should be sent  from the
    Veterans'  Bureau to attend to matters relating to training and who could
    say definitely to a patient that he can have  such and  such training, as
    it is  absolutely necessary to have  such a man and if he  is provided it
    will prevent a large number of complaints* 
•t(r   . 
T h i r d  S e s" s"i"o n
(Wednesday,  January  18,  1922.)
                            Page 22.

DR. GUTHRIE:  stated that he would  like to have some  discussion as to
   whether the representative  referred to by Dr. White  should be  a medical
   officer or a layman; that Dr. WTiite stated that he had  expected, the arrival
   of such a representative for some  time, and as the doctor is a young-look-
   ing man, he thought that if he  lived long enough he-will see this represen-
   tative get there.

GEN. SAWYER:  mentioned that the Board of Hospitalization  has an  understanding
   with the various Departments and the Veterans* Bureau that these things
   are to be settled by the Vocational Director, who, it is understood, is to
   become as quickly as possible a part of the hospital personnel;that he was
   of the opinion that the Board of Hospitalization came to the conclusion
   that it v/as not material whether the vocational representative was a lay-
   man or a medical man, but that  he  personally was of the opinion that upon
   the judgment of a medical man a great deal depends for  the answer that is
   finally given;  that he v/ould like  to encourage Dr. WThite with  the thought
   that the Hospitalization Board  has this matter very definitely in mind in
   order that the  man needed may be provided.

COL. EVANS:  stated, that the matter just referred to was a part of the program
   had been approved and was now awaiting the signature of the Director; that
   the individual  designated as Vocational Director in a hospital will be
   responsible for contacting  the  men v/ith regard to  their compensation and
   their preparation for vocational training;that he v/ill  confer  with the
   medical officers and of course  should be directed  by them, but he is
   responsible for the v/ork,

DR. GUTHRIE:  was  of the opinion that the location of these men in the hos-
   pitals in connection with the work referred to is  most  valuable.

DR. DEDMAN:  Stated that General Order No. 26 has been a wonderful help. In
   connection v/ith the matter  of discharged he thought that four  days v/ould
   be enough, because a ma^s  discharge can be anticipated and arrangements
   made for his vocational training,  provided a representative from the Vet-
   erans' Bureau  is furnished. He  stated that everyone has the same ideals as
   to tho restoration to health of  these ex-service men but that  this matter
   cannot function properly and we  cannot attain the  maximum for  these men
   unless v/e do work together  in harmony and peace in hospitals;  that when
   these representatives come, it  should be distinctly understood that they
   are members of  the official family and staff of the hospital;  that these
   representatives should not  be medical men as a medical  board can determine
   the means and advisability  of training, but that they should be well
   versed in the subject in order  that they may bo competent to judge as to
   what is best for a certain  man to  take up.

   Dr. Dedman added that difficulty had been experienced in getting men to
   to leave the hospital. Ho mentioned the case of a  boy who had  been admitted
   to the hospital with active tuberculosis, who v/as  eventually rated as an
   arrested case and told that he had received the maximum benefit, that this
   boy did not want to leave the hospital and made a  protest to his Congress-
   man. 
 
bird  Session.
(Wednesday, January 18, 1922.)
                             Page  23.

DR. COOK:  stated that he was going  through  his  hospital  one  day  and met  a
   big husky and asked, him v/here he  worked;  that he  replied he  did  not v/ork
   but was a patient;that this  incident  set  him  to thinking and he  got his
   discharge board working with the  result that  he reduced the  number of  ,
   patients from 910 to 500; that  in connection  v/ith existing requirements
   to the effect that no patient v/ould be discharged, from a hospital without
   going through a contact man, he v/as fortunate in  having a  man  assigned
   to him from the Veterans' Bureau  and  every  case of discharge goes through
   his hands; that under this arrangement he has no  difficulty  in discharging
   patients,

DR. EVANS:  informed the Conference  that there was on the Director's  desk a
   ruling stating that personnel from the Veterans1  Bureau v/ill be  under the
   commanding officers on hospitals.

DR. YOUNG:  referred to G.O. 26, authorizing discharges from  hospitals- and
   mentioned experiences where  difficulty had  arisen in this,  connection due
   to the lack of adequate means being provided  to enforce such order. He
   mentioned cases that had come up  v/here men who had received  the  maximum
!: -benefit, would state that they were not going to  be discharged;  that these
   cases v/ould generally occur  on  the eve of a holiday, or on Saturday night
   and the men v/ould go into a word  and  get  into bed.  He believed  that in
   such cases the hospital authorities should be given some means of  enforcing
   this order by the Veterans'  Bureau, as aid can not be had  from the local
   police v/ho will not enter upon  a  Government reservation; that another way
   would he through swearing out a warrant, but  as these cases  generally
   occurred on Saturday and a warrant could not  be sv/orn out until  the follow-
   ing 1'ionday, a man is thereby enabled  to stay  four  days longer.

DR. CHRISTIAN:  stated that in his experience the police had not refused, to
   go upon the reservation and that  he has had one of his staff sv/orn in as
   a deputy sheriff; also,  that upon the date named  in the discharge  order
   the man affected is not officially in the hospital and is not rated as
   present for the  purpose  of being  fed.

      Concerning transfers,  Dr.  Christian mentioned that authority for trans-
   fers has changed a number of times and was of   opinion that it v/ould be
   advantageous  if  stations  like his could be given blanket authority to
   transfer mental  cases when they are not prepared to take care ot them, as
   it would relieve  the medical  officers  of great anxiety and would save tho
   family  of the  man a great deal  of torture; that this could be accomplished
   in a few hours by telephoning to the  nearest mental hospital  and receiving
   an answer in  a short time as  to whether or not a bod was available, all
   of which v/ould expedite  the transfer  of the  patient; that it  is nov/ taking
   too long to get transfers <,

      He also  stated that he appreciated  the  importance of the Inspector's
  Department, v/hich is of wonderful benefit  to the commanding cffidere. 
V 
1 5L i I 1  £££££££•                 (Wednesday,  January  18,  1922.)

                             Page  24.

DR. CHRISTIAN:   (continued)

      With reference  to G. 0.  26, he  thought that the length  of time pre-
   scribed is too  long, as with the generality of patients v/ho  have  received
   the maximum  amount of treatment, it does  not make  a great  deal of differ-
   ence as to how  much notice  they have as to when they are going to be  dis-
   charged,  as  the necessary arrangements can be made in a very short time
   without any  inconvenience;  that there is, however, a certain  class of
   cases v/hich  very often takes advantage of the four days' notice;  that it
   has been  his experience that when  four days' notice is given it apparently
   has no effect on the first  day, on the second day  the patient  v/ill begin
   to  develop symptoms, on the third  day the symptoms are Terv  much  increased
   and on the 4th  day you get  a letter from  the patient's Congressman.

DR. LASCHE:  was of the opinion tha/t all the  authority needed  is given by
   G.O. 27 of the  Veterans1  Bureau, which gives the Medical officer  in charge
   considerable authority to enforce  discipline; that the average patient,
   howeVer,  chafes under the word "discipline"; that  the gentlemen from  the
   Army and  Navy have referred to the advantages of discipline.  He  stated
   that he v/as  on  a discharge  board for soldiers after they came  home from
   Europe and frequently heard them say: "Well, by Jove, v/e are away from
   this---discipline nov/;" that with all due respect to discipline that is
   necessary in Army and Navy  organizations, he does  not believe  that the
   same degree  of  discipline is necessary after these men become  beneficiaries
   of the Veterans'  Bureau;  that in a year's time he  has only had. to apply
   the provisions  of G. 0. 27  on one  patient v/ho was  A.W.O.L. three  times for
   the period of twenty-four hours or more within thirty days;  that  he fin-
   ally discharged this man, who, however, subsequently applied for  re-
   admission and was  successful in obtaining it within tv/o weeks  and all the
   patients  at  the institution know that this man got hack after  he  was  dis-
   charged.

      With reference  to the  question  of Dr.  Guthrie as to whether a  layman"
   would serve  successfully, Dr.  Lasche was  of opinion that the layman is the
   only desirable  person, as the  medical nan's function is exclusively to
   determine the vocational  disability and after this is determined  all  the
   other matters should be left to a  layman, as they  are more or  less in tho
   nature of an  investigation  and a layman who is properly selected  v/ould be
   much better  able to run down and ferret out such matters;  that it is
   important, however,  to select  a man  for this particular function  v/ho  has
   shown an adaptability for research along  these lines, and,some of the men
   v/ho have been in charge of  vocational centers  do not possess the  requisite
   qualifications  to  decide  as to visibility or eligibility in  the matter of
   vocational training.

DR. T.  R.  PAYNE:  thought that the hospital  brand had beo'n placed  on a great
   many men in cases where it  should  not have  been; that once you get a  man
   in a hospital he is  going to repeat  as  long as he  can. Pie  referred to a
   class of so-called gas bronchitis  patients  and stated that it  is  well
   known that during the war all  a man  had to  do was  to say he  had been  gassed 
 
I 2i 1 £ d  Session
(Wednesday, Jemuary 18,  1922.)
                           Page 25.

DR. T. R. PaYNE:   (continued)

   and receive a wound  stripe, and. this  same  man  is nov/  coming  in to  our
   hospitals; that the  office of The Adjutant General  of the Army has  no
   record of such men being  gassed; that he has no chest pathology. He
   thought that these men  should never have gotten  into  the hospitals and
   should have been handled,  outside more by psychology than by  doctors and
   hoped that the dispensaries are going to keep  these men out  of hospitals;
   that there is no doubt  in his mind that a  great many  neurosthonics  should
   never have gotten  i&to  general hospitals; that the great trouble  is the
   compensation given these  men places a premium  upon  their hospitalization;
   that men are in hospital  v/ho have been discharged as  having  received
   their maximum hospitalization; that these  men  have  been taken  out  of voca-
   tional training; that they would, rather go back into  hospital  and  get
   ^>80 a month and three meals a day and be entertained  several times  a
   week; that more care must be taken by doctors  regarding the  men they send
   in to hospitals.

 GENERAL IRELAND:  stated  that it has been found  that  there is  no after effect
   from gases and that  Liout. Col. Gilchrist, M.C., U.S.A., representing
   the Medical Department  of the Army in the  office of the Chief, Chemical
   Warfaro Service, has data relative to this subject, which can  probably be
   obtained by writing  him*

 DR4 LLOYD:  offered'the following resolution, which,  however, vras not
    adopted:

       "That it is the  sense of thi6 body that the Federal Board
    of Hospitalization  recommend to the  Director  of the Vctarans1
    Bureau and to the Surgeon General of the  Public Health Service
    the designation of  an  officer of each service to receive special
    suggestions and recommendations from the  field, criticisms  al6o
    of instructions contained in field orders, circular  letters and
    similar communications;  these designated  officers  to constitute
    a board for the consideration of these recommendations, v/ith  the
    view of recommending to  the Director the  adoption  of such as  are
   Ifcelieved to be of value."

 DR. CHRISTIAN:  offered the following amendment  to Dr*  Lloyd's resolution:

       "That these officers  be detailed  to the Veterans1 Bureau for
    a limited period, say  six months; that they be field officers."

 DR. JOHNSON:  moved that  the resolution of Dr. Llo3'd  be laid on  the table
    indefinitely, v/hich resolution was adopted.

 DR. LLOYD:  suggested  that  it v/ould be v/ell to have one man of each service
    who could be advised as  to what is the matter v/ith certain general orders
    and know that such  matters will not  be pigeon-holed but will  receive
    action. 
 
Third  Session
(Wednesday,  January 18,  1922.)
                             Page 26.

 COL.  BRATTON:  was of the opinion that all suggestions relating to improve-
    ment of service should go through the chief of the service«  He stated
    that no difficulty was experienced in this connection in the Army and
    that it seemed to him that the chief of a buraau should know what was
    going on.

 GEN.  IRELAND:  stated that contemplated changes affecting the hospitaliza-
    tion of patients of the Veterans1 Bureau in the Army are always re-
    ferredftto  his office for review before they are issued.

 DR. BLISS: thought that there should be a representative of the Veterans'
    Bureau in  all Government hospitals v/here there are Veteran Bureau
    patients,  which representative would not have anything to do with the
    internal administration of the hospital.

 DR. WILLIAMSIs  with reference to the matter of bed space in hospitals of-
    fered'a resolution to the effect that the question of floor  space and
    distance between beds be reconsidered by the Veterans'  Bureau,  v/ith
    a  view to  the revision of the present requirements; that unnecessary
    bed  space  is being provided and it should be cut down;  that  he  believes
    the  allowance of six feet is necessary in respiratory cases  and in
    infectious cases,  but that in the ordinary general ward he believed
    that a little less space would be quite  sufficient, as  the larger  re-
    quirement  will cut down the hospital capacity very materially.  This
    resolution was duly seconded*

DR. BARLOW:  With reference to space allowed per patient,  thought  that
    there  should be a  difference in accordance with the classes  of  patients;
    that he has  charge of a  hospital  for  mental  cases,  and  it would be
    necessary  to arrange  for 100 square  feet;  these men are  not  suffering
    from physical disabilities.  He  stated that  the  State Hospitals cannot
    provide even fifty square feet of floor  space  and  that  it v/as absolutely
    necessary  for the  Veterans'  Bureau to take  out of  the State hospitals
    every  insane  patient  they have.

DR. BLACKWOOD:   concerning  the  allowance of six  feet  between beds, asked
   if this was  not  intended  to  mean  six  feet  between  bed centers.
The following motion was  adopted:

     "That the Federal  Board  ask the Veterans1  Bureau  to  re-
  consider the question of bed  space.

     A motion was offered, which failed  of  adoption, to the effect that
the Director of the Veteransf Bureau set aside  a certain  amount for the
reimbursement of unavoidable  losses of property of ex-service men in
hospitals. 
?■■. 
Third  Session.
(Wednesday,  Jan.  18,  1922.)
                              Page 27,

DR. KRULISH:  was of the opinion that if the foregoing resolution was
   adopted, that more trouble would be experienced than before.

   It v/as further brought out that such a motion would carry no weight;
that it was thought the service had this question up once before and the
Comptroller's office advised that no money arrangements could be* made and.
it was not believed that the Veterans* Bureau could make allowance for
losses of clothing.

   It was also stated in this connection tha.t in some institutions steel
lockers had been provided, a small deposit being required, which was given
back when the key was returned, under which arrangement very little cloth-
ing was lost*

DR. HETERICX:  stated that his institution is equipped with steel lockers
   and a small deposit required, v/hich is returned when the patient is dis-
   charged; that the patient is told that due preparation has been made
   for taking care of his clothing and it is in his custody; that the in-
   stallation of these lockers has reduced the theft of personal property
   to a minimum; that some times, however, lockers will be broken into.
The meeting adjourned at 12:30 p.m. 
 
F&urth  Session                Wednesday, January 18,IS22.
                              ~2&-
Present:  Members of the Federal Board of Hospitalization;
          also, about one hundred conferees.
GEN. CUMMING, presiding, called the meeting to order.

DR. WHITE called the roll, and read the following announcement:

   "It is requested that, at the first available opportunity,
    the following officers confer v/ith Dr. Maddox, "C" Build-
    ing, Room 1-319, concerning urgent const ruction, work going
    on c?-t their stations:
          Dr. W..E. Allen, of Boise, Idaho.
          Dr. Y/.C. Billings, of Ellis Island,  N.Y.
          Dr. R. L. Alien, of Aroowheod Springs, Cal,
          Dr. A- P. Chroniuest, of West Rosbury, ivlass.
          Dr. E, R. iviarshall, of Detroit, Mich."

 GEN.  CUM/JNG: "This ofternoon we are going to consider administrative
    policies.  The first paper will be "Professional Service",  by'
    Dr. Lavinder,"

 Asst. Surgeon General C. H, Lavinder:
    "The subject that has been assigned to me is very broad
     in its  scope, and the time is so limited, that if I may be per-
     mitted  I wish to tender a written paper."  Dr. Lavinder read the
     article on  "professional Service",

    "In a discission of professional service,  however brief, no thought-
 ful medical man could forbear some comment on the present general status
 of clinical medicine and its developments within the last few years.  Ihe
 steady trend towards greater educational requirements, the development
 of refinements in diagnosis and therapy and the straining after what are
 believed to be higher scientific standards, creates in many minds some
 uneasiness  jls to whether the medical profession may not, by such things,
 be led astray and forget the very purpose for which clinical medicine
 exists, that is, the comfort, welfare and relief of the patient.  Such a
 fear is by no means a groundless one.  There is always a possibility that
 the medical man may become so enamored of his refinements and of his
 scientific methods as to forget that his business is tne treatment of the
 sick.  It is a truism so trite as sometimes to be overlooked,  that all
 organization and »11 methods in clinic.*! medicine have for their ulti-
 mate end the care of the patient and everything else must be subordinated
 to his interests.

     Leaving this aside and omitting much, there are some things which
  may be stated in a general way concerning professional service, under-
  standing that it is presumed such service is administered in hospitals
  properly constructed,  properly located and equipped, and operated for
  the particular purposes which .*e h^ve in mind. 
 
Foir t h  Session
Wednesday, January 18,1922.
Paue 29.
      1.   There are certain brood policies in this iflatter which are worthy
 of some  comment.

          The flexibility of hospitals is a matter of importance.   The
 Public Health Service has divided its hospitals  into three general groups,
 that is, hospitals for general medicine and surgeryf for pulmonary tuber-
 culosis and for neuro-psychiatry.  V/e have striven* however,  even in these
 broad groups to make such hospitals available, at least temporarily,  for
 any clAss of case which seeks admission.  This has been especially true
 v/ith regard to pulmonary tuberculosis and v/e have been rather insistent
 that every general hospital should set aside a certain number of  its  beds
 for the care of such cases.  A similar policy has been followed with  re-
 gard to neuro-psychiatric disorders.   Even if the general hospital can be
 made no more than a distributing point for these special classes  of cases
 it is, nevertheless, wis? that such provision should be mode,  Consider-
 ation has been given to the possibility of adopting a method which was
 followed by the Army during the war,  that is,  specializing in hospitals  to
 much greater degree and organizing certain hospitals on such a basis  that
 they might be especially prepared, both in personnel and eiuipment,  to
 care for one or two classes of disorders.  The patients with v/hich v/e have
 to deal, now ever, are by no means so easily transported and so easily con-
 gregated in special groups.  This method, therefore, vfaile it deserves
 much consideration, has not been found feasible in our work.   Considera-
 tion has also been given to the establishment of convalescent hospitals,
 and while such institutions have much to commend them,  they also  possess
 some very serious disadvantages,  especially with the class of patients
 with which v/e are now dealing.  We have opened one such hospital  which is
 still in operation _jid is giving satisfactory service.

           It has been a general policy of the Public Health Service,  of
 course,  to seek in every way to establish in all of its hospitals standards
 of professional service in full accord vvith the best modern practice.  At
 the same time we have sought to avoid the fostering of  redical methods
 which might ver^e on the field of fads.   \*e n^ve preferred to adopt a
 somewhat conservative attitude in this regard and have  been un/iliing' to
 makd use of methods until they had been fairly well tried out and  estab-
 lished as useful.

           It has also been a policy,  as far as possible,  to establish a
 uniformity in professional "service,  at  the  same time doing nothing v/hich
 might  interfere with individual initiative.  General Uniformity in pro-
 fessional  service  is  •.•.:$irarlu    not  only for  administrative  reasons,  but
 for  professional  ones as well.

           It  goes without  saying  that we  have  felt  the  absolute necessity
 of establishing a professional service which would  be reasonable  in cost.
 The  expenditure of money in  professional  service  is,  of  course, wise.
 At the some  time it has  seemed to us  that any  professional service  which
 could not be justified on  the  basis of  economy was  probably more  than
necessary. 
, if.c a„
it   ..' *.  ■■• 
fourth  Se_£sip_n                 Wednesday, January 18,1922

                         Page, 30.

     There is one other matter of general interest,; which seems to us
of  the highest importance, and that is the creation in all hospitals,
so  far as possible,  of a broad spirit of human chirity jnd th.3 stimu-
lation of any agency which would help in the creation of such a atmos-
phere.  We have, therefore, done everything we could to assist in the
formation of an efficient medical social service and in the furtherance
of  recreational activities.   It has seemed, to us that the creation of such
an  atmosphere in any hospital is a matter worthy of every effort.

     One other consideration  of general significance is the ideal of not
discharging a patient from hospital until he has reached the maximum
benefit to be derived from such a form of treatment, and was ready for
discharge in a condition which would permit him to return to the outside
world prepared to assume, as  far as possible, the burdens of daily life
and ready to moke social readjustments.  In other words, it has seemed
to  us unwise simply  to discharge a man upon recovery from an acute or
chronic illness without taking pains, through, a medical social service,
to  see that he was readjusted to the  community on a basis which would
prevent his reversion to a state of ill health  and perhaps his readmis-
sion to hospital.


      2. With regard to the application of professional service to the
actual treatment of  sick in our hospitals, we have had in mind, in a
general way, some rather definite things.  In the organization of our
hospitals, whatever  the type, v/e hove arranged ail of the professional
services to meet the demands  of the institution.  Vve have attempted to
adjust these professional services, so far as possible, to the need of
the particular hnspital and the particular class of patient treated
therein and then properly to  coordinate all of these various services
under competent chiefs, supplemented by attending specialists.  An or0an-
ization so established should, we feel, meet jny reasonable demands
which might be made  upon the  institution adthout an undue expenditure in
the matter of professional perso *nel.

       We have established many hijily specialized services, including
 dentistry.  we have not overlooked such things as occupational therapy
 and physio-therapy  -tnd, of course, have talc en Care to supply the nec-
 essary modern laboratories.  X-ray equipment and other matters which
 «*re essential in the best modem professional service.

       We have, of course, not neglected such necessary accessories, in
 the proper care of  a patient, as good nursing and an ade-xuate system
 of  supplying a well balanced ration, properly prepared and served.

       V/e have believed in doin^ much of this v/ork that it was a matter
 of  econony as well  as expediency to furnish as complete medical exam-
 ination^ as possible.   These Cases ^re compensable cases ^nd the m-tter
 of records as to their physical condition is of especial importance. 
 
Fourth  Se.ss.ion             Wednesday, January 18,1922.

                        Page 31.

The veterans1 Bureau has felt the need of Careful and complete exam-
inations as well as records which are dependable.  Pains h-ve been
taken,  therefore,  so far as possible, to take such examinations and
keep  such records  of all cases.

      In some of our hospitals we have felt the need of establishing
special services for special classes of cases, but have not extended
this  any further than was necessary.  For example: we have in one of
our general hospitals a special service on uas tro-enterolOt-y.  In another
we may  have a  special service on surgery, as applied to tuberculous
processes.  Similar special services have been located in several places
to meet special demands and such a policy will, of necessity, continue...

      1/lost important of  all we have striven in every way to secure a
 qualified medical  persoiinei, a matter of no small difficulty.  The demand
for compet-mt  medic.il men is greater taon the supply.  In the operation
of such a large hospital system it is by no means e^sy to secure men
skilled in special lines of endeavor.  We have,therefore, felt the need
many  times of  establisiring some system of educating out  medical staffs
in various matters and, while funds have not permitted the extension of
this  system, v/e hv/e availed ourselves of educational methods as far as
possible.  Schools of various kinds have been held for short periods of
time  and men have  not infrequently been transferred  temporarily to sit-
uations v/here  they mi^ht acquire a special knowledge.  We have also en-
couraged staff conferences and attempted to supply working libraries
and medical mag asines to each of our hospitals— all with the idea of
stimulating among  our entire medical personnel the desire to increase
their professional efficiency as much as possible.

      3. Finally,  we have not overlooked the necessity for research.
Our funds have been too limited to do a great deal in t.iis line, but we
have  felt keenly the responsibility v.hich rested upon us to do all that
v/as possible.  Such activities have been Carried en in a very small way
v/ith  the exception of one or two hospitals which might be really called
research hospitals, notably such a hospital as the one at Waukesha,
Wisconsin, where every  effort is devoted to the diagnosis and treat-
ment  of a definite class of Neuro-psychiatric disorders.  This hospital
has been so organized as to permit the very highest type of modern
diagnosis and  therapy;*."

GEN.  SAWYER:   "This seems to me to be an opportunity to say a thing
   or tv.o which have been in my mind that I wish to express nov/.  First,
   this present administration h_s as one of its ambitions the best
   Public Health Service in the vvorld.  I v.ant you to know that, in your
   engagements here, trying as they are, behind you is a determination
   to help to develop an ideal Public Health  Service, and every man who
   is engOoed in the service of the Public Health of the United States
   should feel that he  is en^^ed in the greatest service that Can be
   rendered to his country. 
 
Fp_u.>r<t}i  S, e s. .§. i o n
Wednesday, January l&il322
                          Page 32.

GEN. SAWYER: (Cont*d)

     For myself, I have  a great ambition that somewhere there should
be established  a post-graduate training department to vvhich the members
of the Public Health Service of the United states could come for post-
graduate training.  We want to be the highest type of doctors that are
to be found  anywhere, and so today we have in contemplation the establish-
ment of a post--graduate  training  shcool in the city of Washington, to
vvhich you can come  to provide yourselves £t&d ©$iip yourselves with all the
new and better  things that from time to time must develop."

SURGEON DEDMAN:  stated that he felt that Dr. Lavinder1 s paper was too
     important  to pass up without a comment or tv/o;  that one thing he
     was struck with was the personal contact to be made with the patients
     themselves.  He said he believed this was a very important matter,
     as the  services of  a doctor  are absolutely worthless until he has
     gained  the patient's confidence.  He felt that the doctor should be
     looked  upon just as the family physician at home.  He stated further
     that when  he first  entered the v/ork he made the following hospital
     rules:  1-  Kindness, 2 - Cheerfulness, and, 3 - Duty, Said that the
     doctors should inject the feeling of friendship into the minds of the
     men as  mucn as possible.  He stated that there ought to be a system
     of uniform hospS tal regulations, that some hospital rules are not so
     drastic as those of other hospitals, and that he believed there
     should  be  a aan.foaa regulation so that the disciplinary regulations
     would be the same in one hospital as in anothers

ASST. SURGEON,  L,L. WILLIAMS : stated that in reference to uniform discip-
     linary  regulations  the charactS'S of the patients, the location of f-j
     institutions and the construction of the premises are all factors
     that affect the provileges to be given the patients.  Believed there
     could be no highly  organized uniformity of regulations.
                               In regard to specialised attention, the
     hospital should be  prepared to furnish any sort of special core possi-1.
     ble.   He stated further that he believed that the specialized patient
     in a general hospital is better off than if in a special hospital,
     but that if he had  a son who had a special ailment he would much
     prefer him in a hospital which had upon its staff men in active prac-
     tice of the kind he was going to need.

CAPT.  LOWNDES:  said there v/as always some patient who v/ould go out and
     make  trouble,  that  he had been investigated by the American Legion,
     by ladies1  committees and by religious societies, all of v/hom he
     invited to  come to   the hospital,  as there was trouble if they were
     told  not to come.   He said he had met v/ith two .^criticisms:  one was
     that  the nurses were particularly harsh,  to which he replied that
    he generally had trouble getting the patients to go out as some of
     them  generally  fell  in love with the nurses;  the other that the
    patients would  not pay  any attention to the Commanding Officer when
    he made  inspections. 
 
  I £. H £ £ h  Session              Wednesday,  January 18,1922

                         Page 33.

  GEN. CUI&UNG:  "The next subject:Nursing^  will be presented by  the
       Superintendent of Aruy Nurses,  Wajor Julia C.  Stimson".

  LisJOR STIIviSON:  read the paper "Nursing",  as 0iven herewith:

       "The subject of nursing in  relation to the Care  of  the ex-service
  man is a very big one an± Con scarcely be handled adequately in the ten
  minutes allotted to it.  There are,  however,  certain  phases  of  it  that
  can be mentioned.

        The response of the nursing profession to  the call of  the country
  during the time of war is well-known,  and  the character of  the  achieve-
  ments of the 25,000 trained wcmefc who  entered the government services at
  that^time has been often recounted,  but little has been told of the
  patriotic devotion to duty that has  been  exhibited, by nurses since the
  Armistice. ^  I have not come today to bring bouquets and laurel wreaths,
  but  I do v/ish to call attention  to the  marvelous development of one
  branch of governmental nursing work under   conditions that in many in-
  stances were harder to bear than most >;ax  conditions,  and to ask for the
  service the  recognition and cooperation it  deserves.  At the present time
  there  are more  nurses in the U.S. Public Health Service, (1796;,  than there
  ore  in the combined nursing departments of  the Army, (774),  and the Navy,
  C*88;.   The  figure  given me  for the present Public Health  nursing staff
  is about  1800,  an expansion  from forty  odd  *X  the time the service w.as
  autnorized to care  for ex-service men,   on Liarch 3,1919 by Act of Congress.
  To realize the full meaning  cf this expansion and the  development  of^the
  organization required  to zun^e the service, it is only necessary  to  re-
  call the fact that in  the spring of  19.19 when the Public  Health  Service
 called^for volunteers for its Nursin^ Service, the Army and the  Navy were
 both discharging from  their Nurse Corps &reat numbers  of women.  In one
 month alone in that year 2500 nurses  v/ere demobilized  from the Army.
 They v/ere all tired, worn-out women.  You all recall the  state of  mind
 of both the soldier and the off ice rt during those months, when morale was
 at its lowest ebb, because of homesickness, fed-upness, and desire  to
 get back to civil life.  Nurses as ..ell ^s men were  full of  complaints,
 and to be freed  from governmental control was the thing that  to  all of
 them seemed the  ultimate Oood»  Ivioreover, irony who Come from overseas
hadbeen marking time for weeks,  awaiting orders  for the breaking up of
their units,  and embarkation,  and upon  their arrival home they found
theircommunities,  v/hich they had  left so short  of nurses, were clamoring
for their services.

        Under  such  conditions was presented  the  need of the ex-service
man.  X new  federal nursing  deportment  asked them to  give up their
personal  desire for  freedom,  their longed-for plans,  and to enter-what?
~nd to  do - what?   It is hardly necessary to describe  the kind of hosp-
itals these nurses were asked to enter,  nor  the conditions under .;hich
they were to live. 
 
urth  Session
Wednesday, January 18, 1922.
                          Page  34.

You would scarcely believe  the  details  that  I  could  tell you unless you,
too, have heard the accounts  of the  r.ble   Superintendent of  Nurses of  the
Public Health  Service.  You know, perhaps, what  some of the  old  Marine
hospitals are  like, and some  of you  know  some  of the old Army hospitals
taken over by  the Publid Health Service v/ere like*   You don't know, I  am
sure, about the utterly unworthy and unsuitable  quarters and messing ar-
rangements for nurses which many staffs have had to  endure,  and  still
do endure in some instances.  The fact  that  there are nov/  1800 nurses  in
the service bears witness to  the clearness of  her vision of  the  need on
the part of the Superintendent  of the Corps, and her valiant presentation
of it, and to  the assistance  given her by the  American Red Cross Nursing
Service which  has spread the  call and facilitated recruiting.

     The Nurse Corps of the Army and Navy were olbd,  established  depart-
ments, with traditions and  customs behind them,  with a status recognized
by all in -the  service and honored by officers  and men alike  for  their
many years of  efficient v/ork.

     The nurde in the U, S. Public Health Service had no such advantage,
and to her and her associates and to the  officials who have  championed
her cause against v/hat nave at  tiroes seemed  almost unbearable difficul-
ties too great praise cannot  be given.

     General Srsr/or has asked me to  present  the  difficulties that lie
in the v/ay of  the kind of nursing service to the veteran that ought to
be given, and  oc suggest if I can, a plan for  meeting these  difficulties.

     The greatest problem of  the nursing  care  of the ex-soldier  is not in
the Army and the Navy, because  the proportion  of the veterans patient  to
the regular Army and Navy patient in those services  is so  low that it
presents no particular problem.  It  is, of course, in the  U.S.Public
Health hospitals that the problems exist  most  noticeably.

     First we  must consider the type of patient.  We are told that
neuro-psychiatric, contagious,  and tuberculosis  cases predominate. Right
here is one difficulty as far as nurses are  concerned. To  contribute the
highest type of service to  people so afflicted requires that the living
conditions, the mental and  physical  recreation and up-building of the
nursing staff, be of the finest order.  I think  that this  is conceded
by all who consider the long  hours during which  the  nurse  is  in  close
contact with the patient and who realize  that  no  individual,  barring
none, has so large an opportunity for personal influence upon patients as
the nurse.

     Nurses who are enployed  for the care of the  veteran should be of
the highest grade.  Not only  should  they  meet  all the professional and
technical requirements, but they should be especially qualified  in all
phases of rehabilitation and  reconstruction, both mental and  physical. 
;• .  a.
 ' -"  'i; 
Fourth  Session
Y'ednesday, January 18,192a.
                         Page35.

 They  should have  an especial knowledge of  the problem of the tuberculosis j.
 patient,  not only as an individual sick man,  but  in his relation to
 society.   They should be thoroughly cognizant of  the magnitude and ur-
 gency cf  the problem of social diseases, and  without an ability to help the
 neuro-psychiatric patient redirect his interests  into the world of real-
 ity and to correlate himself and his snviioment,  they are failing in their
 whole duty to their patient.

    Under the present conditions it is probably  not an easy matter to  get
 such  super-rrvrses in any great numbers, and even  were it possible tose-
 cure   them,  it is not likely that they could  be long retained.   The turn-
 over  in the nursing service in hospitals coring for veterans is unduly
 large,  the reports show.  This has been due in some degree to  physical
 breakdown, and also to dissatisfaction with conditions,  including uncert-
 6*4n.ly as to their status and fears for its future.   V/hat,  then,  is to be
 done?  The answer is not so hard to find,   locally,  it is coffi££rtable
 living quarters,  reasonable hours,  good food,  the right sort  of  recreat-
 ion,  adequate pay*  and opportunity for advancement  and improvement.
 Norses,  like all  other professional workers,  are  coming to recognize  that
 in order to .live  up to their highest ideals and to  give their  best serv-
 ics-sto afflicted  humanity,  it is essential to feake  provision for  con-
 tinual growth,  and that from time to time  added inspiration and  education
 are necessary.  Courses of  special study are  advocatsa,  therefore,  for
 all nurses j  espc-oiaily for those Coring for veterans or any other  parti-
 cularly difficult group of  jaotients.   Opportunity for post-graduate study
 is considered a, necessity in the Army for  both officers and members of
 the Nurse Corps,  ana. it is  even more important in the U.S.  Public  Health 2r>
 Service.   In some ho spit .vis of this service special, courses have  been
 conducted for mirsss with marked success-  but  particular emphasis  should
 be given to this  pha.se of meeting the nurses'  problems.  For before a
 nurse can help to reconstruct a distorted  mental  outlook and restore a
 normal attitude toward, life,  she, herself.,  tyst have an understanding
 and a sympathy and a power  to help  that can only  ccme from steady  inspir-
 ation,  constant study,  and  serenity of mind.

      Second in importance locally is the recognition on the part  of the
 commanding officer of each  hospital and each  Eoenf.er of the hospital staff
 of  the  real place of nurses in the  endeavor to return the  patient  to
 normal health  and life,  and emphasis upon  an  attitude of helpfulness
 and cooperation in all matters concerning  them.   Only these v/ho have
 served in hospitals where tae commanding officer  was heart  an\  soul in
 sympathy  with  the problems  of the nursing  staff and concerned with  every
 detail that  might work for  its v/ell-being,  can know what  a harmonious,
helpful atmosphere  can exist,  and how the  spirit  of  courteous  recognit-
 ion and mutual  respect  con  permeate  from the  commanding officer  to  every
member of  the personnel.  For is not  the nursing  group usually the larg-
 est group  in every  hospital,  and -ill not  the  attitude of  the nurses give
the tone to  the ho spit all?; 
 
Fourth  Session
Wednesday, January 18,1922,
                           Page 36.

 Commanding officers should remember that in their hands and their*s alone
 rests the regulation of this tone.

      In all the presentation of the general subject of the care of the ex-
 service man, at this conference, little if any mention has been made of the
 part of the nurse.  Right here in this very fact, perhaps, rests one of the
 largest snags that lie in the way of the best service to the veteran.   Think
 for one moment of the situation if there v/ere no nurses to work side by side
 with the medical man and to cooperate with him in securing for the patient
 that which he, with ais special preparation, considers necessary for his
 healing.  What results v/ould be obtained?  The time has passed v/hen the need
 of professional nursing in the Core of the sick is a de'eatable >iuestion,
 &nd yet nursing, as vital to the modern scientific restoration of the  war
 veteran, has not been mentioned.

      Here at headquarters is where the greatest progress toward the
 solution of the nursing problem can be iooae, - 1st,  in the recognition of
 the problem and its importance, and 2nd, in a sympathetic, concerned,  busi-
 ness-like attempt to solve it by the method that Is most sure to bring
 about success, - namely the conference method, the collecting of advice from
 experts on the subject,  the formulation of their suggestions,  and an endeav-
 or on the part of all concerned to put these suggestions into practice.

      You,  in this new governmental organization,  which has for its aim the
 highest type of service to veterans and their restoration to complete  living,
 have a. chance to develop a nursing department that should set the standard
 for all the departments of federal nursing as well as for civilian institu-
 tions."

 GEN.  CUMlvIING:  "Discussion will be offered by Mrs.  Higbee",

 MRS.  LENAH S.  HIGBEE,  Superintendent,  N.N.C.:  stated that the  subject  hardly
      needed discussion,  that  it would almost seem that  she could not amplify
      it,  but that was  v/hat she was going to attempt  to  do.   She  spoke  on
      "Nursing",  as follows:

    "Since the nurse viewpoint  of  the  treatment  of patients under the
 Veterans1  Bureau is considered sufficiently important to  be discussed,  it  is
 a matter of  regret  that  the chief  nurses of the hospitals have not  been sum-
 moned to tnis  important  conference.  Of  course,  the  nursing subject comes
 directly under the  Commanding  Officers of the  hospitals but  in presenting
 the more intimate views  of the nurses, the  opinions  of  the  chief nurses
 would be more helpful  than the  opinions  expressed through the medium of the
 superintendent whose knowledge  of the situation is obtained from reports.

     My knowledge of the situation we are discussing  is obtained from  reports.
 Letters have been sent to  the various chief nurses requesting aefinite infor-
mation on this subject and asking if any particular presentation could be
made to this important body vvhich would  be helpful. 
 
Fourth  Session,
Wednesday, January 18, 1922,
                               Page 37.

HIGBEE:  (continued)

                              NURSING.

        At the Naval Hospitals v/hich have had the greatest success in treating
   the Service beneficiaries, the Commanding Officers have put a frank presen-
   tation of the situation to the patients, pointing out the necessity for
   certain restrictions and discipline, and urging cooperation. This pre-
   liminary presentation by the Commanding Officers when followed by the kind
   yet firm supervision of the ward officers and also by the tactful, helpful
   attitude of the nurses, v/ho in turn cooperate with the welfare and voca-
   tional workers, in time break down the attitude of opposition, resentment,
   and destructive criticism which many patients have when first hospitalized.
   The chief nurses have stated that the care of the patients means only
   "more patients." There is no special problem in dealing with them and under
   the above conditions, they accept the neeessary discipline and restriction
   which are fundamental if hospital treatment is to succeed.

        It v/ould seem, therefore, that the problem, as has already been
   pointed out, exists chiefly in the U. S. Public Health Hospitals where the
   greater number of patients from the Veterans' Bureau are receiving care
   and treatment.  A large percentage of these patients would, correspond to
   our Navy ambulant cases and among the  remainder (as has already beten
   stated) the neuro-psychiatric and tuberculous* patients predominate.

        There is considerable discussion among doctors, at present, regarding
   the fundamental qualifications v/hich the trained nurse should possess;
   and there have been charges of over-education and a tendency to commercial-
   ism which result in unrest and in losing sight of the basic principles of
   their profession.  The charge of commercialism is so unworthy of the
   medical profession that I shall let it pass v/ithout comment but I do not
   consider it beside the present question to touch upon the statement of
   over-education.  It may be conceded that a nurse, possessing a preliminary
   graded school education, who has been carefully taught for two or three
   years in an accredited hospital, is able to give nursing care, under
   medical supervision, to the sick bed patient. Her greater value to the
   physician and to the patient because of greater knowledge due to higher
   educational standards nedd not be discussed here.  However, it should be
   conceded, also, that the influence of nurses on the patients of the Vet-
  erans' Bureau is more constructive mentally and morally than is the in-
   fluence of nurses who care for the acutely sick; which is, usually,
   particular personal care for a comparatively brief period.  To care for
   convalescent and Veterans' Bureau patients is to serve long hours of duty
   in which little change in the physical condition of the patients is noted;
   and yet so great is this responsibility, so important is the work from
   humanitarian and economic viewpoints that the nurses must ever be on guard
   against the insidious lack of interest which comes from routine care; and
   they  must keep*themselves so alert that their great opportunities for
   personal influence  among these men shall not bo neglected in any particular.
   With  any degree of   sickness,  there  is distorted judgment and predisposi-
   tion  to  five  undue  stress to trifles.   The educated nurse knows this and
   knov/s  also that the semi helplessness  of protracted convalescence and the
   resultant sense of  dependency,  are  among the chief factors v/hich must be
   considered  in dealing with these  special patients.   She must influence the 
 
						B		© x:				01	©		1			x:
						■H		-p	1			■p ^J			Pu	©	-P	-p
		-p				ri			o	C/J	©	c	d		rH	!>	CO	rH
		3		•p	1		©	•p	u	©	x:	©	g		©	■H	a	ri
-p	-P	x	1	10	p	©	>	a	p.	>H	•p	e			x:	-P	6	©
o	to		c	©	©	x:	rJ	o		O		©	o	u		O		x;
d	3	rH	CD	rQ	X	■p	X!	x:	^H	c	Cm	rH	-p	c	c	E	©	
p	e	rH			C			-p	• H	©	O	©		Cm	• H		£	o
©		• H	TJ	©	a	•p	o	• H	©	tJD			-p			TD		•p
-p	©		£	Xi		d	x:	^	x;	d	c	©	C	to	TJ	C	■p	
c	si	©	d		rH	x:	|3		-p		o	rH	©	p:	©	Ci	d	©
p	w	P		-P	d	-p		>^		M	•H	X>	e	o	©		x;	M
o		d	>^	p	a			Jh	Cm	©	-P	•H	©	to	O	©	+^	o
o	> «\		-P	©	X	LD	'rA-f3		O	x:	cJ	bD hD		rJ	o	>H		-p
	-P	>i	>H	(0	• H	c	TD	c		-p	■p	C	d	cu	a	•H	X3	CO
-p	c	©	t>	CD	>	•H	O	p	CO	o	■H	d	M	Jh	CO	to	©	©
to	CD	si	>H	P	• H	Pi	X)	o	r-i		rH	-P	a			©	eg	p.
a	e	-p	■P	tax)		ri		o	d	x:	•H		O	©	rH	XI	•H	
c	©		O		C	©	TD		©	-p	XI	bO	o	x:	rH		C	o
	-p	■p	d	■p	• H	6	c	M	T3	• H	d	C	c;	-p	•H	bO	bO-P	
CD	CJ	d		CO			d	• H	•H	E:	x:	• H	©		£	p:	O	
si	-p	si	-P	a	C			©			©	bD		Cm		•h	o	X
to	CQ	•p	co	e	d	to	T3	X!	XJ	hD(X		c:	>>	o	©	Pu	©	c
			o			©	C	■P	to	C		d	^>		CO	CD	M	d
*••*>	rH	©	b~	©	CO	to	■H		•H	'H	Xi	>H		C	Vi	©		
CQ	d	N	I-j	xi	E?	u	e	O	Xi	-P	c	>H	^	o	g	r-i	to	p:
pv	>>	>H	3	CO	Pi	a		■P		d	d	d	©	•H	c	to	•H	o
O	o	c	to		2	p	©		©	Sh		©	rH	-P		C		•H
•H	rH	hi			a		x:	rH	si	©	C	M	&	d	ro	a +		o
-P	CO	O	-p	.		X	■p	d	-p	Pu	o		e	C	X		■ H	■ H
O	•H	o	to	■p	10	CD		>^		O	-H	>)	d	d	•P	©		PL,
•H	X	©	3	Pi	• H	-P	Cm	o	c	J	■P	rH	H	rH		,c	©	to
P		P	E	©	XI	d	O	rH	•H	o	CJ	©	©	PU-P		-p	Jh	P
-P	r^J			e	-p	o			d	o	3	M		X	d		o	to
CO	p	-P	Ci	X!		3	CO	©	•P		M	©	>>	©	-^	«-;	e	
CD	d	CO	x:	co	X	TO	©	U	C	c	-P	s	x>		•P	HP		rH
P		a	CO	■H	P	©	• H	d	•H	•H	C/J			c		>H	X	ci
	e	e		rH	d		•P		d		C	Cm	to	c'	•>	1 ,	c	C
rH	10		• «	£-,		>,	rH	O	e	r—1	O	O	•H		CO		d	o
d	• H	©	CO	e	-p	r-x	a	x:		a	o			•»	p:	©		•H
-P	O	x	CO	o	G	c	O	f~.	o	Cm	©	M	-P	CO	o	o	©	-P
•H	■H	w	CD	CJ	©	o	d		•p	CO	K	>H	t-{	to	•H	p:	(h	d
PU-P			n	o	■H		Cm	**		to		Ci		©	-P	©	O	M
10	•H	. ^	t/j	d	-P			>.	©	©	.	Cm	•"	p:	o	T3	X^	M
C	P	C	to		d	.	©	-p	t>	o	X!	cm	to	CO	• H	C		•H
Xi	O	•H	CD	TO	PL.	CO	x:	•H	•H	o	-P	d	©	to	Pi	©	«	
		rH	r-l	C		X	-p	c	J-*	a	rH		x;	©	•P	pu to		>,
n	©	X	P-,	d	p	©		hO-P		to	d	c	•p	r-{	CO	©	P!	O
-P	>	a	rH		ri	©	a	•H	CO		©	d	o	PL	©	X)	©	Jh
	•H	ri	©	P	rH	C	O	T3		>>i			rH	r-l	>H		N	+^
CD	-P	e x		O	a		rH		O	rH		©	o	©		4P	•H	to
t>	O			t>	o	sc	©	X)	rC	©	o	^i		si	t3	p:	-P	©
•H	3	+>	©	d	•H	•H	>	C	^ P-	hJ	-P		T3		p:	©	■H	X
-P	rH	o	txC	©	-P	XI	©	d		• H		-P	c	©	d	o	O	
P--P		a	d	X	P		TO		T3	C	C	O	d	6		CO		o
CD	CO		P	C	d	X		•P	c	•H	©	M		o	■P	©	©	p
O	CD	■p	a	©	P-,	P	0	C3	CJ	Cm	B	G	>»	o	C	• H	>	
CD	X	a	o			ri	-p	©		©		d	©	M	©	a	• H	p:
P		,0	o	C	©			e	•>	rO	©	o	C	©	M	CJ^-P		o
	o		c	• H	x:	e	to	©	>-		CO		o	t>	-P		O	•H
CD	-P	o	©		■p	• H	•H	c	d	©	©	C!	e	O	d	©	Ci	-p
X>		•H		©		x:		>H	ti	rO	x;	©	•>		©	o	.0	d
	>>+>		-p	x	O		c	Cm			-p	g	T3	O	Ih	d	-J	o
o	O	©	o	• H	-p	Cm	o	©	Cm	C			O	-p	-P	rH		a •
-p	c	X	c	Vh		O	•H	U	O	d	©	©	O			Pu	ft	XI >-,
	©	-P		P^	-p		-P			o	M	o	Cm	■p	>>	©	o	© 4p
to	x	d	-p		c	bO d		•>	CO		o	• H		Pi	>-i	Pi	■H	•H
+3	c	fa	l/J	©	.H	C	O	CD	a	c:	p	>	CO	O	d		>	o c
C	©	e	a	fc£	O	•H	P	tiDrH		o	C/J	Jh	d	Cm	to	O	M	-!-> t:'
©	-p	>.	£	ri	P_,X		T3	d	;3	■H	©	©		Cm	to	•P	©	to
■H		CO		P	">	C	©	U	£	CO	J-	CO	x:	©	©		to	M
-P	©		©	a	CD	d		a	>H	tr		1	o		o	M)		O X
ri	x:	CD	x:	o	•H	-P	Cm	o	-P	©	o	K	a	Pi	©	p;	Cm	o pj
Pu-P		rO	CO	o	t>	CO	O	o	C/J	cm	-p	©	L'J	d	p;	• H	O	rH tJ
rH  d
 ©
 >  c
•H  «H
-P
 ri  ©
 p.  a
 Ci  X

 C  x
 o  c
 o  d

 ri  ©
    o
X  -H
 ©  >
x:  v.
 CO  ©
•H  CjO
rH

 c^  d
-P  Xi
 to  -p
 ©
    Cm
 C  O

 ©  r-i
 CO  CD
 d  Pi
Xi  ©
   O
 ©
 o  to
•H  C
-P   «*
 Pi  X
 CD  CD
X  C
 Pi  -H
 CD  d
-p  -p
 c  p:
>H  -H
 Pi  d
 ©  e
 PU
 3  CO
 W  >,
    d
-P  t
 C  rH
 CD  d
 to
 ©  to
 Pi  d
 pux:

 ©  ©
x:  x:
■P  0J

Cm  X
 O  U
    ci
 to  X
 ©

•H  10
■P  P-
    P
-P  O
 C  O
 CD
 CO  CD
 CD  CO
 P  Pi
 PL M
    S3
 CD
x:
-p
    d
-P  S3
-P
 PL^
 ©
 o   •»
 o  ©
 C5  >
    rH
  •» o
X  >
ri   O
rH  -P
 ©  bO
CO  Pt
    a
 bOCO
 Pi
•H  CD
 to  X!
 p.  -p
 M
S3  P
    ©
x:  «o
■p  Pi
rH  m
 Cj
 ©  -P
w  ©

 o
• H  X
rH  Pi
X>  d
 a
Ph  ©
    e
 CD  «H
    -P
Eh
-P
 P
 O
x:
 CO
 ©  c
rH  O
X>  -H
 d  CO
 bO CO
•H  ©
■P  Cm
    O
    Pi
    PL,

    x:
    bO
    •H
    Xi

    ©
    Xi
    -p

    Cm
    o

    ©
    CO
    M
    d
    o
    ©
b
X
 C
 d



 P
 ©
 o
•H
 >
 P
 ©
CO  <J

 CO  CD
■h  x:
x:  -p
-p
    Cm
 O  O
    w
X  ©
 ©  o
Xi  -H
© X
p.  Pi
bD  d
 d  Vh
-P  CD
■P  10
 ci
    p
 ©  CD
 U  X
 rf  rH
    O
 to
 ©  X
 to  ©
 P  c
 a  -h
 c  x>

X  o
 ©  o
•H
Cm  ©
•H  Xi
rH  +J
 d
 P  P
 cr1 't-t

 ©  PI
 P  d
 9  •**
 £  -P
 ©  p
 >  -H
 0)
• H  t'J

 ©  c
x>  ©
    •H
 CO  Wp
•H  d
    PL,

•h  x:
    o

-P  10
 P
 d  <m
 PL, O

-P  ©
 10  p
 o  d
 e  o

 ©  ©
si  si
-p  -P

 p  x;
 o  o
Cm  -H
    Xi

 o^
Xi  to
 t  ©
    •H
 10  -p
 ©  -H
 CO  rH
 P  «H

 2  -°
 C  «H
    CO
 ©  c
 to  O
 ©  CM
x;
■p  CM
    •H
 ©
 O    ->
 C  -P
•H  P
 10  »H
    o
 •*» PL,
 ©  t
r-i  CD
■H  «H
Xi  >
-p
c
©
EH  co
>> c^
d
PL, ©
    p
    C
P  6
p  o
o  c

"=  s
to  ©
H
    c
e  d
C  6
p  o
    p
 r'  C71
 3  ©
 CT P
 ©

 d  CD
    Xi
 to  -p
 ©
 co  Xi
 P  CJ

 c  x:

 ©  *"*
 to  w
 ©  c
x:  o
-P  «H
    -p
 ©  -H
 t>  x
•H  C
 bO o
    c
 o
•P  bD
    o
   -p
 ©
 p  ••>
 d X
    ©
 C  P
 O -H
•H  d
-p -p
 d  C
■p  ©
 ©  o
 P  'H
    >
 O  }h
-P  ©
    CO
 ©
X  <M
 d  o

    Xi
 CO  -p
 ©  -H
X  >
 d  -h
 G  rH
 ©  ©
x>  x
    •H
 ©  PL.-H
Xi  co
-P  CD
    P
X
 ©  rH
 Pt  d
 a  c
 o  o
 O  .H
 P  -P
 PL..H
    X
 bOx
 C  erf
•H
 t>  ©
 d  xi
W  -P
-P
 d
Xi
-P  Xi
-P
•H
   ©
   CJ
   H
   >
   P
   ©
 ■» CO
C
O X
to ©
Cm  10
Cm  ©
 ©  CO
    d
 >> ©
 M  P
 ©  O
 >  C
 ©  -H
 d  C
 ©  -H
 P  r^
    P
 P  -P
 ©
Xi  P
-P  O
 O  Cm
    •H
    d

 ©
 P  ©

X
 Pi  o
 d  -P

-P  ©
 CO  P
 ©  d
 P
    ©
-P  r4
 d  cJ
x:  p
-p  o
    £
 ©
 t-J  x
•H  C
 P!  d
 bO
 O  CO
 O  X
 CD  P
 P  ri
    X

-P  r'
    -P
 •*>  CO
 C
 CD  rH
 6  d
 o  o
 is  -H
    10


 Pi  PL,
•H
Cm  CD
 ©  Xi
 P  -P

X  «m
 C  -H
 d

^  >>
X  P
 ©  d
-P  w
 d  10
 O  ©
 2  CJ
X  CD
 ©  c
 I
■p
 O
P
d X
CO  CD
       p:
bD  cr -h
O  CD  -P
o  Pi  d
•H
 d
 6

 ©
Xi
-p

 p
 o
X
 c
 d
X
rH
P
o
p
 >> ©
X  Xi
 ri  -P
 ©
 p
Cm  pq

 © -
 i
 p
 O
Cm
cm
 O
 P
 ©


 PL, ©
    Xi
 ©  -p
Xi
-p
 d
 P
 o
•H
 10
 to
 ©
Cm
 O
 P
 PL, ©
    x:
 p  -p
•H
 ©  Xi
x:  -p
-p  -H
 o  to
Xi  c
-P  o
    •H
 >>-P
 to
 p
 ri
 P
 ©
■P
 ©


 ©
x:
-p

Cm
 O

 to
•P
 P
 CD
• H
-P
 d
 PL,

 ©
Xi
-p

Cm
 O

 to
X
 C
 ©

 d
XI

 P
 d
Xi
-P
Cm
 O

 CJ
•H
 P
s>
 a
<m

 ©
Xi
•P
to  c
P -H
-•  d
a -p
    p
 ©  -H
 P  d
    £3
■P
 C  O
•©  -P
Cm  ©
 ©  ©
 C  tn
 ©
X>
 ©
 bD co
X  P
 ©  ©
rH  M
    P
X
 ©
■P
 CO  U

'OX
X  c
 d  ri
a  o

©  CO
P  >1
d   o
P
©
-P
ri
©
P  Xi
bO o
    a

©
>  P
CD  O
    Cm
Cm
 O   I
     I
 ©
 >  •-
•H  X
-P  ©
 o  C
 P  -M
X  d
 O  -P

 PL, O 
 
  ou. rth  Session,           Wednesday, January 18, 1922.

                             Page 39.

MISS LUCY. MINNEGERODE, Superintendent of Nurses, U.S.P.H.S., gave a
   further discussion of "Nursing", as follows:

         Major Stimson has placed before you some of the most urgent
   problems and difficulties existing in the Nursery Service of Public
   Health Service hospitals dealing v/ith the ex-service men.

        The difficulties of the problem can be realized and understood
   only by those v/ho are in close association with the Services, and
   that the Nursing Department of the Public Health Service has been
   able to accomplish even a measure of success has been in a large
   manner due to the co-operation, counsel and advice given by the
   Superintendents of the established Nurse Corps of the Government.

        On March 3, 1919, the Public Health Service had available 1500
   beds in 23 hospitals, and practically no nurses.  Chief nurses were
   unknown in any of the hospitals. There was no machinery for the re-
   cruiting of nurses.  In regular Service hospitals, there were no
   quarters for nurses, and the Service is still concerned over a
   solution of these difficulties.  At the present time, there are 1796
   nurses in the hosoitals ooeratrd **T J-,~'3 Public Health Service,

        As has already been saia, the problem of giving the most efficient
   care to the disabled ex-service men in the hospitals of the Public  Health
   Service is a little different from that of the Army, due to the funda-
   mental differences in the organization of this corps of nurses.

        The ^urse Corps of the Public Health Service  is a civilian
   organization, pure and simple, though 99$, probably, of the nurses
   now serving in the Public Health Service are ex-service  nurses and
   familiar with the problems of the care of ex-service men.

        The aim of the Nursing Department of the Public Health Service
   is to give as efficient nursing care to the  patients in these hospitals
   as can be given, to see that the nurses co-operate in every possible v/ay
   with those responsible for the care of the patients  - that is, the  Medi-
   cal Officers in Charge,  - to recruit a sufficient  number of qualified
   nurses to meet the needs  of the Service, and to recommend the establish-
   ment of such policies  in the Nursing Department as will  increase  the
   efficiency of the  nursing corps.   The co-operation of the Medical Officer
   in Charge  is essential;  his  sympathy with and support of the Chief  Nurse
   must be  unquestioned,  if the nursing service is  to reach the greatest
   efficiency.   The place  of the  nurse  in the administrative unit of the
   hospital  should be  clearly  and definitely defined, understood and. ob-
   served.

        One great difficulty confronting this department is the lack of
  nurses specially trained  in  the  care  of  neuro-psychiatric and tubercu-
  losis patients, who constitute  a  large proportion  of our patients.   To
  partly meet this need, a  school  for  nurses conducted at  Oteen in  September
  1921, v/as organized and, v/hile  this  school was most  successful,  it  barely
  touched the fringe of our necessities.   The  Service  is considering  a 
 
H5LH.Li.il  §. ft L £ i. 2. Hi.         Wednesday, January  18,  1922,

                             Page 40D

 MINNEGERODE:  (c ont inued)

   similar course in neuro--*psychiatric nursing as  soon as there  is establish-
   ed a station where all conditions, quarters, lecturers and teaching facili-
   ties can be guaranteed to produce the desired result.

        One  piece of nursing work v/hich has been far-reaching in its ef-
   fects, was the establishment of a Public Health Nursing Unit  in the
   office of the Supervisor cf District #4, for the purpose  of making con-
   tact with the claimant of the then Bureau of War Risk Insurance, v/ith a
   view to giving the claimant, v/ho for any reason was not hospitalized, the
   benefit of health supervision and health instruction. The success of the
   work of this unit more than justified its establishment by the U. S. Pub-
   lic Health Service.

        The type of nurse needed for this Service  is the broad-minded woman,
   cultured, well trained,  with those qualities of mind and  heart v/hich
   would enable her to grasp the tremendous responsibilities in  the v/ork v/e
   are trying to do - who will be sympathetic, but firm - who will be able
   to emphasize the need for obedience to orders for treatment - v/ho can be
   friendly, without familiarity, and loyal to the highest ideals of her
   profession.

        The turnover is too large, by far, and is  due in some measure to
   conditions which are unavoidable, since they are the result of the sudden
   expansion of the Serv?.ce5 the need for immediate action, and  the great
   difficulty in securing durable hospital stations, both from  the stand-
   point of construction and location.  These conditions are adjusting
   themselves gradually, and a distinct improvement in service and morale
   in the Nursing Department, a clearer understanding of the many problems
   v/hich confront the administration and the Service in the  effort to give
   the best medical care and treatment to disabled veterans  of the World
   War, is evidence*** and,  at the present time, the U. S. Public Health Ser-
   vice is able to keep the nursing force up*.*fco the necessities  of the Ser-
   vice,

        It is believed, however, that uniformity,  throughout the organiza-
   tions caring for these patients would go far toward establishing a more
   satisfactory service, and it is hoped that this meeting of all connected
   with and interested in the care of ex-service men will succeed in bring-
   ing about this desired result.

        In the final analysis, however, it is conceded that the  responsibil-
   ity for the proper and successful conduct of these hospitals  rests with
   the Medical Officers in Charge, and I can truly say in behalf of the
   nurses  of the Public Health Service, that the nursing section v/ill co-
   operate in every possible way to promote the successful organization of
   the hospital program,  and to assure this meeting that the nurses of this
   Service will continue  to "carry on" and to render all assistance in their
   power toward the  accomplishment of this result." 
 
Fourth  Session.
Wednesday, January 18', 1922.
                               Page 41.

GEN. CUMMING:  asked for discussions, stating that only two minutes would
   be allowed for each.

GEN. SAWYER:  stated that the women were very anxious to have their
   suggestions,

CAPT. BLACKWOOD:  stated that he wished to pay his tribute to the splendid
   work that has been done by the nurses. He said he had experienced hos-
   pital work when they were dependent upon the most undesirable man that
   could be found to take care of the sick. The man who could not do any-
   thing else was the one that took the place of the nurse.  He also told
   his experiences in Boston when the influenza epidemic came, how in less
   than a month over 1300 cases v/ere being tr.eated by a staff of nurses
   scarcely larger than before, how the women worked day and night without
   rest and often without food, and how many of them lost their lives ,;.
   in the struggle.

        He stated that one  of the most important questions confronting us
   today is the question of pay of the nurses, that they had not been recog-
   nized in the way that they should be, that stenographers whose v/ork is
   not as valuable receive from $100 to $150 a month and nurses from $60
   to OlOO, and that effort should be  made to pay them more in proportion to
   their qualifications.  He stated that the charwomen received more than
   the nurses*

        He stated further that the ratio of nurses to the number of patients
   v/hich had been stated as 1 - 10 was too much to expect in hospitals such
   as his, where only  about 15$ of the patients were bed patients.

COL. EASTMBN:  stated that this should  be one nurse to every ten bed patients,.

SURGEON  STITES:  said he did  not believe any Commanding Officer could run
   a successful hospital v/ithout the cooperation  of the Chief Nurse. He
   spoke also  on the statement previously made "Kindness without familiar-
   ity", stating that  if too friendly  some patientsthink others get more
   attention because of familiarity with the doctor, nurse or attendant.

SURGEON HEDDING:  gave the  situation at Ft, Bayard, ten miles from any-
   where  with 1100 patients and 86 nurses taking care  of them.  He stated
   that the Public Health Service had  authorized the keeping of 50 riding
   horses.  He said that the nurses were happy, that the men v/ere happy,
   and that many nurses were asking to come to Ft. Bayard.

GEN. CUMMING:  asked Captain Wieber to talk.

CAPT. WIEBER:  stated that  he was  from Ft. Lyon, Colorado, 7 miles from
   the nearest city, an establishment v/ith 400 patients at the present
   time and nurse corps of  21.  He said that the  nurses v/ere happy and con-
   tent with the work given them.  He  also v/ished to give his tribute to
   the field and other nurses in the service.  He stated he had had the 
 
   Fo_urth  S e s s _i o n^           Wednesday, January 18, 1922.

                                Page 42.

CAPT. WIEBER:  (continued)

   same experience as Dr« Blackwood in the early nursing service, and that
   some of the men who took care of the eick were half idiots.  He said he
   fully realized now the value of female nurses, and believed he could not
   get along without them.

GEN. CUMMING:  "That next subject is a very important one - !Diet! - to be
   presented by Miss Clara M. Richardson, Asst. Supt, of Dietitians,
   U. S. P. H. S."

MISS CLARA RICHARDSON:  read the following paper - "Diet".

        "The subject "Diet" is a rather broad term and would suggest a
   variety of different phases, all of which might be equally interesting.
   Let us consider the subject however in its relation to the ex-service man
   and the care given him in hospitals established for his benefit.

        Among these patients we find the necessity for a wide variety of
   diet, ranging from the more common types as liquid, soft and light to
   the more complicated pathogenic diets. In what are termed the General
   Hospitals are found patients suffering from many ailments such as
   nephritis, diabetis, colitis and many gastric disturbances.  In some
   Public Health Service Hospitals, as many as four hundred special diets
   are served daily.  In planning and equipping new buildings provision
   should be made for such a volume of work.  It is impossible to satis-
   factorily serve many special diets from a general kitchen without proper
   facilities.  Careful planning is not only necessary in the kitchen,  but
   also in the serving and dining rooms.  The patient en regular diet who
   may, perhaps, be eating corned beef and boiled potatoes is not likely
   to see his neighbor eating broiled steak and mashed potatoes, without
   making some comment.  If this is not handled carefully, serious trouble
   may result.  Where there are a number of small dining rooms it will  be
   found wiser to use some of them for spe cial diets.

        In one hospital the large mess hall was divided into sections.  There
   happened to be a number of doors, over each of which were placed signs
   reading - Diabetic Diet,Nephritic Diet,  etc.  This arrangement worked
   very satisfactorily,the patients filing  in in an orderly manner wherever
   their particular diet v/as indicated.   This is a matter which is entirely
   dependent on the construction of the  hospital however,

        Of course,  care must always be taken that patients on regular diet
   who want a  few extras do not slip into a special diet dining room. In a
   hospital too  large for the  dietitian  to  easily recognize her patients,
   this  may be  regulated by a  pass  of  some  description.   Often times  the
   Officer  of  the Day in making his  inspection of meals  may discover one of
   these visitors. 
 
Fourth  Session.
Wednesday, January 18, 1922.
                                   Page 43.

MISS CLARA RICHARDSON:   (continued)

        Not only must we consider the patient v/ho comes to the dining room, -
   the bad-ridden patient is perhajs  worthy of even greater consideration.
   His appetite must be coaxed, his tray must be attractive, and above all,
   his food must be hot or cold, as the case requires.  The satisfactory
   conveyance of food from kitchen to patient is a problem in all hosoitals.
   Many institutions are so arranged that it is necessary to serv© a few
   trays in almost every corner of} the building.  In such cases, it is well
   nigh impossible to attain the de3ired results.  The ideal arrangement is
   one whereby the sick patients are focussed at a point near a kitchen. If
   Medical Officers would arrange this, other conditions permitting, they
   would find that many of the difficulties of food service would be elimin-
   ated,

        A very successful development of this method in a hospital of a
   thousand bed capacity was recently brought to my attention.  There were
   probably about two hundred patients on special diet, all served from a
   central diet kitchen.  Trays were all set up under the direct supervision
   of the dietitian - a card bearing the patient*s name was placed in one
   corner, and the tray was immediately taken from the kitchen directly to
   the patient.As a result, patients from other parts of the hospital made
   every effort to be put on wards thus served.

        The preparation of satisfactory menus and procuring of the requisite
   foods for special diet cases of course necessitates buying certain
   fruits and vegetables out of season.  It also increases the number of
   chops, stekke, etc. used.   It must be expected that the ration expenditure
   of a general hospital where such cases are cared for will be proportion-
   ately higher than where few special diets are served, as for instance in
   a neuro psychiatric hospital.  It must also be expected that the ration
   of a hospital caring for tubercular patients will be higher in accordance
   with the increased amount of eggs  and milk consumed.  It is usually
   necessary to make special effort to tempt the appetite of this type of
   patient - he often is not hungry and is apt to waste his food.   The market
   conditions in different localities v/ill also be  found to have  a very
   direct bearing on the cost of the  ration.  The central northwestern states
   provide the best and cheapest market in the country. A menu which  might
   cost 54/ in this section would perhap run 20^ higher in some other local-
   ity.

        In the preparation of menus,  too much stress cannot be laid on the
   value  of fresh fruits and  fresh vegatables.   Of  course,  it is  necessary
   to use  dried  and canned goods  to a certain extent,  but care should be
   taken that the fresh articles  are  not entirely eliminated.   The patient
  will probably  say that he  does  not like salads.  They are good  for him,
   however,  and after  a  little  persuasion he will learn to  like them,  and
  will often ask for  them.   The  personality of the  dietitian counts for much.
   If she will go among  the patients,  talk v/ith them in the dining room and
   let  them know  that  she  is  really interested  in them, they on their part,
  are  ready  to cooperate.  Such  cooperation is  absolutely  necessary,  for
  upon the attitude of  the patient depends  the''.atmosphere  of order  and
  quiet in the dining room. An undercurrent of dissatisfaction is sure to
  result disastrously. 
 
ourth  Session.            Wednesday, January 18, 1922.
                             Page 44.

MISS CLARA RICHARDSON:   (continued)

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

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

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

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

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

        The question of diet in these hospitals therefore resolves  itself
   into three problems - first, an effort to secure the foods necessary for
   a  wide variety  of diet;  second,  an effort to serve these foods in a
   wholesome,  appetizing manner amid  attractive surroundings; and third, an
   effort to instill  in the ex-service man a feeling of contentment and
   satisfaction which will  go far as  an aid  to dietetic treatment." 
 
Fourth  Session               Wednesday,  January  18,  1922.
—-—•-*■ — — —  — — — —. —.«— —

                              Page 45.


MR. J. D. SULLIVAN, of St. Elizabeths Hospital,  gave the  following  dis-
    cussion "Diet  and the Service  of Foods,  at St. Elizabeths  Hospital".

         "in preparing menus  and estimating  the  amounts of foods needed
    for  the population of St, Elizabeths Hospital, v/e base our calculations
    on the  standard dietary tables, as  published by  the office of Home
    Economics,  and the experimental stations of  the  department of Agricul-
    ture.

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

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

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

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

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

         As the  report of the daily average  per  capita consumption  of foods
    used will show we use slightly more than the amounts  considered suffi-
    cient accordin to the standard dietary  tables, because  of the  mental
    condition 6f ;   y of our  patients there  is apt to be  a considerable
    amount of food  ^avoidably wasted;  also  approximately  three-fourths of i -
    the population are male adults, and for  this reason they require more
    food than would be needed for an evenly  mixed population. 
fc.
*":  ay.
■••'  if :  ."f.-.i.....> ;.  j-
; r  ■* v-'  ■   'A •>-v;
Kr..
"•r;"
" i
a ■*  r
* Ti
xii:-: 7.Wr 
Foutth  Session
Wednesday, January 18, 1922.
                              Page 46.


MR. J. D. SULLIVAN:  (continued.)

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

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

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

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

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

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

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

    At Walter Reed there are all kinds of patients to deal with. They
    have at least one dietitian present at every meal, and the patients feel
    free to bring comment or criticism to them at any time. In the v/ards the
    nurse is directly responsible for the service of food.  If any food is
    not just as it should be the nurse is expected to telephone to the kit-
    chen and report it, and it is immediately corrected.  The nurse also
    knows just what is appetizing to certain patients and may request cer-
    tain foods for them.  One big problem is the patient v/ho has been in  /
    the hospital for a long time and needs special attention, and it is
    these patients that the dietitians try the hardest to please. The menus
    are sent daily to the ward, and the nurse makes out her diet request
   ilist.She stated also that for the regular diets 1 pt. of milk and 1 egg
    are allowed per day;for light diets 1 qt. of milk and 1 egg; for soft
    diets 1§ qt.  milk and 2 eggs; and for liquid diets lj- qt. milk and 4-6
    eggs. 
•  T 
Fourth  Session
Wednesday, January 18, 1922,
                               Page 47.

CAPT. EARL F. GREEN, Mess Officer at V7alter Redd:  Stated he had been three
   years at the Walter Reed and that during that time many problems have
   come up.  He stated that food and service are the two principle things
   about feeding people, but the greatest difficulty is service. It is very
   important to get the people serving the food confident that it is all
   right. He aaid a nurse could take the best food to a patient and if she
   thought it was not good the patient would not eat it. Good food can be
   bought with money, but service cannot. He said he used to get his com«
   plaints from the Post and Star, but this has been eliminated by requiring
   the nurse to report anything which she thinks is wrong in the diet, and
   that no complaint is too small to investigate. He believed the mess de-
   partment could hide nothing, but should be fair and above board.

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

MR. L. C. SPANGLER, Associate Medical Purveyor 0f the public Health Service
   presented the subject "Hospital Supplies", reading as follows:

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

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

        By referring to the standard list requisitioning officers can ascer-
   tain the articles kept in stock at supply depots. Requisitions for  ;.
   articles not appearing on this list should be reduced to a minimum and
   when such requisitions  are submitted they should be accompanied by a de-
   tailed explanation as to the necessity for the supplies requested. 
 
Four t;'h  Session              Wednesday, January 18, 1922,

                             Page  48.

MR. L. C. SPANGLER:   (Continued)

        Standard specifications are in course of preparation for all supplier
   which are purchased in large quantities. Such specifications enable the
   Supply Section to  obtain wider  competition from manufacturers and insures
   the delivery of a  uniform and satisf ?.ctory product.
        Commodities purchased in relatively small quantities can be obtained
   more advantageously when manufacturers stock articles are specified, as
   lov/er prices will  be received and earlier deliveries secured.
        The careful test and inspection of all supplies purchased either dur-
   ing their manufacture or after  delivery has been made is an important
   function of the Supply Section. The inspection £f supplies shipped direct
   to hospitals by contractors devolves upon the receiving officer who is
   furnished with either specifications or samples to enable him to protect
   the interests of the government.
        Satisfactory  distribution  of hospital supplies is extremely difficult
   unless suitable warehouses are  available which should be centrally located
   at points having good shipping  facilities, preferably both rail and water.
   To attempt to use  buildings for a supply depot which have not been con-
   structed for that  specific purpose delays the work and appreciably in-
   creases the cost of administration.
        Approximately 25 per cent  of the supplies now being issued from Pub-
   lic Health Service Supply Depots were received from surplus Army stores.
   These supplies will be issued on approved requisitions until the stock
   is exhausted and no further surplus is obtainable.  Every effort should
   be .made by service officers to use these materials and avoid the purchase
   of supplies as far as possible, as with few exceptions such supplies are
   in good condition. Such items as rubber goods, suture materials and  others
   of a perishable nature received from Army surplus are occasionally found
   defective due to the fact that they were purchased several  years ago.
   Attempts have persistently been made to eliminate such deteriorated  art-
   icles from stock by examination at the Supply Depots before shipment is
   made.  This process has been successful in preventing the  issuance of
   inferior  goods except in a few instances in which the material forwarded
   was in original unbroken packages.
        In the interest of economy  substitutions of articles  received from
   Army surplus will continue to be made  for special items requisitioned  for
   unless  some compelling reason requires a purchase be made,  The  necessity
   for the continuance of this  practice will be  understood when it is con-
   sidered that  sufficient funds have  not always been available to lay  in
   stocks  of standard supplies  to permit  us to intelligently  anticipate and
   arrange for our  future  requirements,  or  even  at  times,  such as  during  the
   last quarter,  to  enable us  to rake  purchases  for actual and urgent needs
   of  the  Service,  a condition  of very serious concern to the  efficiency  and
   proper  functioning of  the work of purchase  and supply.
       The  proper  care and  economical  use  of hospital supplies should  be
   insisted  upon by  officers  in  charge  of hospitals and the  officer who per-
   mits loss through excessive breakage,  negligence of theft  fails in the
   performance of  one  of  his  most  important duties.  To delegate this duty
   to  a subordinate  .and fail  to  require  its  strict  enforcement does not
   relieve the officer in charge  of his responsibility, 
 
si
o
.H
si
*

si
hO
3
o
p
si
-p

©
p
3
X
 ©
o
 o
p
 PU

 ©
si
-p


 I
 c


 O
-P

 3
 o
 >>  c
    •H
 O  ©
+> X

 bO  P
 c  ©
>H -P
-P <M
 co  d
 ©
 P  CO
 ©  ©
 ©
 p
 ©
si


 c
 o
•H
-P
 d
-P
 CO
 I
to
©
o
©
C

P
©
•P
d
-P



 ©
 o
•H
 t>
 P
-P
•H
 co
X

x)
 ©
X
 o
-p
 d
 Cu
 CO
■H
X
 ©  X
CO  P
    d

 c  C
•H  O

 ©
-P
 P
d
PL,
X  C
    o
 >>-H
 d  -P
 e  -h
    to
V  .H
M  3

    ©
    P

    d
 *-,
 3
Pu

 ©
X!
-P

 p:
•H

X
 ©
 fc>
•H
 ©
 O
 ©
 P

 CO
• ri

■P
■H

 CO
 d

 C
 o
 o
 ca

 to
        p
    H -ri

    cr-  cr*
    ©  C
    P «H
X
 ©  X «M
    O -H
    +>
    PL,  CD
    •ri X
    ©  d
    O  £
    ©
    P
■P
 PL, CD
•h  x
 ©
x
x
"P  ^H
 ©
tJ  X
    ©
-p
 d
 C
• H
 to c
•H  >H
 P  ri
 O  -p
    p
-p  ©
P -H  O
       d

   r-i  Cm
   rH  O

   Cm  «o
    ©  ©
    P  rH
    d  o
    O  »H
       -P
    10  5-,
   •h  d

   -p  ©
   •H  X

    ©  r-i
    U  O
    ©  C
   «  -H

     »  o
    U  -P
    ©
    O  X
    •H  P
   <H  3
   <M  O
    O  Ch

 »  tO »S
 P"  C  »H
 O  .h
 ©  i>  -P
 P  O  «rl
 ©  P
si  pu-p
•p  pu-h
    d
 tD    X
 d  ©  C
'ri  si  a
 p  -p
 d     X
 ©  o ©
 PU-P  .p
 PU     O
 ri  to   C
    •H
 CO     CO
 E  PU-P
 ©  ©   G
■P  -p   ©
•H  TO -P
        C
 hOX   O
 C  C   o
•H  O
 C  O  to
 P  ©  -P
 ©  CO  «H
 O
 c  ©    -
 o  si X
 OH©
        c
 >>     c
 Pi      d
 d      O
 CO      CO
-p
 d
x
-p

 o
-p

X
 ©
X
 p
 d
 co
 to
 d
rH
 O

 ©
si
•p

cm
 o
 •  C
Cm  -H
 o  d
    -p
 t-JO u
 c  ©

 t>
 o
 p
 D^«H
 PU-P
 «  ©
d ,*
O  d
d
©
rH  C
PL. O  ©  CD
pu-p  si x
3 ©  -p
to         CO
     •» O -P
   >>4->  c
   PL,     ©
   c3  X  E
   P  CD X
   q>  c  c
   X  In  CJ
   -P  3  E
   O  -p  d
   •H  Q)
   to  p si

   >?    +*
   Si  CO -H
   PM  «H  te
  •>CH
X  O
 ©
 C
 o
•H
•P
■H
 CO
-H


 ©
 P
 c
 o
•H
-P
 d
 E
 P
 o
cm
 C
•H

 P
 ©
si

 P

<M
 o
■p
H X
>  ©
P -P
©  O
Xi  3
    p
bO-P
C  co
    c
    •H

    ©
    P
    d

    CO
    -p
    o
 CD
 >


 3
PU


 Q)


 -P


 O
 -P
-P
 d

 E
 ©
si
-p

-p
 c
 ©
 to

 CO
 ■ri

 C
 o
 ■ri
o
o  x
-p  ©
w  CO
    d
P*  X
    o
CU-p
©  O
(3  d
 ^-P
>4'H
03
Si  Uj
P -H


P <H
© Q  X
rM
3
    d  p
       ©


Pti  o  d
to  -P
o   d   .
    p
    c

    d
W
 ©
 PI
«H
 P
 d
S

 ©

■P


 O

 c
 O
•H
■P
 O
 ©
 to
   -p
    3
    o
   si
   ■p


C  ^
■H 4*
 CO
 ©
■H
■P
■H
-P
 c
 d

 cr< ©
    Si
 ©  -P
si
-p  ©
    o
 fcD C
 C  ©
>^ CQ X rH  «H
           pusi

           7S
          CO  c_,
              O
           ©
          Si  c
          -P  o
    p
-p  3
 C  CL,
 c
    ©
Cm  P
rH  d

  »  to
 P  <D
 ©  r-H
x  o
 P  -H
 O  +J
    U
 bD d
 C
-H    «»
 •PLt CO
 PL, ©
•ri  «H i
J«  d
to
• M
c
p

CH

C
-P

CO
d
co
©

o
p   >.
Pl<rH
PL,  ©
d   p
   •H
 P
 O

<M


 >>
•P
-P
 CO
 Q

 cr
 ©
 P -H  CD  X
rt  P
■H -H

CT ©
©  P
p  d
 C
 o  p
•H  Q)
-P  O
 d  -h
X  <+-i
    co
 ©  ©
-C  O
•P  c
    d

 C  to
•H  C
 >>-H

>H  CD
■P  E
 o  o
 C  co
CO
10
©
CJ
©


©
si
-p

o
-p

©
>
•H
-P
d
rH
©
P
PU  ©
PU-H
d
    e
Pu  ©
cusi
3 -P
©
   3
PUX
PL, ©
3 si
PL,  O
o
o  ffl
 c
 o
•M
•p
 d

 to

 ©
jt:
-p

 o
■p
•  o  en
 3
X  c
 C>  »H

 O  X
d
 K  ©

 >»-p
rd
   (0
   ■p
   o
   d
   p
>>-P
    -P
    o
    d
    u
si  -p
 o  c
■M  o
X  o

 *  >,
 CO  rH
 E  Pu
 ©  PL,
■P  3
nH  l/J


 C  to
■H  O
 P  X

 d
 E  P
 ©  o
 P  Cm

 QJ  »*
X  O
-p

 P  *Q
 O  V
CH  O
    PL,
X  <L
 ©  o
 p
 2  >^
 PL,rH
 ©  PL,
 p  o-
 Cu 3
    co
 C
 CJ  ©
X  X
-P  -P

 ©  -P
 P  d
 d

 w  o
rH  O
 d  -p
 to  to
 o
 cu c
 O  «H
 p
 PLX
    ©
 P.  -H
 d  p
 rH  ^
 3  d
 o  o
 p
.H  -P
o  o
    c

    ©
    p
    d
        ©
       X
X <♦-« -P
 Q)  o

 to X  to
 ©  O .H
 3 -H  C
 cr p  il.
 cu  ©  3
 P  Pm«M

 (D  d  o
 p     -p
 d  P
    ©  hfl
 It, V  p
X <H «r-«
•h  d  ©
CQ      OJ
   X  P.
  *  p:  to
 <&  d  d
 ©
-P  co  P
-P  ©  o
•H rH -P
 E  O  O
 E -H  d
 O -P  Jh
O  P +»
    d  c:
 >,     o
rH  >, O
 PurH
 PL, Ci, ©
 3  PuX
co  3 -P
    CO
rH      O
 d  o -p
 p -P
 ©      ©
 C  © X
 (D r-i  Ot
O X  E
    d
 d
 CJ
■H
Cm
•H
 O
 ©
 PL,
 10

 to
 to
 ©
*H

 3
 Q)      CO
X  © «H
-P  P
    d x)
 >>     p
X  w  d
    d  £
X      d
 CO  CO
 o  E
 d  P
r-i  -H
    X
    ©
    CO
    d
    X
    o
    p
    3
  •  PL,
 o
 O  ©
•H  X
 P
 Pu C
    d
-P  o
 co
 ©  ©

 D  O
r-i  -ri
    -P
 ©  P
X  d
■P

v  &
 d  d
    x
 ©  ©
X  P
-P  'H
    10
«M  ©
 O  X
X
 to
 3  -P
        co
        >>
     .  d
 PL, Cm ro

 C  >>o
 ©  C rH
 ©  d
X  E  O
       -P
-P  to
 o  d to
 d

 ©
»H
X
 d
-P
-P
 C
 ©
 E
-P
 P
 d
 PL,
 ©
O

-P

 ©
 E
 C
 P
 ©

 o



 &
 d

«H
 O

 to

 o
 o
p
 CO

 CO
 3
rH
 PL,
 U
 3
 CO

 ©
X
-P
    ©
    P
    o
•H Cm
 3  ©
 CO PQ
E  E
c  n
p <*p
X «M <M
    to  o
 >» d  P
 P     Cm
■ H    »
 3  >,X
 CT< rH  CD
 C  P^  P
■H  CU
    3
  •»co
X
 ©  r-i
-P  d
 PL4 P
 e  ©
 ©  c
 K  ©
 ©  o
3
o
©
CO

©


c
d
o
 d  PL,
 CO  PL,
 O  3
 PL, (0
 O
 P  CD
 PuX
    -P
 P
 d  ©
rH  U
 3  3
 O  O
 P  CD
•H  CO
 o
    o
 ©  -p
X
■p  ©
    rH
Cm  X
 O  -H
    to
 ©  CO
 o  o
 C  PL,
 d
 3  co
 co  -H
 CO
■H  V
    ■H
 o
-p  -p
    d
 P  X
 O  -P
•H
 }-.  (0
 PL, ©
   •-P
 C  d
 ©  -p
£4  to
 d
-i-'  P
    o
 co  -p
•h  d

X  -H
 P  X
 d  p
 hD O
 (D  O
 P  O

 co  Ch
 •ri  Q>
 X  -H
 ^->  X
  ,  O

 •H  CD
    X

 o
 ♦H Cm
 ■P  1H
 ©
X
■P  cp

X  -H
-P  V
•H


 ©  X
•p  -p
 d
 cj  -P
    d
C
3

I
o
U X
    ©
 ©
X
-p

-p
 to

 I
    o
 ©  -H
 a  -p
    p
  •» d
•P
 C  CD
 ©  X
 0  -P
-p
 P  <M
 d  «h
 PL,
 ©  ©
©  X

d   tt)
x
    P!
    o
    •H
    ■P
    •ri
    X
    c
    o
    o

    p
    -H
    ©
    X
    -p

    to
    p:
P  -H
T<  X
3  P
 O
-P
■P
 P
 d X
 PU ©
    c
 d  o
    •H
c*-» +>
 O  C
    ©
 co  E
 3
rH  -P
 Cu CJ
 p  ©
 3  E
 CO
©
-p
 P  rH
 Ci  «H
 Pu d
 ©  >
«iH  X  d
            o
           -p

        c  c
X      HO
+>         -H
•H      >^-P
 ^     rH  d
        CL.-P
X      PL,  C
 ©      3
 o      to  cc
 d         X
rH      O +>
 PL,     C
            c
 •0      «  CD
•H     -H  t>
           •ri
 p      ©  to
 ©      p
x      o  to
 P     X -H
 O     -P

 C     X -P
 O      O -H
•H     -H  P
+J     X  O

 E         -P
 »-,     ^  3
 O      o  d
Cm
 p:      co   -s
•H      EX
        ©  ©
 to     +> J^
•H     »H  O
X          O
v      p: -p
       •H  10
^M      d
 O     -H  >,

-P     5^ ^

•h   *  * ri*
 ©  J>3 c^  o
 ©  C  C  3
 ©  <D
 P  E  to+a
    -P  C  ©
 p;  p -h  c
 o  d  ^
 PU CU 3  ©
t>  ©  O  P
    X  o  d
  •      p
X  P  CUX
 ©  d      o
-P  rH  ©  >H
 w  3  X  X
 ©  O  -P  fc
 3  -H      »*
 CT-P  P  P
 ©  P«  o  o
 P  d  fx,
    PU     X
 o          O
 C0  CD      O

 *3 *%      -^
 d  #      to
    ©
    X   «
    -P X
        ©
  -» ©  c
•P  to  o
 C  3 «H
 d  d -p
 o  O -r-l
•H  ©  UJ
<M  X -H
C  P
to c
•H
l/J
3
CJ1
©
P
    p:  e
    O  CD
    •H V
 (0  -P -H
•H  d
    -P  P
 >> P  d
-P  O t-H
•h  CU 3
■p  to  o
 C  C -ri
 ci  d A*
 3  P  P
 tf-P  c!
        PU
 ©  <m
X  O  <d
■P     X
    -P +>
 QJ  CO
 to  O  C
 3  O "H
 d      d
 O  (D-P
 ©  X X
x  -p  o

 p  to >,
 ©  C r-i
X  -H  to
-P  >> 3
•H  <H  O
 CD  'H  CD
    -P  to
 >, to  d
rH  3 -P
H-nP
 d      d
 o  -p  >
 o  o x
rH  C  d

 CO    «* (D
rH  rH  P
 d  rH  O
 co  d  E
 o  S
 Pu ©  c
 o      d
 P  ©  o
 PU 3
    rH  C
 C  d  o
 »H >  -H
 d      -P
 -P  ©  d
 X  X  -P
 o  -p  co 
 
H 2. H. L t Ii  §. 2. £ ! I 2. ,n.                  Wednesday,  January  18,  1922.

                               Page  50.

MR. L. C. SPANGLER:  (continued)

        Of course  this routine regarding  requisitions does  not apply  to  emer-
   gency requests. They  are always cleared without  delay and  every effort
   made to furnish the supplies called for as expeditiously as possible.
        It is  not  a part of the functions of the Purveying  Service to approve
   or disapprove requisitions for hospital supplies* This duty is performed
   by an officer v/ho represents the  Marine Hospital Division  and who  works
   in the office of the  Medical Purveyor  that the prompt handling of  requisi-
   tions may not be delated.  It is  greatly in your favor if  you have in the
   eyes of the approving officer a reputation for practicing  economy  in  the
   use of supplies,.  Many  of you have not met this  approving  officer, but
   you are all old friends of his. He has made you  acquaintance through
   handling the requisitions prepared under your direction  and he has formed
   a very accurate idea  of your ability to forsee your needs. He knows whet-
   her your requisitions are closely scrutinised before  you approve them,, or
   v/hether your chief  aim  in life is to have the contents of  the Supply
   Depot shipped to your station before the other fellow gets it."

LIEUT. JOEL T. BOOK'S,  U. S. NAW : presented the next subject  - "The Social
   Service "Worker" , as follows:

        "llr. Chairman, members of the Federal Board of hospitalization,  and
   fellow guests -

        The subject given to me to present is wc.vthy of  more  expert and more
   specialized elucidation than I am able to furnish v/ith ny  meager know-
   ledge of the functions of the Social Service Worker. We  are interested to
   know just what  position the Social Service Worker should advantageously
   occupy in our sincere efforts to  provide the very best care and the very
   best care and the very best treatment  for those  unfortunate individuals
   who have been disabled in the service  of our country  or v/ho have suffered
   disabilities as a result of or traceable to that service during the World
   War.
        Ky knowledge of  the Social Service1 Worker for the most part is limited
   to his or her duties  associated with Naval institutions* For almost three
   years I have represented at national Headquarters of  the American  Red
   Cross the Surgeon General of the  Navy, who is the Navy Department's re-
   presentative on the National Executive Committee.  Ky official position has
   been one of liaison but, in the organization of the Red Cross, I am the
   Director of the Bureau of Naval Affairs. In that position  it has been my
   privilege to assist in the adoption of a Naval-Red Cross program for the
   orarrying out of one of the purposes of the Red Cross Congressional Charter,
   which obligates the Red Cross to  act,  "in natters of voluntary relief, and
   in accord with the military and naval  authorities as  a meriun of communica-
   tion between the people of the United  Statos of American and their Army
   and Navy." 
 
LO

©
to
d
Ph
x»
 ©
 3
 P!
•H
-P
 c
 o
 o
§
O
pq
8
*"3
w
rH
►H*
P
CD


P
O
    l
   • H
 •  G
it:  .h
fJ  «m
©  ©
E  X
    ©  ©
    X Si
 ©  -P -P
 c
•H  hO to
 >  C -P
Pi  «H -H
 ©  -P  E
CO  CD -H
    P rH
rH  CU
 d  Pi  CU
•H  ©  3
 CJ  -P  O
 O  p  U
CO  >H  tO
    O
 >■> o
■P  to
>H
 G rH
 2  ri
              X

               1

              X
               ©
               G
              •H
               d
               p
              ■p

               ©
 ©  to  CD   ©  p
X  PU C   PU d
sp  3 O
    o
(HP*
 o  to ?->
 ©
 p
 ©
si
 p^
 CO
 O
■p

 co
 d

 co
 G
 o
•H
-P
 d
•P
X

 M0
 3  P
^ 2
-i X
©  p
p
3  ©
PU CO
    O
    rH
x  d
>H  3
 ©  X
•H  «H
«H  t>
    •H
 ©  X
X  G
■P  «H

 o  c
•P  ri

 G  si
 o  -P
• H  «H
-P  p
 d
•p  tc
•H  C
 E  -H
■H  r-i
rH  d
    ©
 O  X
 c
©  CO
■P  d
 G  ,H
 ©  CJ
 E  o
 ©  CO
 CO

 E  d
 d  o
    •ri
  •» x
rH  CD
 d  E
 G
 o  >,
 ©
 c
 g
 o
 CO
 p   «
 ©  to
 PU P
    ©
-P  m4
 G
    o
g -h
o nJ
•h  d
CO  N
CO -H
3  C
o. d
    to
»H
X
S
 ©
 E  P
 ©
 to  ©
 3.  o
 E  «H
    >

 ©  ©
X  to
-P
tf
d
    o
    o
..  X
to  O  CO
H   CO
       rH
    o  d
■P  o
    o
X  co
 c
 c
rH
3
o


©
M
 ©
X
-P

<M
 O

 to
 c
•H
X  x
 o  G
•h  d
X
 P    •»
    to
rH  rH
 ©  ri
 G  3
 c  x
 o  »H
 CO  >
 P  -H
 ©  X
 PU G
    •H
•P
 d  Cm
X  o
■P
    to
 o  E
■p  ©
    r-i
 G  X
 o  o
•H  M
■P  PU
    c
 10  'H
 ©
 ©  P
 CO  ©
    M
  * U
 PU o
 3  p
 o
 P  X
 hO ©

X  -H
 C  rH
 O  CJ
 O  «H
 ©  O
 10  ©
    PU
 ©  co
X
+>  >^
    rH
 ©  si
r-i  tO
• H  -H
.G  X

 11  „

 co  >>
 P  X
 o
M  G
 p  o
 O  -H

 *  1?
    CL
 ©  P
 O  ©
•H  PU
 >  O
 P
 ©  <H
 CO  O
•P
 d
 ©
 P
 o
 ©
 p

 ©
si
-p

 CO
 ©
-p
 d
 P  CO
 d  P
 PL, O
 ©  -p
 CO  O
    ©
 PU P
 3  -H
 o  x
 p
 to o
-p
 o
•H
 P
-P
 to

 ©
X
■P

 E
 o
 p
<H
• "P
    ©
 d  E
<h  G
rH  >H
 ©  d
 P  -P
 P  ci
 CD  «H
X  O
• H  O
 CO  to
 G
 o  *+-<
 o  o


 3  P
 o  o
 p  to
 to ©
    -p
x  ci
 G  CJ
 o
 o  ©
 ©  X
 10  -p

 ©  p
X  ©
•P  X
    Pi
 p:  3
•H
 Cv5  X
 to ©
 d  o
    d
 ©  rH
rH  CU
• ri

•?  >>

 • *  CD
 CO  CU
 P  o
 ©  p
M  Cu
p
 o  to
 p  d
 o  ©
• H X
 E -P
 ©
x  o
 d -p

 d  G
    o
 W ;->.
■ri -P
X  d
-P  Pi
 -  ®
 Pi X
 H .H
    CO
 ©  P!
 P  O
 ©  a
X
    to
to   .
    >>
to  -p
tfl.H
G  >
• H  -H
X  -P
-P  O
    d
r-i
r-i  Cm
d  O

o  x
-P  r-i
    ©
■P  -H
■H  <M
E
•H  P
rH  ©
    X
cJ
    p
    O
 ©  to
X  «H
-P
    •P
 C  ci
<H  X

 >> ^
■P  X
•H  C
 G  d
 d
 CO  «i

X
 ©
 ©
 Pi
CO
-ri
    CO
©  -H
P  X
X
 ©  -H
-p  >
 CO  H
 ©  to
 P
 ©  G
■P  -H
 G
■H  +3
    -H

 ^r
rH  Cm
 u  o
 cJ
rH  r-i
 3  3
 O  «h
•h  X
-P  G
 P  -H
 d  E
 PU
    ©
-P  X
 o
 G  X
    rH
 ©  3
 P  O
 d  X
    co
 o
::.  ©
-p
 3
X
  »  X
 to  ©
r-i  -P
 d  .H
-P  E
■H  -H
 PUrH
 10
 O  CO
X  -H

 P  P
 3  ©
 O  m4
    P
Ch  O
 o  p
•H  -H
-P  >
 d
 P  ©
-P  CO
 CO
•H  r-i
 G  d
•H  «H
 E  O
X  o
 d  co
X  ©

 d  -p
t--  ^
    •H
    ©
  •  X
 C  -P
 o
.H  «H
-P  O
 d
 N  ©
•H  >
rH  «H
 d  4J
•H  O
 CJ  ©
 ©  PL,
 PL, CO
 CO  CD
    P
Cm  P
 O  -H

 ©  CO
 to CJ
 ri  o
    •H
 PJ  10
 d  co
    ©
 PJ  <H
•H  O
    P
 to cu
 c

US
•H  O
rH
    <H
 ©  o
X
 o
 o
-p
■p
 o
 c

X
 p:
 d
 ©
 to
 c
 ©
 to

 ©
 to
 p
 o
si

 p:
 o
 E
 E
 o
 CJ
 ri
 O
•H
■P
 CJ
 ri
 P
 Cu

X
 o
 o
 to

X
 ©
 ©
 PJ

 <b
 «
X
    <H
-P  «H
    c
    ©
rH  >H
 ri  +>
•ri  d
CJ   PU-p
 o
 to  to
    .H
X  X
 ©
•H  <m
    o
•H
.*  w
 to  E «h
    ©  o
 d  rH
    X  P
X  o  ©
 ©  P  b>
■P  PU P
 d      CD
 P  ©  CO
    •C X
 CD  -P  O


 PJ  -P  ©
 d  -H  <D
 o  p ^

 P  rH  ri
 ©  d
 U  ©  CO
•H  X «H

Cm  O  cd
O  -P X

 tO-P <H
 CJ  C5 -H
■H  CD
X  -P   *
 PJ  © rH
 d  &• d
 I  g  3
 E  o x
 O  O «H
o     <h
    © >H
 ©  P X
    Q  C
    E -H
    ©
o  o
P -H

B^
©  ri
©  P
CO  CL,
    P
    o
    ©
co  X
ri  -P
-P  X
 to  o
 3  3
•O E
X
•P
 ©  P  P
 >  ©  ©
 ©  A4 X
•H  P +)
rH  O  O
 ©  P
X      >
    ©  PJ
nod
    •H
    >
    P
 d  to
 O  «H

 ©  ©
 P  X

-P  Ch

&■*

    X
  •» o
 P  o
 O  rH
Ch  X

 CO  X
 ©  c
Si  d
 o
 P  X
 d  co
 ©  <D
 CO  rH
    ch
 ©
X  to
    •H
«H  X
•H
    ©

-p  p
 p  ©
 cJ  to
 ©  x
X  ^


 d  rH
    ©
-H  ^
 P!  CD
 ©  e
•H
•P  -P
 d  o
 PU C
    T -
 ©  X
si  cj
■p  2
    Cm
    <H

    X
rH  C
 ri  ri
 o
•H    *
 »  ©

X  ri
 Pu c
 ©

 d
■P

 o
-P
 ©  d
X
-P  to
    d
 to
 d  -P
    o
r-i  CJ
rH
 ©  X
 P  C
    cJ
 co
 d  >,
    r-i
 tO  rH
 to  d
 ©  3
 PJ  X
 co  .h
 co  >
 ©  «H
rH  X
■P  CJ
 CO  »H
 ©
 P  -P
    PJ
rH  CD
 d  -H
-p  -p
 p;  d
 ©  PU
 E
    CO
 ©  -H
si  si
-p
    to
+>  p
 o  ©
 ©  x
 P  «H
X  d
 ©
-p  ©
 co  x
 ©
© si
CO +J
 ©  3
x!  o
+>  to

 to  ©

X  .p
 p
 ©
-p
 c:
•H

X
 O

 I

 to
 d
 ©
X
■P

Cm
 C

 to
 CJ
•H
X
 c
 d
-p
 10
 p
 ©
X
 PJ
 3

 o
•H
■p
 ©
X
-p
 ri
 PU
 E

 CO

 ©
X
•P
+>
 d
X  ©
>P  P
    ©
  -x;
X  £-•
•H
 d   •
 co
 U)
 CJ
•H
X
 CJ
 d
-P
 CJ
 ©
•H
-P
 d
 PU

X
 CJ
 d

 P
 ©
 o
•H
Cm
Cm
 O

 PJ
 ©
 ©


 ©
X
 o
o
PJ
o
cu
CO  Q
© X
P 8h

to   •
P  u
©  ft
O  E
•ri
Cm
Cm
 O
 I
 to
 o
si

 d   -*
    -P
Ch  3
 O  X

 PJ   *
 O  co
■H  -P
■P  CJ
 ri  ©
 P  -H
 ©  -P
 PU d
 o  cu

 ©  <M
X  O
•P
    P
 o  ©
-P  rS
 ©
X
-p
PU ©
   o
   co
 . »
P P
   ©
   CJ
   M-l
   Cm
   Cm
   O
■P  ©
    si
x
 ©  Cm
 PJ  -H
    to to
    P  c
Cfl ^H  -H
©XX
    C  CJ
    d  d
X  P
 PJ  O
 d  o
    X
 >^
 P  X
 ri  ©
-P  CO
.H  O
r-\  r-i

■go
    d
 ©
X  ©
-P  MTi
    •H
 C  rH
•H
    10
 ©  X
 to  CJ
 O  ri

5  -^
■P  to
si  o
-p  to
    ©
  * p
 to  o
•P  ch
 to
•H  ©
 X  si
 ©  -p

■p  ©
n. >j
    ri
<h  E
10  J>^
•H X
X  p
•p
    ©
p -p
o  d
ch «h
•P  3
 CJ  CJ
 ©
X  ©
-p
 PJ
 ©
•H
-P
 ri
 Cu
X  ©
-P  P
    ri
P  <M
O  rH
Cm  ©

.  "
P  CO
ri —
CJ  -p
    CJ
o  ©
■P  «H
    -P
rH  ri
©  Pu
P  ©   E
O  CJ
H  CJ   O
    o  -P
CD  CO
O  P  X
d  (D   C!
H  Cu  ri
PU
    O    i
p -p   ©
©      p
PU-P   3
OCh+i
P  ©   c'
PUrH   CJ
CO
©
©

O
■P
 c:
 ©  r-i
•ri  ©
■P  C
 d  C i-i
 P- O  CL,
    to  E
 ©  P  ©
X  ©
•P  CUrH
        ri
Ch  <h -p
 OOP
        (D
        E
        CJ
        P
ri
©
C  ©
o  c
co  Pu
ri  PU
©  d
 c:  d
•H  rH

 CO  d
 ©
•H  Cm
•P  O
 3
X  «P
    c
 ©  ©
X  E
-P  -P
    ri
rH  PJ
rH  m
 d  H->

 n  x
 w  c
 o  d
cp*
 p
 ©
    ©
    p
Pu  ci
    O
       to
       CO
       ©  E  E
       PEE
       PU o  o
       E o  o
       H
           to  ©
©  to © -H  X
       Si X  -P
>>
c:
o
X  d
    ©
   X
Cu-p
 O  r-i
 C  .H

 .b
X  3
    O
X  >H

 3
 o
X
 co
 d
■P
• H
 Cu
 O  X
 C0  +3
 P
 ©  P
 cu o
    Cm
Cm
 O  >,
    ■P
 co  -h
 ©  rH
 PL, H

 r^-°
-P  -.H
    to
 to  £
 3  o
 o  Cu
■ri  10
 P  ©
 Ci  P

    to
 ©  -H
 >  X
 i!
X  ©
    -p
-P  ri
 to  tO
 3  ©
 E  r-i
    ©
 ©  X
X
    -P
 ©  o
rH  C
■H  CJ
X  Ci
 P  O
 d  ©
    X
 03
•H  .p
    W
 ©  3
 p  E
 ©
X  X
-P  O ch
    •H  O
 co  X
rH  p  10
 a.      p
•P  Cm  ©
■ri  O -P
 PU    -p
 w  CJ  d
 o
 to  to
 E  ©
 ©  co
r-i  CO   ©
X  -H
o  E
X
 O  r-i  O
 P  o  to
 PU
    rH X
 >,r~i <ri
-P  d  d
• H      PL,
 PJ  ©
 3  >  ©
 g  d,o
 E  X
 o      o
 o  o -p
    -p
X      to
 PJ  © rH
 ri
	-p	o
p	ri	-p
3	p	
o	©	©
	PU	E
Cm	o	■ H
O	H	P
c	■H	©
o	d	P
•ri	p	• ri
•P	©	-P
d	X	PJ
N		©
•H	©	
PJ	X	CO
ri	-p	-P
'iO		■H
P	©	
O	o	CO
	•H	©
©	>	-P
X	P	o
■p	©	>
	O	©
    r-i  c"
    X -P
 >, Ci -ri
rH  J-,  O-
■H  -H  tO
 E  co  o
 ri  © x
Cm  X
 (/J      -p
 ©      H
-P  -P  10
 ri  o  O  *
■P  c   v.
CO  Cm  ©
        C
x  X  c>  ©
-*  -P
ri   to  -p
    o
    E
o
to
p  ©
© ,o
PU
   X
© r-i
si  3
-P  o
 ri X
• H  fj
 CJ .ri
 o si
 CO  [:
 tO     3
 p;  -p  o
•H  .H
X!      CJ
 O  >,«H
 3  rH
 O  co  to
■P  3  PJ
    O «H
 CO  'ri  M
 P  >  P
 'D  X  O
-*->  O  p
tox

©   E
 ©   O
■P  -H
•H  X


      •»    -H
 ©   ©  >>
X  «H  O  CO
EH   PU -r-jrH
     O  CJ  d
 •   ©  © V
X   CU    .ri
 PJ      OP
 d   to -p  to
X   3      O
 ,   O X X
■p   p  ©
 d   ©  m
     G -H
X   © »H
 PJ   tO cJ
•ri     -P
Cm  X -ri
     P*  PU  P
 ©   d  to  to
 p      o  o
     O X  P
-P  "H      CU
 ri  -P  o
Si   O -P r-i
 p  X  ri  ri
    -P  C .H
Ch   d  3  O
 o   cu-p  o
     E  p  to
 to   >> o
 ©  W Cm  P
 >      PJ  3
rH   •» 3  O
 ©   >>
 CO  rH  © Cm
 P  X X  O
 3   CJ +J

    ^J  P  o
rH      O  3
•H   d Cm  E
 P
 3
 o

Cm
 O

 (0
 c:
 o
■«-»
-p
 ri
 M
■H
CJ
 ri
 P
•H
 tO
 ©
X

 c
X
 ©
X
-p

 p
 o
<h
 ©   ©


X
    X
M   ©
     N
 PO  .H
-Cj  rH
     d
     to
     ©
        ©
    ©  X
   rH  «H
    CU  >
    O   O
    ©   P
fcJD  CU  PU
P
O  G
    d
    o
 o
-p
X  to
 c  p;
 d  o
    <H
 PU-P
■h  d
X  N
 Ul  -H
 p
 ©
 CO
 ©
• H
■p
»H
 P
 O
X
-P
 3
 d
c
ri
to  ©
p   >
o   o
    to
©
CO  x
 d
 E
     co
 ©  d
 O X
■H
 t>  10
 P  10
 ©  ©
 CO   u
     to
 P   o
 ri   o

5S
 to ©
 ©  X
 p  -p

 ©    «s
X  co
+>  Jbd

 w  d
 cJ  E
    ©
rH  C,
rH

 P  P"

 co  Cm
 d  O
 >  X  ©
 ri  -P rH

^■■rt-°
 CO
 3  X  co
 E  ©
    -P
 ©  ri
 P  rH -p   O
    7i -ri
  i d,     ^
 ©  o  to   3
 o  PU ©   o
 c     ^
 ©  co  c<  Cm
 XJ  -H  ti   O
    P
H  G
to  ©
    M
O »H
PU-P
 ©  ©
X  -P
■P  3
    -P
X  -H
 t^O-P
 3  to
 O  G
    P
 >,X
X £-i
>>
P
-P
G
3
O
PU o
 o
 CJ

-p
 to
•H
 10
 to
 d

 o
 "p
X
 ©
r-i
X
 d
 CO
•H
X

 P
 d
 P

 ©
X
-P

Cm
 O

 ©
 P
-P
 P
 ri
 pu

•P
 CO
 p
«H
Cm

 ©
X
-P

 G
•H

 X
 ©
 -p
 d
 •P
 CO 
r -,  i-   1 .... ,.
'?fyj* ,"
%-v-
4 ,.*r i.
..' . '1 : ..
•j.-w.v   .'•.•?• •-.;•■ .«■
j..,  . 
L £ H I i ll  £ £ £ i I £ £'              Wednesday, January  18,  1922.

                               Page 52.


LIEUT. COL. T. BOONE:   (continued)

   assistance the American Red Cross  can  render  the Army  and Navy. When  the
   veteran is hospitalised in Naval  institutions he is  given every considera-
   tion and treated as a naval patient. We cannot and  have no desire  to make
   any distinction between him who is serving  his country today, and him v/ho
   went to its defease  yesterday. The truly  patriotic would  not  have it  other-
   wise. The  service man  of today has been actuated by  just  as high  patriotic
   motives to serve his flag as  the  man who  stood willing to sacrifice^his all
   in the  days when  our beloved  land was  outwardly threatened by a visible
   enemy«
        To those  of us  who are  intensely  interested'in  every phase of the
   veteran problem and  v/ho do not look upon  the  veteran as merely a  medical
   or surgical case, the  testimony  given  and the tribute paid to welfare
   endeavors  and  all forms of social service by  Doctor  White yesterday morn-
   ing,v/as most gratifying!  Those  of us  of  the  medical profession have  the
   highest regard for  the keen  insight of a  patientrs mental condition,
   possessed  by Doctor  White0
        Social  service  should have  a definite  place in  hospital  organization.
   Social  service should  be the  agent of  the Commanding Officer  for  dealing
   with;  (a)  the  relationships  of the hospital to other groups  in the com-
   munity;  (b) the  relation of  the  patients  to their  families and their
   community; and (c)  in the relation of  those matters  which affect  the  social
   conditions which  are involved.
        Of course everything in the  Social Service Department as in  any  other
   department of  the hospital must be under  the  absolute control of  the  Com-
   manding Officer,  It has a relation to  the administration  of  the hospital.
   and to  the patients' treatment.  In its relation to the hospital the
   Social  Service Department may:

         (a) Provide  entertainment.
         (b) Regulate visiting under the Commanding Officer!s direction,
         (c) Receive  proper donations previously  authorized by the Commanding
                Officer.
         (d)   Stimulate in the adjacent community resources v/hich can be
               beneficial to the patients.

         In the  Navy the funds for our entertainment  program are primarily
   provided froniallotment made by the Morale Division of the Navy Department
   and  from ships shore or canteen profits.  The  Red Cross supplements  our
   endeavors  and.  assigns  dt certain hospitals other  personnel than Home
   Servicevor Social Service Workers,to assist in recreational  measures.
        The Social Service Department's relation  to the  patient1s treatment:

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

        (b)Securing reports on home conditions for help of physicians in
                deciding whether or not to discharge  a patient to his home. 
 
  ourth  Session,"        •          Wednesday,, January 18. 1922 „

                              Page 53.

LIEUT. COL. T. BOONE:  (continued)

        (c) Correspondence v/ith home communities to adjust home
                situations, thereby making it possible for patients
                to remain in hospitals. This sometimes involves
                financial aid to familiess
        (d) Arranging through local communities for men v/ho return
                home to have proper care and assistance in adjusting
                him to civilian life.

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

        (a) Helping to connect men approved for vocational
                training to get in contact with the proper government
                officials later. With a Veteran Bureau's representative
                in the hospital, this should be much simplified.
        (b) Following up patients who leave the hospital A.W.O.L.  or
                against advice, to see if they return or if leaving
                against advice that they are placed under proper
                supervision in the home community.

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

        (a) Communicating with family doctors and other to assist
                in securing affidavits necessary to substantiate
                government claimse
        (b) Information to families regarding patients'  personal
                and family affairs v/hen advised to  do so by the
                C omman d i ng C ff icer.
        (c) Furnishing information to patients regarding government
                legislation.
        (d) Furnishing information regarding government insurance.

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

        The Red  Cross  at present provides  the  personnel  for social  service
   endeavors  and  I cannot  conceive how  any  other agency  could  undertake to
   provide  this  service without  providing  the  cobweb  like  organization spread
   out  over the  United States with thousands of  Home  Service sections  as the
  Red Cross  maintains, prepared to furnish information  to the government
   officials.  Until the government can  provide  a similar, and an adequate
  service, I know  of  no other civilian  organization which enjoys the  semi-
  official recognition imposed  by  the Congress  and to which we  in  the govern-
  ment can turn for assistance, than the American Red Cross, 
 
— £ £ E ^ !l  £ £ £ £ Jl £ £•             Wednesday, January  18,  1922.

                              Page  54.

LIEUT. COL. T. BOONE:  (continued)

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

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

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

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

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

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

        It is a well established principle for the efficient distribution of
   supplies that tne final "break-up" be  made as near  the ultimate destina-
   tion of the supplies as is practicable. This requires, of course, a suf-
   ficient number of supply depots  located in suitable sections of the
   country from which the individual hospitals can secure their supplies v/ith 
v '•   .'' V'.' 
C\i
C\J
cr>
co
 >>
 P
 ri
 3
 C
 d
»"3
 ri
X
 to
 ©
 G
X
J©
P=
 PJ)

 ol


 »l

 w|

 ©|

co|


XJ|

•Pi

 Pi

 31

 o|

Ph|
LO
UJ

 ©
 to
 d
Ph
X
 ©
 3
 G
•H
-P
 G
 O
 o

Ph
M

b
P3
8
CJ
 ©
 p

 10
 d

 c
 o
•ri
■P
 ri
 o
 o
X
 G
 ri

 ©

•H
 to

Ch
 O

 G
 O  .
•H  -P
■P
 C
•H
 O
 PU
X
 G
 d
■P
 co

 ©
X
-P

 E
 o
 p
•	P
p	o
•H	E
CO	
©	
X	p
	©
©	X
u	E
c	3
E	G
-p
 to
 ©
 3
 CJ1

 u
X
EH
 &
r-i
 ©
X

 ©
r-i
X
 d
 o
•H
•P
 O
 d
 p
    x
    ©
    -P
    3
    X
    .H
    P
    -P
    CO
    ♦H
 ©  X
X
 "  ©
    X
©

   ch
    O
 ©
X

•p
 ri
 ©
 P
 to
ch
 O
©
 o
-p

 ©
 p
 ri

 to
 ©
•H
r-i
 PU
 PU
 3
 to

si
 o
.H
X!
 U3-P
 fi  3
 d X
rH .H
    P
   V rH
    CO X
   •H d
 to X P
-P     «H
 O -P co
 CU PU ©
 ©EX
x  o
    p ©
 P  PU P
   -p
 «» G
G -H
PU-P <h
   to
   o
   o
 ©
5
    CO
    •p
    o
rH  CU
 d  ©
-P  X
 G  ,

 p  o
 o
 H
-P
 d
 P
 ©
 Ph CO
 o
    ©
 PJ si
•r» -P


 E  o
 o  ©
 PL, P
Xi  d
 G
 ri x
-p  ©
   -P
    3
   X
   •H
    P
   ■P
    10
   •H
   X
 P
Ch
    >>
 • * rH
 ©  ©
rH X

 d  p
©



G
o
PU
3

©
X
•H
o
©
X

o
•p

CO
c
o
•ri
-P
•H
X
G
o
o

CJ
•H
Ch
Ch
ci
P
-P

X
G
d

to   •
©  o


rH
    ©
G  to
O  ©
•H  X
-P  -P
ri
-P  G
u  ©
o  ©
p- p
to  -P
G  ©
ri  X
Pi
-P  G
    d
Cm  ©
o  E


>> £>
X  Cu
3  PU
-P  d
co  X
   Pi
I  ©
G  X x>

o  o  ©

©
    G  ©
rH -H  X
-P     -P

•H  p  O
rH  d  -P
    CO
 >. CO  >J
 u  ©  o
 ©  o  o
 >  ©  -p
    C  co
 to
 ri  co -
X «H  to
    ^  X
 co X  -P
 ©  O  G
•H >H
rH X
 PU P

 3* ©
 to  o
    d
rH  PU d
 d  to
-P     co
•H  ©  O
 PU hO CO
 co  d  3
 o  p  o
X  o  X
   -P  ©
 co  to  c<
 ©     ri
 co <H  p
 3  o
       ©

X  PJ  -P
    3

    E  »h
    d
    ©
 i X
co -p
3
rH  G
rH -H
H-4 X
   -P
G -H
©
to
p
d
d  p  -p

(O  PJ    «,
'4  O  CO
   «H  rH
 « -P  CD
-P  d  rH
PL, Pt
•H  ©    «
©  PUrH
o  o
©     p
P  G  ©
   •H  X
G     ^
ox©
P-, d  >
3 X  O
£&
P
 ©
•P
 d
• H  ©
x X
 O -P
 E
to
©
-p
   -p
cm CO
G
O
l/J
P -P
 ©  ri
 PU O -H
    p -p
 ©  to
 tO    rH
 d  © rH
 P  X  d
 ©  -P
 >     -P
 d  cm  d
    O
 ©      !>,
si
Eh
 ©
X

 >w
 d
 E
-P
 C
 ©
 E
■P
 P
 d  ©
 PuX
 © -P
P
    d
    O
C0  •ri
G  X
 G
 O
•H
-P
 PL,
 ©  o
 CJ -P
CJ
 o
•H
-P
•H
 CO
<H
 3
 cr
 ©
 p

•p
 d
X
-P
©
>  d
  •H
•» P
 to
 G
•H
 P
 ©
 to
 to
 ri
-P
 to «h
    O
 o
 CO
 CO
•ri


-P
 ©
 ©
«H


 ©
 P
 ri

 3
 cr
   x
   G
3 d
o
>»rH
   ri
   P
   •P
   G
   ©
   o

   ©

   -p

   c
   •H
ri  m
©  ^
P
d  >,
co   I
PU-H
X
 to
■p -p
 ©
 to P
    O
rH <H
© X
N G
H d
CO rH
PU CO
co
   c
   • H
 P
 O
 o
r-i
ch

 ©
-P
 CO
■p
•H

Cm
 O

 G
 o
•H
   PU ©  Cm
tO ri  CJO
O  ©
P
to  d
to  ©
ri  p
    ri
G
O CO
O X
   o
X
-p
 ©
 E
   -p
  »» ©
 CO  ©
■P ch
 O
 PU ©
 ©  p
X  d
    3
    cr"
    to
 ©
■P
 ri
 3
 cr
 ©  ©
x)  X
 d  -P

5*
    -P
•H
■P
 3
X
-H
 P
rP
>>-H
©  E
o  o
o -P
o
  "» CO
    PU
 to PU
 G  d
•H
 J>> CO
 d «h
 CO
   •p
 >>-H
X

 © -p
rH  O
X  d
•H cm
 to
•H  G
rH M
rH
 CD   •
-P -P
 G  O
•H  ri
    P
 © -P
X
 ci  ©
 E  P
    o
 ©  ri

■°  X
 >.-p
 d  P
 E  O
   cm
-P
■h  d

  ~<M
 co  O
 ©
-P -P
 d  d
-P X
 to -p

 G  w
 P X
 ©  ©
 PU

•p
 CJ
 d
 P
■P

 d
■H
P

3
o
>>

CO
©
r-i
to
-H
d

x
G
d
   X
w  d
 d  O
 o  P
    PU
 ©  pu
 ©  d
 P
X   •>
Hp  CO
 I
X  P rH
o  o d
3 Cm -H
CO     Ci
     * ©
Ch  © -P
O  co d
    P E
    3
    O «h
    O O
 ©
 >
•ri
 ©
 O Cm co
 G  O
    CO
    d
  •» E
 to
 G  ©
•ri si
-p
 CO
           o
        - X  ©  K
Xcudpp©dcoo
3 rH  Cm
O r-i  O
>-> d
       C
H   «* O
H  CO  'ri
    ©  HP
 • >H  PU
CO rH  ©
©  P-> CJ
P  PU G
0  3  0
>, to
-P  3
p  o
.H  X
X  ©
-P  P
    d
©  £
P
©  ©
fe  ©
    p
©  X"
P  -P
CD
x  to
-P  G
    •ri
■P  >
d  d
X  X
-P

X  rH
G  d

E  -H
    PU
G  to
•H  O
    X
P
d  r-i
©  ci
X  P
    ©
G  G
©  ©
X  to

    ©
  •  to
©  P
-P  d
d  rH
X
    to
HP  -P
 3
 o
 >>

X
 G
 d

 co
 ©
•H
rH
 cu

 3
 co

X
-P
.H
 P

X
 ©
   p
   ©


   p
 , 3
© <m
P
 P
 3
 CJ

 P
 o
<M

X
 "3
 P
■H
 3  .
 cr-p
 ©
 P  <h
    O
 ©
r-i
X
•H
 CO
 CO   I
rH  ©
 E  P
 p
 ©  -p
 Ph d
    si
 ©  -p

■°  E
 >> o
 d  P
 E  cm

^->    •>
•H
    co

 P  x^
co
ta
C  G
.H  ©
CO  ©
CO  p
© -p
p  ©
X x

rH  10
d  3

•H  >.
tox
p
3 X
to  ©
H  CO
©  ©  ©
P «H  O
© r-i  -ri
H  C- >
PU PU P
B  ^  o
    CO  CO
cm
 O




•H
-P
 G
 d
P  ch
d   O
p. <h
pu  o
3
CO
       ©

       3
       d
       to
G co
© © Ch
PU'H  o
3 X
Cr"
    P
 d



-P «H
 d  p


 E  o
 P  d
-tj  ©
H  «
 ©



ch
 O

 d
 ©
x
•H

 G
 d
 >>
•P
•H
-P
 G
 ©
X
 d -P
 P  d
 tox
   -p
■p
 co   «
 ©  G
 CO «H
 P rH
 d  to
 o  3
 o  E

 ©  ©
X X
•P -P

 o   -
-P
   <H
    O

  '  to
    G
   •H
   +5
    CO
   •H
    CO
    C
    o
    o

   -p
    o
    G
 P-M

 ©  p
 t  °

-:

   X
    G
    ri
 o


■p
 G
 ©
•H
 O
•H
Cm
Cm
 3
 co

 10
 d
 G
•H

X
 ©
 P
•H
 3

 ©
 p

 to
 d
 P

X
 CJ
■ri
si
 P


 G
 P
 d
G x
O  G
       co
       to
       ©
       0
    * H
>,rH  ©
© -P  CO
-H
tO-P  CD
G  G  X
    d  -P

    tO G
       O
    ©
    E  w
    O  HP
    co  o
 3
■P
 o
 d

 to
x
 ©
X
P
o
-P
d
3
D^Ch
© rH
 ©
X
■p
 ©
X
-p

 G
 O
CD
cr d
    3
©  C71

5
C-H
-P X
 ©
 to ©
    CO
 C  O  .
 d X  rH
 CJ -P  -H
    ©
    CO
 C  P
 P  ^
 &  o
X  o

 to  Cm
 r -P
  * ci
CO
   X
   HP
r-i  P
    d
  * ©
X^
 o  ©
 P X
 ri -P
    X
    ©

 d  o
X  O
    X
 G
•H

X
 ©
 P
>H
 3
 cr1
o X
    G
  * d
to
G C-
»H r-i
-P CD
np rH
©
to  •»
P CO
o
Cm rH
X  -H
 G  E
 3
 O  X
 p  ©
 ci  P
    X
 ©  C
X  3
•H  X
    ©
   si
   -p

   Ch
    O

    ©
    G
    O

    O

   t
   •H

   X
    ©
    P-
    PU
 G  O
 ©  P
 © X
x
   x
    G
    ©
    to
Ch  ©
 O -P
    d
 P -P
 © co
rQ
 G
• H


 ©
 O
 G
 ci
-P
 CO
•H
X
 E
 3
 G
   • ri
 ©  G



    ©
 • X
 © -p

 d  G
 PL.-H
 CO
    CO
 O rH
-P
X
 © X
 o
-p

X
 G
 ©

X
 G
 d

 ©
X
■H
 to

 >>
X

 ©
X
■H
 CO

X
 ©
 0
X  d
 P  P
 ci  ©

    ©
 ci  CO
 ©
 >
 ci
X  P
    ©
-P  X
X  -P
 to o

 E  ©
    X
■p  -p
•ri
Ch  X
 O  -P
    •ri
    P

    ^J
    -P

    d
    ©
 d X
-P r-i
•ri  3
 P. O
 to  p
 o
si

 ©
X
-p

 G
•H

 ©
 CO
 3

 ^-,
 p
 cm
X
 G
 ©

 o
-p

X
 G
 ©

X
 ©
 CJ
 ci
 PU

 c
 ©
 ©
X

X
 d
X

 to
 ©
 CO
 CO
 ©
 p
-p
-p

■a

 ©
 X
 -p
tox
G   G
Cm
•H
O) CD
es cm
rH  O
 ©
X"
-p
©
p
d
3
DH
CO
 E
 P
 o
Cm

 O
-P

X
 G
 ©
 I
•H
P
-P
to
■ri
X
p
d
CO
to
CD
CJ
CD
C
>>  o
H -p  CO
P-,  <J  'ri
i   ii
3 «h  X
CO  to  ©
   •ri  ti
© -P  3
G  d
P  co
 ©
X
 O
•p
Cm X
 O  G
    d
-P
 p X  w
    pu ©
    E  rH
    o  0
    P  -H
    PUnJ
       P
    P  d
    O
   ch
P-i



P
Cj
CO
©

©
G
P  rH
Cm
 O

-P
 CQ
• H
CO
•H

to
G
•H
CO
3
O
X
©
P
ri
P

P
©
 C-
 o
p
Ph
 ©
 P 13
    P
 to  ri
 d x
    G
 to ri
 G -P
•H  IQ
 to
 3  d
 o
X   -
 ©
 P
 ri
 P
-P
 G
 ©
•H
 O
-H
Ch
Ch
 ©

 P
 o
Ph
CO
©
•H
r-i
Pu
PU
3
to

Ch
O


G
o
•ri

3
X 
 
  ourth  Session               Wednesday, January 18, 1922.

                                Page  56

COL. EDWIN P. WrOLFE:  (continued)

   These articles should be grouped in  the warehouse in conformity with the
   class to v/hich they belong, - textiles in one place;drugs, medicines and
   reagents in another; hospital furniture in another, and so'on through
   the entire list of supplies.

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

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

        From years of experience in presenting the needs of the hospital
   service of the Army to Congress, I am convinced of the urgent necessity
   for economy along all lines of expenditure and activities.  Economy does
   not necessarily mean the elimination of activities nor the discontinuance
   of the use of various articles in  order to bring the gross expenditure
   within the sums appropriated. It does mean, however, that no greater
   quantity of any article, hoi/ever,  insignificant, which may be issued to " 
 
                                           ""ednesday,
 L £ £ £ Ji ll  £££££££•            January i 18, 1922.

                             P"-gc  57.

COL. EDWIN P. WOLFE:  (continued)

   tho user, shall bo used for that purpose than is actually necessary to
   accomplish tho results desired., It means that tho services of employees
   shall be fully and efficiently used.  It means that the articles v-hich
   are not consumable in character shall be handled with such are and regarrd
   to their future usefulness as will continue them in efficient service for
   the greatest length of time.  As an illustration, it is common practice
   among many physicians v/hen writing prescriptions for various ailments to
   prescribe a four ounce mixture and to dismiss the patient. The same prac-
   tice has obtained very laregly in the hospital services of the Government.
   If, instead of issuing the usual four ounce mixture a two ounce, or a
   one ounce mixture had been prescribed, equally good results would have been
   obtained, since the patient in many instances actually takes only a quar-
   ter, a third or a half of the four ounce mixture, recovers from the ail-
   ment for which it was prescribed, and throws the medicine away. This is
   particularly true in military practice. If the lesser quantity be pre-
   scribed and further medication be found necessary, the patient for whom it
   is prescribed will return to the doctor,giving him an opportunity for anoth
   er and mjre complete physical examination and consideration of the remedy,
   of the result obtained and of any other more suitable, or have the pre-
   scription refilled if it be necessary. A dozen tablets should, be dispensed
   in place of customary two or three dozen. In other words, in the hospitals
   and dispensary services of the Government the medicines issued should be in
   quantities not to exceed the requirements of three days. This v/ill result
   nnt only in the saving of drugs themselves, as well as of bandages and
   surgical dressings issued, but will result in material saving in the cost
   of the containers in which they are issued. We too infrequently consider
   the sum v/hich the aggregate saving of the few cents here and the few cents
   there will feach at the end of a year in the larger hospital services.
   With supplies abundant and seemingly easy to secure everyone v/ho uses
   them is prone to become prodigal in their use and I cannot emphasize too
   strongly the need for economy along these lines. The application of the
   eld saying, "take care of the pennies and the dollars v/ill take care of
   themselves" to the every day use of supplies in hospitals v/ould result in
   enormous savings at the end of the year.

        I was very much impressed with the remarks of Dr.  Lavinder on special-
   ization of medical practice and the tendency in governmental institutions
   to carry it to extremes.  This is no v/here more pronounced than in the
   demand for hospital supplies,   WTiat our patients need is plenty of atten-
   tion and simplicity in equipment and treatment.   Efficiency, yes, but sim-
   plicity especially.  How often it happens that a medical officer at a gov-
   ernmental institution becomes  imbued with the  idea that he requires certain
   special apparatus v/hich must be obtained at considerable cost to the pro-
   curing  agents  to carry out his  theories  of treatment.  In a few months, or
   a  couple  of years  at  the  longest,  he is  relieved from those  duties, at that
   hospital  and.  goes  elsewhere.   The  officer who  follows  him conceives that
   an entirely different  set of instruments and equipment  is  necessary for the 
■»-1 ■  ■•  -( ■'  .-: 
  ourth  Session.              Wednesday, January 18, 1922,

                               Page 58,


COL. EDWIN WOLFE:  (continued)

   treatment-of the same class of patients than those used by the former
   medical officer. The instruments and equipment of the former officer are
   returned to the store rooms v/here they take up valuable space and new
   equipment is secured by the incoming officer to take their place.

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

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

COLONEL JAMES A. WATT IS ON, Chief, Surgeon, N.II.D.V.S,

        "Of the various papers which have been read this afternoon on the
   medical side, nursing side,               diet and supplies, the two
   words which seem to have been the key-note of each of these papers have
   been * standardization1 and 'cooperation1. It seems to me that the matter
   of standardization on the subject that I am to talk on is one of the
   most important factors that v/e can consider." He stated that standardiza-
   tion could be oarried not only through the individual hospital, but
   through every government agency "hich does this type of work.  He contin-
   ued, reading the following article - "Hospital Supplies".

        "Almost every group of hospitals follows a different system in the
   business management, especially from the stand-point of procuring, con-
   serving, and issuing of supplies.  It is believed that a decided step
   forward for U. S.  Veterans'  Hospitals v/ould be a standardization in tho
   method of prccvr'.ng, handling, and issuing of all supplies. At the present
   time most of our agencies have different lows regulating the methods by
   which supplies are to be purchased and handled.

        In some branches of the service practically everything has to be
   procured on competitive bids.   In some, greater leev/ay is allowed and
  • certain articles may be purchased, by circular letter, while others give
   still greater leeway in allowing the purchase of a large quantity of
   supplies in open market. There are advantages in all of these methods and
   at the same time there are opportunities, at least in some cases of some
   of the methods being greatly abused. This, however, depends almost v/hollv
   upon the personnel responsible for the transactions. 
 
Fourth  Session.
Wednesday, January 18, 1922.
                                Page 59.

 COLONEL JAMES A.  MATTISON:   (continued)

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

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

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

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

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

        In reference to the supplies themselves,  as has been stated, the
   first thing is  to decide what is needed.  The  second, as to the  best method
   by which these  supplies may be purchased. Third, the amount of warehouse
   space available for storing these supplies.  Fourth, as to the best grade
   of supplies to  secure for the particular parp»?e for which they may  be re-
   quired.  Fifth, considering warehouse  space and the non-perishable  class
   of supplies#what are the  most economic quantities in which they  may be pur-
   chased. 
 
Z £ £ £ i ll  £ £ £ £ i £ £l            Wednesday,  January  18,  1922.

                               Page  50.

MR. M.  SANGER:   (continued)

        There  are  one  or two  matters  pertaining  to the  question of  supplies,
   however,  that it  6eems  he  has  notetouched  upon, and  which I will  discuss
   for  a  few minutes.  The first  is in relation  to those v/hich may be  con-
   sidered the non-expendibles, or  more  specifically  those supplies  "hich are
   necessary in  connection with machines of various classes; whether it be
   automobiles,  refrigerating machines,  boiler*,  large  tools,  or what  not. As
   soon as a machine of  this  sort is  secured, an entry  should  be made  showing
   date of order,  date of  receipt,  cost, name of make,  from whom purchased,
   and  any other information  of a similar nature.   This information  will be
   needed in order to purchase repair parts,  and when needed,  as in  case of
   a  breakdown,  it will  be needed in a hurry. Parts  may have  to be  purchased
   by telegraph.   The same information would  be  needed  in  case  of inventory,
   or,  if a  cost system  v/ere  in effect,  to show  depreciation, wear and tear,
   or gr""e other information  in order to secure  accurate cost  figures.

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

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

        These things,  though they seem small  in themselves, as your experience
   will  doubtless demonstrate, are  of such importance that I cannot place too
   much  weight upon them; and  I think that a very early and close study of
   these qusetions  will assist you to a raterieCl extent in meeting the prob-
   lems  that  will confront  you, and enable you to overcome many of your diffi-
   culties." 
, .:  .Itrrwe.
,:\r
• t »a
: *  t
• )'  "O
 .•   A. ?.•/■' ff •-•; "l wrw '.i.-.i.   A:A
 'a-   r'.u'iiWj.  -i   ." "  ,  ■■•••■•r.v.--•:..'■'  fiaw  ^wa . M**'  *   -.-i
,... .• «f .* v* r, i"   ■■;'   '  '  •  '■" ',""  .»/tH  "••■ ■*'■'  "■]    , "►'■;••;.  >•?
 V i-iJ-.-."--—.-!■ ''?■::•  e\-v-  ai  f.uw.wwr  -■'." »,£>•/■  • :w /.
w:  aW  -V.-  v.a.  ,  rw i J/x-  -f^-;>  ■■?•-.«.; «i  ^ai'
         wvyl:wW  ..<  .::jv> tJ-^iwri;.:   ■•;^/^■'•,' ^r
/ jy-.. -.••/.:a   W/   • •  r.-M:'.

 *■v '> % .".•■■?  ,  -W •.. / •"■"'  ••'- • 'v
« ? ;> '  '< '. W.« f*
■•' >;f?    ■-.'  n. h-  rl  ,iiww/>i,;-w:o  W
IV .; .  ;   .  ; .  ■ •  *'. i    • I - , -  •»  ' '.'».. • •/   ■ ■•
.";' Vi;
 i - -
i  ■•  »
■■■+   ;.«.  '!■■  .W'- V1
-rwr.-aa-."ifW
.w.'  .. w. •.  .,SW';'.:  'W   *■''.'■
  i   .ri''j..:-'  ■  ;'a<Ji:  bra  oc>:    WW
'\!.a.'V  'V:*  -woo'a ??•:.-. *?:  !.'■'* a* a',
........;,  f^,.. v-vijCi.;'>W  vv  ■avw;:;""
,  ,h,v 'So  yt»f.,i.,i.-"M.-.',.i'  '   at'  ••  , a:

    .  -n/-.';  •\i.;.r--.?  '-•?<.'. .__:■■  ."•;; -'.J
'W    /.■■'ri!,ri.i:.  alWa.'i  rt:'  •'■"WW   a'ai;  *
  -'./-. : f.  1-ri-w.wa'w  .-U<;.">  ■?. ?f :><|* i-;
■  •{:■;' i.'-.'-i    .-:'XiJ.-5:.'.I :*.{,  WW.*  ':•-.'£
■   'w.    ■.:■:-:.-.   ■■■'•}■  vrv;;.;;>,;: !:vt:;:r
  .  ....  ..f,  .;.-><•* -;..  ;,.•.,? »; OWi^tf^
    -  .. .-     ....   ,.V   .  •    .•,..,.  < '.jl.,-  -■
  i •'  f  ? V-  ■■••■?  '•
A\io *"•;"  j--''f."''  ;\
. , t
I';.' ,'--v  .• •  .  : ■'<  '

'•'■••   '   -      •....■,   ,!     <J
{■•
'  .W .'' \' 
Fourth  Session.
Wednesday, January 18, 1922.
                               Page 61.


MISS RUTH EMERSON, of the American Red Cross, taking Mr. PearsonTs place on
   the program, stated that it was because the Surgeon General of the Public
   Health Service turned to the Red Cross that they came into being in this
   particular connection.
   She stated that certain fundamental principles had been written down
   between the Public Health Service and the Red. Cross, v/hich had been
   abided, by, and that it had been a great problem which was taken up with
   the Commanding Officer to keep out the things that were undesirable and
   to bring to each hospital the best things for that hospital, not only
   for the patients but for the personnel.  She stated further that on the
   information side the Red Cross had. been a great aid in bringing to the
   patients knowledge about various government regulations, but that nov/ as
   more and more attempts are made by the various departments to get this
   information to the man the need for the Red. Cross in this regard becomes
   less.  Another important function of the social service worker is to find
   out the home conditions to which a man with tuberculosis is going when
   disch arged from the hospital,

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

   The motion was carried and the meeting adjourned at 4:45 P.M. 
 
£ i £ 1 ^  §£££-££                Thursday, January  19,  1922.

                             Page  1,

GEN". SAWY2R:  "I would  like  to ask if  either  of  our  committees are
   ready to report or whether they have any inquiries to make".  He
   asked Captain Blackwood for a report,

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

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

ADI.URAL STITT:  "The first paper is "Discussion  of Disciplinary Regu-
   lations of Veterans1 Bureau as  they affect the beneficiaries and
   hospitals", which, someone will  read for Colonel Patterson, who is
   still ill."

Iv&JOR R. W. BLISS. U, S.  Veterans' Bureau, took up "Discussion Of
   Disciplinary Regulations  of Veterans' Bureau  as they affect the
   beneficiarias and hospitals", as follows:

   "In a discussion of  U. S. Veterans1 Bureau General Orders 27,
   dated September 3, 1921 and 27-A dated January 14, 1922. covering the
   Disciplinary rsgulations  governing  beneficiaries  of the Veterans1
   Bureau who are patients in hospital, it is assumed that even before
   September 1921, all  present recognized the advisability and necessity
   of some lawful method by which  the  small lawless element, often present
   in hospitals,  as it  is in any other community might be effectively dealt
   with.

               It is further assumed that the provisions of the September
   General Order #27 ar. generally v/ell known to this audience*

               Therefore,  this present paper will be limited to a brief
   statement of fact of the numbers of patients discharged under this
   order,  and to a statement of the essential differences in the September
   G.  0. #27 and the G.  0. 27--A,  issued yesterday, leaving any comment to
   the  general discussion,

               I have here a chart showing the name,  location and type of
   every Government  hospital receiving Veterans1  Bureau patients,  and giv-
   ing  the  total number of patients in each,  and the toal number of
   patients discharged from each one,  under the provisions of General
   Order #27, between the  aates  of the issuance of this  order,  on
   September 9,  1921 and January 14,  1922. 
 
1 £ J: J: =i  ^£££x££              Thursday, January  19, 1922„

                              Page 2.

BLISS (Cont.)

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

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

              Between the dates above mentioned, there have been in and
   admitted to these 97 hospitals,  44,318 patients.  Of this number,
   4t74,  or a trifle over 1$, have been discharged for disciplinary
   reasons; 732 or  2% have  left against Medical Advice,  and 1804 or
   4$ have been absent without leave for a period of 7 days or over,
   and have so been dropped from the rolls of the hospital*  This is a
   total of 3010 or 1%

              In the 67 Public Health Service hospitals there  have been
   33,028 patients, of this number 336,  or 1% have been discharged for
   disciplinary reasons,  520  or 1.5% have left against Medical Advice,
   and 1233 or 3.5% have been dropped as over 7 days A.W.O.L*.   This  is a
   total of 2089 or 6%.

              In the 14 Naval hospitals,  there have been 2571 patients,
   Of this number,  44,  or 1*7% have been discharged for disciplinary
   reasons,  49 or 1,5% have left against WIedical Advice,  and 44 or 1.7%
   have been dropped as AWOL.  This is a total of 107 or 4%.

              In the 9 soldiers homes there have been 4721 patients,,  Of
   this number 56 or 1.2% have been discharged for disciplinary reasons,
   111 or 2.3% have left against Medical Advice,  and 437 or 9.2W have
   been dropped as A.V/.O.L.  This is a total of 604 or 12.7%.

              In the six Army hospitals,  there have been 3076 patients.
   Of this number 44 or 1.4% have been discharged for disciplinary
   reasons,  50,  or 1.6% have been discharged against medical advice,  and
   65 or 2% have  been dropped as AV/OL.  This is a total of 159 or 5>.

              St.  Elizabeth's hospital has had 922 patients ana our
   records show that none have been discharged for disciplinary reasons,
   none  left against advice and none  havo  been dropped as AWOI*

              In a  general way,  the  large  tubercular hospitals show the
  'greatest  nurtber  and percentage  of  discharges under this order*
   One or two hospitals show over 30% discharges,  these  being  mostly
   against advice and absent without  leave.

              Since  the  issuance  of the  September General Order #27
  a  great deal of adverse  critiscism of  it  has been received  from many 
 
i ft h  Session
Thursday,  January 19,  1922*
                            Page 3*

BLISS (Cont,)

            With this in mind and with  the knowledge that penalties
   were prescribed in the original order which did not conform exactly
   to the wording of the Sweet Bill General Order #27 has been
   rescinded and General Order #27A issued in its place.

            The essential features and  changes in General Order #27-A
   are as follows:

   1,       There are four classifications:

            (a) Patients leaving institutions against medical advice*.
            (b) Patients leaving institutions without permission,
            (c) Patients discharged from institutions for disciplinary
                                               reasons
            (d) Patients disciplined by forfeiture of compensation v/ihout
                dis charge»

   2.       Under Paragraph (a) patients leaving institutions against
   advice, there is a definition of when treatment is completed*
            Patients leaving the hospital against Medical Advice the first
   time receive transportation and expenses to their homes*  Thoy may bs
   readmitted to hospitals.

   3.       Under (b),  Patients A. WW, 0. L.

            Patients AWOL for a period  of 7 days may be readmitted to
   hospital but oniy to the hospital from which they are absent.   After
   7 days, absence,  they are dropped from the rolls Of the hospital,  and
   further hospitalization can be authorized only by the Director*

   44       Under (c) Patients discharged for Disciplinary Reasons,  there
   are three limitations

                  1.  Ho patient who is mentally irresponsible shall be
                     discharged for disciplinary reasons.
                  2.  No patient shall be discharged for disciplinary
                     reasons,  if his physical condition is such as to
                     endanger his life by reason of such discharge,

                  3.  Wo patient shall be discharged for disciplinary
                     reasons,  except on the recommendations of a Board
                     of Officers approved by the Medical Officer in
                     Charge of the institution*

  Provision is  made  for minor punishments.

                     The Board  of officers  above referred to is  to be
  comrosed  of tv/o medical  officers  on the  staff of the  hospital  and a 
 
a. £ £ m k  §££££££               Thursday,  Jarruary 13,  1922.

                             Pag2 4.

    representative of the U. S. Veterans1 Bureau appointed by the
    District lianagero  When it is impracticable for the District Manager
    to appoint a representative he will request the Medical Officer  in
    Charge of the hospital to appoint a member of his staff to represent
    the Veterans' Bureau,.

               Patients discharged for the first time for disciplinary
    reasons receive transportation home.  They arc not readmitted to hospi-
    tal except by the authority of the Director*

               On the second or subsequent discharge for disciplinary
    reasons cr for being AWCL,  the board may recommend a forfeiture  cf
    compensation up to a maximum of 75% each montn for a period of three
    months time.

               Patients discharged under any of the above classes who are,
    following their first discharge,  readmitted to hospital and after this
    2nd- admission are discharg-d for completion of treatment revert  to their
    former status with a clean record.

    5.         Under (d) patients disciplined by forfeiture of compensation
    without discharge.  Provision is made whereby patients who have  com-
    mitted an offense when it is not deemed necessary or advisable to recom-
    mend their discharge because of the nature and gravity of the offense,
    or because of the patients  physical conaitiaa,  forfeiture of their
    compensation up to a maximum of 75% each month for three months  may  be
    made effective.

               Provision is wade for the proper recording of all patients
    discharged in all districts,  for the making of all forfeitures effec-
    tive and here after all admission cards will bear a notation indicating
    whether or not the patient  has been previously discharged under  this
    order Section II of General Order 27-A is as follows:

               Patients discharged for disciplinary reasons nill not be
    readmitted to the hospital  from which discharged.   So  far,  of the
    patients discharge!for disciplinary reasons,  71 have been readmitted tc
    hospitals.

               The principal complaint received from patients  discharged
    has been that they kitew notning  of General Order #27."

ADMIRAL  STITT:  stated that it  had been the  rule to have all the  papers
    read before  opening  the discussions.

SURGEOIW P.  S. RAWLS,  W.  S, P.  E.  S.  (P.):  read the  next  paper,  "Relation
    of District  Managers  to Hospitals",  as fo Ilea's:

    "The District manager and his District Medical Officer need no intro-
   duction  tc you.  You  are all  familiar with their responsibilities.   They
   are the  representatives of  the Veterans'  Bureau with whom you come in
   contact most  frequently. 
 
Fi.fth  Session               Thursday, January- 19, 1922.

                            Page 5*

RAWLS (Cont.)

        The office of District Manager was created by the Director, Colonel
   Forbesr whew he assumed direct control of District organisations,,  The
   District Manager  is charged with the responsibility for all phases of
   the work of the Veterans' Bureau in his district.  The Director also
   appointed a District Medical Officer who*  through the District Manager,
   is responsible for all phases of medical work of the District- the
   examination, treatment, hospitalization;,  dispensary,  convalescent and
   follow-up care -  in fact the entire physical rehabilitation of patients
   of the Veterans1 Bureau.  And only recently the additional responsibili-
   th of  the determination and rating of disability lias been added..

        The medical  organization of the District Office has been developed
   primarily for the purpose of establishing claimants of the Veterans1
   Bureau as patients entitled to treatment,  and the furnishing of proper
   treatment,  under  regulations,  orders and instructions issued by the
   Central Office.   The District Manager and his District Medical Officer
   are charged execution of these instructions.  They are charged with
   hospitalization of patients in your hospitals and during such hospi-
   talization,  they must look to you to assume the burden of responsibili-
   ty.  In order to  prevent misunderstanding and to define the relation of
   the Veterans1 Bureau and its District IWonager to the Service hospitals
   and their Commanding Officers,  Field Order #23 was issued which states
   in Paragraph #2 and #3 as follows:

        You will note that one of the duties of the District Manager is  to
   keep you informed of the general aims and policies of the Bureau,
   This means contact - close personal contact, if possible, with the
   Commanding Officers of the hospital,  working together,  keeping informed
   - the District i.jjanagor with the work and problems of the Commanding
   Officers informed of instructions through the official channels of the
   Service to which he belongs.

        When the District Manager hospitalizes patients in your hospital,
   he must,  necessarily,  have certain reports,  as he is still responsible
   to the Director for these patients.  The reports of physical examina-
   tion,  on the proper Bureau forms are obviously essential,  Important,
   too,  is the prompt and accurate report of admission to and discharge
   from hospital of patients of this Bureau,   Mention has been made of the
   multiplicity of reports asked  for and the  Bureau and its District
   Offices are making definite effort  to relieve you of this burden.  With
   the extensive decentralization of the work of the Bureau to the District
   Offices and the closer cooperation of those offices with your hospitals,
   the request  for reports made upon you in the past will be reduced.  I
   feel confident that this result is  already evident if comparison is
   made  with conditions  of:; year  ago*   During the recent conference in
   Washington  of District Wanagers,  District  Medical Officers and Vocation-
   al Officers,  the  question of reduction of  reports and forms was urged 
 
ifth  Session
Thursday,  January 19,1922.
                           Page 6,

BLlSS(Cont.)

   resulting in a careful revision and some elimination which should indir-
   ectly affect you.

        The most direct method of improving this condition will be placing a
   representative of the District Manager in your hospital,  He will be able
   to act with the authority of the District Manager on many matters now caus-
   ing difficulty and delay.

        I should, like to take this opportunity to call your attention to cert-
   ain phases of treatment which the Veterans1 Bureau and the District Manager
   expect you to give to patients, namely, to disease or disability develop-
   ing for which the patient was not admitted to hospital and to conditions
   which are not apparently of service origin in this connection, I v/ould
   remind you that the Director is charged with providing treatment to benefi-
   ciaries taking Vocational Training for disease or disability mot due to
   misconduct, although not re.lated to any service disability.  This is embod-
   ied in Regulation #12 recently issued and from which I quote: -

        The relation between the District Manager and the Commanding  Officer
   of Service hospitals should be one of mutual cooperation.  The success of
   the hospitalization program of the Bureau depends on this.  The intelligent
   and sympathetic support of everynCommanding Officer is essential and the
   Central Office firmly believes that every District Manager v/ill give you
   his unqualified support in your work in  hospitalization of patients of the
   Veterans1' Bureau.  The one thing that I would impress on you above all
   others and v/hich will do more than all the instructions that could be is-
   sued,  is get together v/ith the District Manager."

COLONEL H.M„ EVANS,  of the U.S.  Veterans*  Bureau: discussed the subject
   "Physiotherapy and Occupational Therapy in Hospitals" as follows:

   Mr. Chairman,  Ladies,  and Gentlemen:

        The subjects of Occupational Therapy and Physiotherapy constitute what
   has been designated as the Section of Physical Reconstruction in hospitals.
   Early after the United States entered the War the Surgeon General of the
   Army realized that it w-s necessary to utilize all the agencies that would
   aid in the recovery of men disabled in the War.  He,  therefore,  established
   a Section in the Hospital Division of Physical Reconstruction, to include
   Occupational Therapy,  curative work-shop instruction,  and Physiotherapy
   which includes Electrotherapy,  Hydrotherapy,  Mechanotherapy,  Thermo therapy,
   massage,  and directed exercise.   Col Frank Billings,  of Chicago,  v/as made
   Chief of the Section,  and the Work v/as developed until there v/ere 48 hospi-
   tals with more or less perfect equipment in Physiotherapy and Occupational
   Therapy,  2000 Occupational Aides and curative work-shop instructors,  and
   1200  Physiotherapy Aides  and  Medical Officers.   There were as many as 34, COC
   men engaged  in some form of  Occupational Therapy in one month, and 20,000
   different  men treated  by  Physiotherapy. 
 
£ i ± i k  Session             Thursday,  January 19,  1922.

                              Page  7»

COL. EVANS  (Cont,)

            Upon the  retirement of Col„  Billings I was made Chief of the
    Section, and the work  continued to develop until 69 per cent,  of all
   hospital patients  were doing some form of work in Occupational 'Therapy
    or  Prevoca.tinnal Training.  There were many hospitals that maintained
    an  average of aOOO Physiotherapy treatments a week for a number of
    mont?as0  As the men. v/ere discharged fiom Arny Hospitals the burden of the
    Fublic H*&Jth Il-'.saatais became greater,  and many of the mdiv.ia.uals
    who had  been. aa-Jvo "in the Army v/ork became associated  with the Public
    Health and established as a part of their hospital program, the Section
    of  Physical Peeenstxaction., to include Occupational Therapy and Physio-
    therapy,  Thws work nas developed throughout the past year and a half.
    It  was not thought within the province of the Public Health to develop
    Prevocational Training*

             TWae speaker-  having resigned from the Atay. accepted a com-
    mission in the Pay lie Eealth Service and was detailed to the Federal
    Board for Vocational Education as Medical-Officer in Vocational Train-
    ing*  For a year and. a half in this capacity he assisted in develop-
    ia.a 181 c^atere, most of v.hich were in connection v/ith hospitals?  in
    which the Prevocational Training was the major part of the work*  Under
    this maria-emant there v/ere about SCO teachers employed, and about
    14,00 men engaged in. some form of work.  Unfortunately, the necessity of
    calling this Fr«vocational Training, in order to have it come under
    the Federal Board, lew. ga~e a wrong impression of the v/ork as done in
    hospitals.  When  the Veteiaas* Bureau cane into existence, it took over
    the ac^.ivites of  the Federal Board and the Bureau of War Risk Insur-
    ance and correlated these with the Public Health Service, the Veterans'
    Bureau having; under the  law, power to do anything that v/as necessary
    in the rehabilitation of  the ex-service men*

             The Centers that had been operated under the Federal Board
    were divided, and all those attached to hospitals v/ere put under the
    Medical Division and the v/ork was considered as Occupational era Pre-
    vocational; all Centers that v/ere for Section 2 trainees v/ere des-
    ignated as Vocational Schools, and on November 17,  1321 a program
    for Physical Reconstruction in Veterans' Bureau Hospitals was ap-
    proved by the Director, as outlined in Exhibit A,

             In accordance v/ith this approved plan, v/hich had previously
    been approved by  the Federal Board of Hospitalization, it became nec-
    essary to have a procedure; as/all other personnel in hospitals .vers
    responsible to the Commanding Officer and controlled from the head-
    quarters in Washington,  it v/as deemed advisable and consistent  to have
    all Veterans' Bureau personnel that were detailed to a hospital placed
    on  Central Office  Payroll and directed by Central Office,  in accord-
    ance v/ith this,  on January IS, 1922, a procedure was approved,  to be
    issued as  a General Order, as shown in Exhibit B.

             This makes it very plain as to the attitude of the Federal
   Board of Hospitalization and the attitude of the Director of  the Vet-
    erans1 Bureau toward Physical Reconstruction. 
 
Fifth  Session
Thursday,  January 19,  1922.
                              Page 8,

COLc EVANS (CONT.)

             In addition to the agencies described, which are usually a
   part of Physical Reconstruction, there have been placed for admin-
   istrative purposes the Follow-Up Nurses of the Veterans' Bureau, which
   includes 265 graduate nurses, distributed throughout the various dis-
   tricts, and acting in the capacity of Follow-Up Nurses under the direc-
   tion of the Medical Officers, performing duties in accordance with
   regulations as outlined in Field Order #18, Exhibit C«

             During the past month the Follow-up Nurses performed the
   duties as shown in Exhibit D.

             Upon the division  of the so-called Training Centers,  as out-
   lined, the number of teachers and the number of trainees which were
   strictly in hospitals were reduced, so that the Report for December,
   1921, shov/s a summary,  as given in Exhibit E.

             The greatest difficulties in the way of proper establishment
   of physical reconstruction have been,  First,  Adequate space for hos-
   pitals.  Up to the present time this has been considered an extraneous
   service and it has only been possible to secure suitable quarters in  a
   relatively small number of hospitals;  but upon the approval of  the
   Federal Board of Hospitalization and the Director of the Veterans'
   Bureau, it now becomes an integral part of the hospital program,  and
   little difficulty should be experienced in the future.   Second,  It
   has also been difficult to secure proper personnel,  particularly for
   Occupational Therapy for mental cases,  and in order to have this work
   efficiently done it is zuy opinion that school of training should be
   established at St J Elizabeth's Hospital,  whereby a sufficient number
   of occupational Aides,  who have had experience with other types of
   patients,  may have the opportunity to  receive  special training  in
   handling mental cases*   When you remember that in the Army there were
   only 48 special officers in Physiotherapy and  that we now have  100
   hospitals,  and most of these would need a special officer for this
   work and are contemplating establishing a number of clinics in  each
   district,  it is absolutely necessary to make  some provision for train-
   ing medical officers in Physiotherapy.

             Wre have  had authority for some  months to employ 100 Physio-
   therapy Aides  and  have  utilized every  aide that has  been made avail-
   able  by Civil  service,  and have but  7«   If we  are  to meet the require-
   ments  in Physiotherapy  it will be  necessary to establish a training
   center for Physiotherapy Aides,  and  it  is  suggested  that the  facil-
   ities  for this work  at  Walter Reed Hospital and the  various Bureau
   Clinics, and the Hydrotherapy department at St.  Elizabeth's be
  utilized for the training, and that  a regular  program be utilized
   and course of study  provided  to  meet the requirements  of this ser-
   vice. 
.•:?Www

:..l.i •;'  Y'.
■..:'   ,a
 • A  '!,",
a-;  •. a
a .>•„ 
 Fifth  Session                  Thursday,  January 19,  IS 21.

                              Page 9.

           Another one of the difficulties that is not only applicable
 to hospitals,  but to all centers of Vocational Training,  is the
 method of disposing of fabricated articles.   The amount of paper work
 necessary incident to this and the fact that the money does not revert
 to the service but to the general treasury makes it  a veiy unsatis-
 factory and cumbersome procedure,  and some legislative should  be asked
 for to enable the Veterans' Bureau to proceed as the Indian Service
 proceeds in disposing of fabricated articles,  or articles that are the
 result of the work of the. trainees.  Under the new procedure ail per-
 sonnel of the veterans'  3ureau detailed to a hospital are directly
 under the Medical Officer in Charge.   The special work is directed
 by the Educational Director,  who should be considered as  one of the
 staff of the hospital,*  Hie greatest  criticism that  has been par-
 tially sustained in regard to Occupational Therapy has been that men
 v/ho are physically able  to do more purposeful things have been kept
 making trivial things, First,  because it was  relatively easy to  amuse
 them,  Second,  Because of some of the  articles  the patient has  derived
 considerable revenue from the sale thereof.   The whole scheme  should
 have in mind,  First,  The Therapeutic  value of the activity,  Second,  The
 Prevocational Training of the activity,  with  the hope that you could
 shorten the time of hospitalization and also  shorten the  time  of Voca-
 tional Training by the amount of Prevocational work  done  in  a hospital.

           Prior to the work in Army Hospitals  much individual work had
 been in Physiotherapy and Occupational Therapy,  but  this  was not  cor-
 related.   One  man emphasized the static machine,  another  man built up
 his  institution upon the basis of Hydrotherapy,  another upon the  physi-
 cal exercise,  but it remains  for the  work in  the Army Hospitals  to
 coordinate these agencies and present a solid  front  for Physiotherapy.
 One  of the things that remains yet to be accomplished is  a proper co-
 ordination betv/een Physio the rapy and  Occupational Therapy.   It is waste
 of energy and  money to have a Physiotherapy Aide spending hours  of time
 in massaging a stiffened joint when,  if her work could be  supplemented
 by properly directed physical exercise in a shop or upon  the farm, the
 same member could be so  used  as to assist in  restoration  quite as readily
 as from massage.   It is  expressly  understood  that all the work in Occu-
 pational  Therapy should  be  upon prescription  of the  Medical  Officer in
 Charge  of the Hospital or his designated agent,  and  a proper cooperation
 between the Medical staff and the  staff of the  Reconstruction Section
 will insure most satisfactory results,  and that this  cooperation  of the
 v/ork will be very necessary in order  to secure  proper efficiency.

           In the General Order referred to the  ratio  of teachers  to
 patients  per teacher most be  considered as a general guide only,  as it
 is quite  well known  that in mental hospitals  the  number of men  that
 can be  cared for by  a single  aide  or  teacher will be  less  than in other
hospitals,  and  it  must also be understood that  the character of  treat-
ment in Physiotherapy will  also  modify the number of  treatments  that
may be  given by  each  individual. 
 
Hi££k  1 ££ii £S              Tuesday, January  19,  1922..

                             Page 10.

   EVANS (Cont.)

              I am particularly grateful for this opportunity to present
    the matter of Physical Reconstruction to the men who are caring for the
    disabled veterans,. a»d v/ho can do so much to make this phase of the
    hospital program a success.

                              EXHIBIT A

                                           November 17,  1921,

    Assistant Director, Medical Division,
    The Director, U. S. Veterans' Bureau.
    Physical Reconstruction Section*
1.-   Modem hospital treatment requires that Physical Re-
construction be established as a part of the hospital pro-
gram.  It is our duty under the Sweet Bill to render this ser-
vice to the beneficiaries of the Bureau while in hospitals
and in dispensaries.  Such service includes,

               (a)  Occupational therapy and
               Pre-Vocational Training.

               (b)  Physiotherapy,  v/hich compre-
               hends directed physical exercise,
               Mechanotherapy, Massage, Electro-
               therapy, Hydrotherapy, etc.

               (c)  Follow-Up Nursing,

OCCUPATIONAL THERAPY AND PRE-VOCATIONAL TRAINING
     In order to carry out the v/ork in hospitals
of Occupational Therapy and pre-vocational train-
ing it is necessary to have

          (a)  Personnel.

          (b)  Equipment.

          (c)  Expendable material.

          (d)  Suitable space for v/ork.

(a)  It is estimated that it v/ill require 50
additional trade and industrial teachers, 50
additional commercial or academic teachers,
and 100 occupational aides,  making a total
of 200,  salaries ranrinp from $1600 to $2400,
(b)  As the new hospitals opened will be re- 
 
a. A £ Ji k  §sssion              Tuesday, January  19,  1922,

EXHIBIT A (Cont,.)           Page  11,

         ceiving men from smaller hospitals,  the  equip-
         ment that has been used  in  the  small hospitals
         may be transferred to  the larger ones.   It  is not
         possible  to make an  accurate estimate as to what
         additional material  may  be  needed,  as v/e do not
         know how  much  of this  can be secured from other
         branches  of  the Government, but in hospitals
         numbering less than  200  patients the amount to be
         expended  for equipment would be relatively  smallT
         In the new hospitals,  however,  numbering over 200
         patients, where pre-vocaticnal training  is  desired,
         a  reasonable equipment would have to be  furnished.

          (c)  As  to  expendable  materials for occupational
         Therapy  the  past  experience has shown  that  it will
         amount  to $2.00 per month  per  nan actually  at v/ork,
         and possibly 25 per cent of the entire hospital
          population will be doing some  work of  this  character.

               I  would recommend the  approval of the  plan  in
          operation in the  Public  Health Hospitals for disposing
          of salable materials made  in Occupational Therapy  or
          trade work,  which is that  the  patient  may make two
          a.rt:cles0 giving  one to the Government to be  sold,
          and the other retained by himself,.  The  price  for
          which the article is to be sold shouxd be established
          by a Board of Appraisal., appointed by  the Medical
          Officer in Charge,   or Superintendent,  the proceeds
          to be used as a revolving fund for purchasing supplies
          for this work, if it is xegal -.if not,  the proceeds
          to revert to the Treasury.of the rjnited States,

     PHYSIOTHERAPY

               The personnel  for  this work has been previously
          authorized to the extent of 100 physiotherapy aides
          and 10 Medical Officers in Paysiotherapy.  It will
          be necessary,  of course, to have  suitable equipment.
          This will be  recommended by the District Managers
          and approved by the Medical Division before a re-
          quisition is filled.

               There is a small expense  for expendable material
          in Physiotherapy, which will not  amount  to more than
          50^ per month per man for  treatments.

     FOLLOW-UP NURSING

               The plan for Follow-Up Nursing has  been approved
          and 300 nurses have been author!zed„ These are 
 
1 k 1 1 h  Session
                                      Thursday, January  19*  1922,
                               Page  12,
EXHIBIT A. (Cont.)

        practically all assigned, and we are requesting
        authority for an additional  50 as  they may be needed*

   NATIONAL  SOLDIERS' HOMES

              It  is  the desire  of the Board of Governors  of
        the  National Soldiers' Homes that  the personnel  and
        equipment for  the  reconstruction work, including
        Occupational Therapy,  pre-vocational training, and
        Physio-Therapy, be furnished by this Bureau*

   NAVY

              It  is  desired that  the  personnel, equipment,
        and  material for reconstruction service, covering
        all  phases  of  the  v/ork,  be furnished to the Naval
        Hospitals and  detailed there to work under the
        direction of the Medical Officer  in comnand,

   ARMY

              It  is  the desire  of the Amy  Hospitals serving
        the  Veterans' Bureau patients that they be permitted
        to operate  the entire  reconstruction program  for
        these men,  and  to  submit monthly statements pro-
        rating to the Bureau its proportional part of the
        expense  incurred  in serving  the patients, the
        entire personnel,  supplies,  and equipment for these
        hospitals to be  furnished by the Army, and compen-
        sated on the pro  rata  basis.

   CONTRACT  HOSPITALS
   STATE AND COUNTY INSTITUTIONS

              The Bureau has  been furnishing all personnel
        and  equipment  for  the  work in these hospitals, and
        this work should be  established in the hospitals
        where there are 50 or  more 7/ar Risk patients, and
        continued in the smaller hospitals v/here it is now
        established until  the  number available for this  work
        is reduced  to  20.   In  all contract hospitals  where
        contracts are  to be  made in  the future suitable
        supplies should be required  of the hospital for  this
        work as  a part of  the  minimum standard for hospital
        requirements,,

   PUBLIC HEALTH HOSPITALS

              Formerly  the  Public Health Service furnished
        all  personnel and  equipment  utilized in Physiotherapy* 
 
Fifth  Session
Thursday,  January 19,  1922.
EXHIBIT A (Cont.)             Page 13

         The personnel utlized in Occupational Therajy was
         also furnished by the Public Health Service but the
         workers engaged in Pre-Vocational Training v/ere
         furnished by the Federal Board.

              In view of the consolidation of all three
         agencies for the care of the World War Veterans in the
         U. S, Veterans' Bureau, the following relation is
         reconnrended between the Public Health Service and
         the U. S. Veterans' Bureau,  Physiotherapy Aides,
         and Reconstruction Aides used in Occupational
         Therapy, v/ill be furnished by the Public Health
         Service and v/ill be paid by them from appropriations
         made from time to time by this Bureau*  The workers
         and teachers utilized in Pre-Vocational Training in
         Public Health Hospitals will be furnished and paid by
         the U* S. Veterans' Bureau,  The Aides will v/ork directly
         under the medical officers in direct contact with the
         patient under the general supervision of the Medical
         Officer in Charge of the hospital*  The teachers and
         workers in Pre-*Vocational Training will operate-
         directly under the Educational Director of the hos-
         pital,  who in turn will be directly responsible to
         the Commanding Officer or Medical Officer in Charge
         of the Hospital.

         SUPPLIES

              Supplies and equipment for the work in Physiotherapy
         and Occupational Therapy and Pre-Vocational Training will
         be furnished by the Public Health Service or upon request
         of the Public gealth Service by the U, S, Veterans'
         Bureau.

    SUITABLE SPACE FOR WORK

             It is necessary,  in order to carry on the work in
         Occupational Therajy and pre-vocational training to
         have well lighted space,  properly ventilated and heated,
         suitable situated,  and approximately,  ten per cent
         of the bed space in a hospital.  This, however,  does
         not have to be in a ward,  but r:ay be provided in a
         separate building.

    3*    The general outline of the policy is that to serve the men
    in Occupational Therapy  and pro-vocational training it will
    require one teacher for every 20 men at v/ork,  or for every 40
    men in a hospitals  exclusive of the administrative force,  as
    it^is estimated that only 50 per cent will be available
    for this work.   Experience has taught us that,  where there
    are 50 beds  there v/ill be 20 or more men availblc for this
    work,  and that  in such small groups trade vork should not bo
    undertaken,  but in h.spitals of 200 beds or more the work should 
 
ifth  Session
Thursday,  January 19,  1322,
                             Page 14,

EXHIBT A. (Cont.)

   be organized on the following lines - Occupational Therajcy
   for v/ard work and pre-vocational training,  to include academic,
   commercial, agricultural and trade work, as the survey of the
   hospital indicates and as the Medical Officer in charge
   may approve*

   4,   In organizing the work in new hospitals a survey of the
   needs and facilities shall be made to the Medical Division for
   approval before the v/ork is established.  When the hospital
   population has been so reduced in any unit that it is deemed
   impracticable by the Medical Division to continue this work,
   it may be closed at their direction,

   5.   It will be necessary to have specially qualified and
   experienced individuals in Central Office to be detailed to
   the Inspection Section from the Reconstruction Section to make
   inspections of the work in the hospitals, and approval for
   travel authorization and expenses incurred by this personnel
   is requested,

                                   Robt. U. Patterson,
                                   Assistant Director,
                                   Medical Division,

   Approved:  C. R. Forbes
              Director* 
a.; 
INHIBIT 3                    Page  15.
U. S. Veterans' bureau                        January IS,  1222.
Subject:
 effective
 employees

 1.
 Medical Division,  -ine includes Occupational Therapy,  Pre-
 Vocational Training,  and Physiotherapy in hospitals and dis-
 pensaries,  and Folio./-Up Nursing outride of hospitals,

 2.          The internal nana^ement of hospitals of the  Army,
 Mavy,  Public H.e.lth,  National Soldiers'  Homes,  St- Elizabeth' 6
 Hospital,  and Contract Hospitals fa^is under the jurisdiction
 of  the several services mentioned,  or in private iind State
 institutions under the superintendent.

 3.         - Occupational Therapy,  Pre-Vocational Training,  and
 Physiotherapy are  a part of the hospital care and treatment,
 and  fall under the Lanagea.ent of tho Medical Officer in charge
 of  each institution,  ana do not come under the jurisdiction
 of  the District jvaiaager or the District Medical Officer.

 4.          Institutions formerly known as Training Centers
 h eve been divided  into t./o "roups:

            (a)  Aj.1 cent^as called Vocational Sckooj.s
                 are  under the Rehabilitation Division,

            (b)  Ail centers in hospitals will be called
                 Reconstruction Center's and are under the
                 Medical Division.

WJM

            In  all  Any Hospitals serving the U. S. Veterans'
Bureau beneficiaries  reconstruction aork .ill be establishes,
 ..ad personnel,  equipment,  jjA expendable rasterlais for
 Occupational  "Therapy,  Pre-Vocational Training,  and Physio-
 therapy will be  furnished  throu.jh the Surgeon General oi  the
GENERA^  ORDER  NO.
0WGA1I7ZATI0II Ailj ADMINISTRATION OF THE SECTION
OF PHYSICAL RECONSTRUCTION, IWtLNICAL DIVISION,
U. S. VLTNRANS' BUREAU.
 The folio:.ing General Order is. hereby promulgated,
this date,  for observance by all officials and
of the U. S. Veterans' Bureau,

 The Section of Physical Reconstruction is under the 
 
EXHIBIT B (Cont.)      Pa.~2 i6
 Army and eeid for by the U.S.  Veterans'  Bureau  on  a pro  r^.tn
 basis for such service to its  beneficidries.

 NAVY

           In all Naval Hospitals  serving U, S.Veterans'
 Bureau Beneficiaries Physical  Reconstruction will  be  astabliehoi
 and the personnel,  equipment,  and sullies  for  Occupational
 Therapy, Pre-Vocational Trednin^,  and- Physiotherapy will be
 furnished by the U.S.Veterans'  Bureau for its beneficiaries
 in such hospitals.

 PUBLIC H54LTH SERVICE HOSPITALS

           The Occupational Aides  and  Physiotherapy  Aides in
 Public Health Service Hospitals will  be  furnished by  that
 service.  The teachers in Pre-Vocational Training will be
 furnished by the Veterans1  Bureau.  The  Physiotherapy Aides
 will be directly under the Medical Officer  in Charge  of
 Whyr?iotherapy,  or,  if  no such  officer is assigned,  under
 tne ward surgeons.   The Occupational  Aides will work  directly
 under the Reconstruction Officer,  if  there  is one assigned;
 if not,  under the ward surgeons.   Teachers  and workers in
 Pre-Vocational  Training v/ill be directly under  the  Educational
 Director.   The  entire  personnel of the hospital v/ill  be under
 the direction of the Medical Officer  in  Charge.

            Supplies and e'-fuipment  for Occupational Therapy and
 Physiotherapy will  be  furnished by the Public Health  Service.
 Supplies and equipment for Pre-Vocational Training v/ill be
 furnished direct by the Veterans1  Bureau-

 NATIONAL SOLPlffRS'  HOIKS

           In all National  Soldiers1 Homes Reconstruction service
 v/ill  be  established, and personnel, equipment,  and  supplies
 for Occupational Therapy, Pre-Vocational Training,  and Physio-
 therapy  v/ill  be  furnished  by the U.S.Veterans'  Bureau.  The
 Aides  in Physiotherapy  cu"e to v/ork under the direction of the
 Medical  Officer( Physiotherapist) assigned,  or,  if  there is
not such an officer, directly under the ward surgeons.  The
Occupational Aides  and  teachers in Pre-Vocational Training will
be under the direction  of the Educational Director.  The per-
 sonnel detailed  to  the  Homes ore under the direction of the
Medical  Officer  in Ch^r0e. 
 
EXHIBIT B (Cent,)           Paye  17.
C;n.:r:-.l Order <-58


  ?u  ELIZABETH'S HOSPITAL

             Physical Reconstruction has been established as a
  part of  the work in St.  Elisabeth's Hospital.  The  personnel,
  equipment,  and supplies  for Occupational Therapy,  Pre-
  Vccational Training,  and Physiotherapy ./ill be furnished by
  the  U* S.  Veterans'  Bureau.   Tine Physiotherapy Aides will be
  under the  direct supervision of the Medical Officer assigned to
  the  Physiotherapy Section,  cr,  if-no such officer is assigned,
  under the  Medical Officers  in charge of the patients being
  treated.   The  Occupational  Aides ^nd teachers in Pre-
  Vocational Training ./ill be directly under the Educational
  Director.   All personnel will bo under the general direction
  cf the Medical Oificer in Charge.

  ee. xl'^.di. lie .r j j ; 1. p

             In  ^li Contract  Hospitals,  where the number of
  beneficiaries  justifies,  the Reconstruction Service will be
  established.   All Personnel ciad equipment -"ill be  furnished
  by the U.  S. Veterans1 Bureau.   The Occupational Aides and
  teachers in Pre-Vocational  Tr.lining will be directly under
  the  Educational Director.   Physiotherapy Aides will be
  directly under the ward  surgeons.   The personnel assigned
  ..'ill  be under  the general direction of the  Meaic.1 Officer
  in Charge.

  PROPERTY ACCOUITT/WBILPTY

             The Educational Director in .:. center at a hospital will
 designate e.n employee under  Wis jurisdiction as a  Property
  Custodian,   which  Property Custosi..n ..ill i.ake  the  same semi-
  ;rau ,1 reports  tc Central Of fie. >.s j,r^  required of District
 Property Custodians by General  Cr-.r v52.

             The ^ccranting for ^hy siothcrapy  say.--lies and
 equipment v. ill be  in . iceerdUaic. with General Order No. 52.

 -W"PnI T~c

            Supplies ana equipment for  Physical  PeConstractirn
 in  hospitals other the,n Ar:ry ...ns Public Health  Service  a^l
be  re paisitisned  from Centre 1 Office.  Rjopiis itaons  ;aist be
yrep^red  in xcoriancc  with  Field Order No.  45. 
 
 EEIIIEIT B (Cont,)
                          Page 16


 SECURING PERSONNEL

            The personnel in the Reconstruction service is
 obtained through Central Office from Civil Service register.
 When the Educational Director at a hospital desires additional
 personnel he ■•./ill make request through the commanding officer
 of the hospital to Central Office direct, stating the qualifi-
 cations of individual required.  Central Office wili then
 sake the most advantageous assignment possible and order the
 individual to report for duty at the designated station.
 In securing porsonnel for-dispensaries and for follow-up nursing
 the request will co:a from the officer in charge through the
 District WNdica.l Officer and District ilinager to Central Office^
 stating the qualifications cf individual required.   The Recon-
 struction Section will secure the name or names of individuals
 and request the District Medical Service Section to secure  the
 appointment of the same through Personnel Division,  and
 notify tli2 District Office of the date the same shall go on
 their payroll end the amount of salary they shall receive.
 All personnel in the Reconstruction service,  except the
 Occupational Aides and Physiotherapy Aides in Public
 Health Hospitals and Army Hospitals, -ill be on Central
 Office ^.ayroil.  This will induce teachers and occupational
 aides.

 VW -''T^.Tpq
 iI i.... Oi. x,r.o

            Transfers of personnel in hospitals will be made
 by Central Office upon the recommendation cf th; Commanding
 Officer and the Educational Director,   Transfers of personnel
 on the District Office payroll in dispensaries and  the follow-
 up nurses may be made within the  District by the District
 Menager.   If it Is an int a-aistrict transfer,  the same must
 be ~x.Ae by Central Office*   All surplus  personnel,  edther in
 hospitals,  National Soldiers'  Homes,  or  in District Office,
 or in  Sub-District Of:ice,  shcu-ed be reported promptly to
 Central Office.

 COIWUNI CATIONS

           All corw.ur.ic^tions  from Central Office to personnel
 in  a hospital .ill be routed through the  Medical Officer  in
 Charge  of hos  it:il.   Ail communications  from personnel in a
hospital  will be  scat through  the  Commanding Officer to proper
destination.   All cor.nunications  to personnel in Reconstruc-
 tion Section  out.,ide  of  hospitals  will be sent through the
District Iranigcr  to  its  destination.   All communications
 from personnel outsieo of bespit,.is within a District  shall
be  sent through  the District Manager to  its  destination. 
 
ZWZIBIT B (Cont,)             Page IS

 SUPERVISION OF  OCCUPATIONAL TfrRaPY
 AND  PKE-VCCATIONaL TRAINING .

           There shall be a sufficient number of supervisors
 of Occupational Therapy and Pre-Vocational Training
 employed and placed on Central Office payroll to properly
 supervise the work in all districts.  Their duties shall
 be to  supervise the work under the direction of Central
 Office,  to keep Central Office fully advised as to the
 condition of the v/ork and the needs of each reconstruction
 center they visit, and to recommend any changes in per-
 sonnel,  giving  reasons for recommendations.

 PHYSIOTHERAPY

           There shall be a medical officer skilled in Physio-
 therapy  designated as Chief of Physiotherapy for each district.
 He may bo a part-time or a full-time man, as the necessity
 requires.  His duty shall be to supervise and direct the
 installation of the equipment in the District and Sub-District
 Offices,  and, upon request from-Contra} Office,  to visit
 and  report upon the work in any hospital in his district.
 His  line  of communication will be through the District
 Medical  Officer and the District Manager to Central Office;
 r.nd  Central Office's line of communication wil 1 be to the
 District  Manager - Attention,  Chief  of Physiotherapy.

 FCLlCN-UP NURSING.

           Field Order No. 18  covers  the entire  matter of
 Follcw-Up  Nursing.




                         ^^f^T^^—

                               C.  R.  FORBES,
                  Director, U.  S.  Veterans'  Bureau. 
 
Page 20.
                            EXHIBIT "C"

U. S, VETERANS* BUREAU                                File No.

                                                  October 19, 1921,

                     FIELD  ORDER  NO, 18
Subject:  STATUS ANT) DUTIES OF NURSES WORKING- IN THE PHYSICAL RECONSTRUC-
          TION SECTION OF THE MEDICAL DIVISION, U« S. VETERANST BUREAU*

          The following Eield Order is hereby promulgated, effective this
date,  for observance by all officers and employees in the District Offices
of the United States Veterans1 Bureau:

          1. Appointment of Nurses,

                  All appointments will be made by the U, S. Veterans*
Bureau on the recommendation of  the District Medical Officer with the
approval of  the District Manager under the regulations of the U, S. Civil
Service Commission*  Preference  will be given to nurses who have had at
least  three  years1 general nursing experience outside of an institution,
particularly to those who have had experience in "tuberculosis, neuro-
psychiatric  and Public Health Welfare nursing*

          2„ Administration*

                  Nursss on duty in the districts will be carried on the
District pay-rolls and will be responsible to the Chief Nurse of the Dis-
trict, vho  in turn will be responsible to the District Medical Officer
under  the District W-anager.,  The work of all nurses in the various dis--  .,
tricts not  on duty  in hospitals  will be directly supervised by the District
Medical Officer who will be responsible through the District Manager to
the  WIedical  Division- U« S* Veterans' Bureau (Physical Reconstraction
Section), to whom communications on matters in connection with their work
should be addressed*

          3« Chief Nurse*

                  In each district a Chief Nurse will be appointed by the
Central Office of the U, S. Veterans1 Bureau through the Assistant Direc-
tor  in Charge of  Medical Division upon the recommendation of the District
Medical Officer and with the approval of the District Manager.  The duties
of the Chief Nurses in the districts will be to superintend the activities
of the nurses in  their respective districts, to visit the local offices
when directed by  the District Medical Officer, to inspect the worf; of the
nurses, to co-ordinate the work  of the nurses in the districts, sub-dis-
tricts, and  local offices and to check up the nurses' reports.  It will
also be the  duty  of each Chief Nurse, through the District Medical Officer
and  the District Manager, to keep the Superintendent of Nurses in the
Physical Reconstruction Section  of the Medical Division,  U. S# Veterans'
Bureau, informed  of the quality  of the work performed by the individual
nurses under her direction.  Reports of especially good work, or 
 
Page 21
                             EXHIBIT  *C"  (Cont.)

unsatisfactory  >;ork,  should  be sent  in detail to  the  Superintendent  of
Nurses  through  the District  Medical  Officer and  the District Manager.
The  Chief  Nurse in each district will instruct nurses under her charge as
to the  proper form for conducting  correspondence  and  of  the channels through
which the  same  willbe sent.

4.   Duties of Nurses.

                          General Duties.

            (a)   To assist Medical  Officers  of the Districts, whenever
there is one at their station,  in  the care  of beneficiaries who may re-
quire medical supervision and care.

            (b)   To keep contact with claimants and refer possible claims-
ants to the proper authorities for the adjustment of  their needs.

            (c)   To conduct medical follow-up ./ork under  the immediate di-
rection of the  local or sub-district authority where  there  is no medical
officer on duty.

            (d)   At station where there is a social service worker to re-
fer  proper cases to  them.  If no co-operating social  service agency is
available  the nurses -will perform  such social service duties as time will
permit  in  addition to their  regular  duties.

            (e)   Whenever the address of a beneficiary is found to be in-
correct, nurses will report  correct  addresses to  the  nearest Bureau Office
immediately.

            (f)   Nurses,  when visiting claimants,  will give  their resi-
dence address for emergency  calls  to each claimant under their care and
supervision.

                                Special Duties.

            These may be grouped under three heads:

            1.   For Tuberculosis Claimants:

            (a)   Ascertain state of health from time to time.  Record pulse,
temperature,  etc., to detect evidence of tuberculous'toxemia.  Note gain or
loss of weight; presence of  cough.   Amount  and character of sputum, etc.

            (b)   Ascertain their state of morale and that of their families,

            (c)   Give  simple  instructions regarding health and appropriate
advice  from time to  time.

            (d)   Furnish literature of appropriate character v/hen same is
available.

            (e)   Emphasize  the  value  of hospital care  for those who become
sick from  other causes  or whose  pulmonary condition becomes active. 
 
Page 22
                      EXHEBT MC"  (Cont,)

           (f)   Report promptly to  the  nearest medical  officer beneficiarie;
whose  condition seems to indicate  that hospitalization is necessary.

           2.     For Neuro-Psychiatric Claimants:

            (a)   Health instruction and  definite advice with regard  to
home  conditions.

            (b)   Advice and supervision  to  prevent  intemperance, excessive
use of tobacco,  drugs,  etc*

            (c)   Advice regarding  habits, whether married or single.

            (d)   Note general behavior and  mental state, such as stream of
talk,  mental activity,  characteristics of same, such as incoherence, inat-
tention,  distractibiiity,  etc.

            (e)   Note mood of beneficiaries, such as preoccupations,
hallucinations,  illusions,  etc.

            (f)   Endeavor to obtain insight as  to how  much the patient
realizes  the nature  of his present condition or cf  previous illnesses.

            (g)   Enterpret claimant's, condition to  his  family and instruct
them  in the necessity for tolerance of claimant's peculiarities.

          3.     For Claimants with General Disabilities.

            (a)   Make visits to  beneficiaries pending hospitalisation, or
after  being discharged from hospital,  while in  training, particularly
those  said to be absent from training  on account of illness, reporting
results of investigations to the local medical  officer.  If an emergency
arises the claimant  should bs sent immediately  to a designated physician,
if too ill to report to a physician, a physician in the employ of the
Bureau will be  notified of the name and  address of  the  patient and request-
ed call.   A report on each case  v/ill be  made to the nearest local office,
together  with recommendations and  a statement of any action that has been
taken.   If Claimants absence from  training was not  due  to illness that
fact will be communicated to the local Bureau authority.

            (b)   Report on every case  assigned  to her and render sub-
sequent reports  on such cases as nay be  required from  time to time;  to
make supplemental reports from time to time as may  be necessary.  Such re-
ports  will be made on Medical E, or other designated from, and will have
for their object the discovery of  present results of service disabilities,
intercurrent ailments,  or physical conditions which are preventing the
physical  rehabilitation of the man.  The attention  of  the District or
local  medical officer will be called to  any seemingly  improper conditions,
and recommendations  will be made looking to their correction. Subsequent
reports will show whether or not these conditions have  been remedied.
For the purpose of reducing the  number of visits that  are required the 
 
Page 23
                        EXHIBITS"  (Cont.)

 claimant will be  induced  to  call at  the  office  if  practicable*

               (c) When calling at the home  of a patient  the nurse will
 notice  the sanitary conditions of the home,  particular attention being
 given to plumbing,  adequacy  of rooms, air space per capita, light, heat,
 bathing facilities,  number of flights  of stairs necessary  to  reach quart-
 ers,  etc.   Information as to how long claimant  has lived there and if he
 has  made frequent changes of residence.   Recommendations will be made for
 improvement of conditions which appear  to be prejudicial to the health
 of the  men and  his famjjy and an earnest endeavor  will be  made to have
 them corrected.  In case  the family  of a beneficiary needs medical treat-
 ment or other attention the  social worker or in her absence the Red Cross
 or other Co-operating agency will be notified.

           (d)   Reports on Medical G, or  other designated form, will be
 made on cases  that break  down in training,  indicating  when possible the
 cause of the interruption of training, whether  the same  is actually due
 to a reactivation of the  original disability, to an intercurrent condition,
 or to extrinsic causes connected with training,  work,  or living conditions.
 Medical Form G, or other  designated  form, will  be  forwarded through proper
 channels to the District  Medical Officer or his nearest  representative.

           (e)   To visit at stated intervals  all cases  in localities in
 which there are not county nurses, and to endeavor to  obtain  contact oc-
 casionally with county, nurses,  where such are on duty, with a view of keep-
 ing  them informed of conditions for  the  best interest  of the  ex-service
 man.

           (f)   Field notes on all all of the above duties  will be con-  ...
 veniently  kept  on Assignment Memorandum  Form 701,  or other form that Bay be
 designated herafter.

      5.    It is not the function of  the  nurses  to  supervise Vocational
 Training,   She  is not to  intimate tc the beneficiary any doubt as to
 whether he is assigned to the proper course,  or whether  institutional or
 job  training is best suited  to his needs, but any  suggestions she can
 give  to the Training Officer in regard to the man's  attitude  towards his
 training,  v/ill  be helpful in his  rehabilitation.   Jftirses will not call
 men away from  their work  for the  purpose of interviewing them, unless by
 special arrangement,  suggested by the Training  Officer.

      6.    In territory where a nurse and a  Social  Service  worker are both
 on duty, the nurse  is not to attempt to  investigate  social conditions or
make  recommendations for  rectifying  them, if unsatisfactory conditions are
 found.  Per contra  the Social Service worker is  not  to assume the work of
 the nurse  in investigating conditions affecting the  health of the bene-
ficiaries.   Emergency cases  will  arise where it will be  obviously advan-
tageous to  the  interests  of  the beneficiaries for  wither a nurse or a
Social Service worker to  take  immediate  action  on  a matter not strictly
within her province,  but  v/hen  this has to be done  the  other should be at
onee notified of  the circumstances. 
 
Page 24
EXHIBIT  "C"  (Cont.)

      7„  Nurses will  not be  expected  to  assist  in special nursing  ex-
  cept in  training  centers,  or in temporary emergencies  when it  is impos-
  sible  to hospitalise  claimants,  or liaa tba re  is no person available
  to  give  instruction in home  nursing.
                                        C.  R.  FORBES,
                                        Director,  U*  S.  Veterans1  Bureau.

EXHIBT "D'N

                   NURSES' CONSOLIDATED REPORT
                              for
                         N0VEI2ER,  1921.
                         SUMMARY

Superintendent of Nurses                     1
Neuropsychiatric Chief Nurse                 1
Chief Nurses                                14
Follcw-up Nurses                           246
       TOTAL NUMBER NURSES ON DUTY        ____
November 30,  - 1921 -                         262
No. Cases treated at Dispensaries & Relief Stat'ns  610
No. Visited at Homes                               6907
No, Needing Medical Care                          12938
No. Medical E's made out                          15^79
No, Medical O's  "    "                             339
No. Needing Social Adjustment                      15±6
        TOTAL MEDICAL ACTIVITIES                       37,389

No. Neuropsychiatric Cases under supervision            7,329

Total No. Interviews -  (Home, Placement)
                        (School, Office)                45,487

No. Appointments approved curing November, 1921            27

No. Reported for duty (Oaths rec'd Central Office to date) 20

No. Resignations submitted                                  5

No. Declinations Appointment                                 1

         TOT/iL NO. CLAIMANTS UNDER SUPERVISION
         NOVEMBER 30, 1921 -                           63,397

                                (MRS.) EN C HOUGH,
                              SUPERINTENDENT OF NURSES- 
 
                     Page 25




                 Exhibit  "E".




RECONSTRUCTION  TRAINING




            SUMMARY" BY DISTRICTS




               January 1, 1922.
Dist.	Number of Institutions	Number of Staff	War Risk Patients	Assigned to Classes	Enrolled in Classes	Percentage of Avail.Patients Enrolled
1	7	30	1443	552	429	66
2	11	50	^282	926	782	84
3	7	16	819	34<±	257	75
1 i	o	51	2538	1228	846	68
5	8	66	3846	2053	1394	68
6	4	18	1185	563	452	80
.7	19	49	2309	916	753	82
8	15	52	1631	914	711	78
9	5	12	303	260	239	92
10	11	33	1432	707	521	74
-11	2	19	1577	517	341	55
12	15	55	2546	1117	725	65
13	3	9	549	172	138	81
14	1	13	942	442	30C	70
Grand Total:	' 117	483	23602	10911	7888	72
 
 
Fifth  Session
Thursday,  January 19,  1922.
                              Page 25

ADMIRAL  STITT:  reminded  the  men that  at  the  meeting yesterday  afternoon
   a motion was made  to  discuss the papar on the  "The  Social Service Wor-
   er" this morning,  and there  were about 25 minutes  for the discussion  of
   each  of the  four subjects -  the  social service worker,  disciplinary
   regulations, relation of  district  managers,  and physiotherapy and
   occupational therapy  in hospitals,

CaPT» BLACKWOOD:  said it was his  opinion that the social service worker
   has done more  to aid  the  Commanding Officer and tc  follow up the work
   on  the ex-service  man,  as well as  the service  man,  than anything
   else  he knew of that  has  been introduced  into  the hospitals.  The
   social service work in the Navy  is ail done by the  Red  Cross, one of
   the most wonderful organizations in the united States for doing good.

SURGEON  CHRONQUEST emphasized the point  that diversion and recreation
   should be  distinguished from the social service, with which it is
   so  often linked.

SURGEON  LA3CHE: stated that  at  first  he  v/as  sceptical  about  the intro-
   duction of people  under extraneous control into the hospital, but
   that  he incorporated  the  Red Cross into the official  organisation
   of  the hospital and made  the director a member of the  staff.  Ho
   believed in.  keeping a fairly close supervision over the activities
   until he knew  th3  individual,  and  made a  rule  that  the  social worker
   shouxd send  a  carbon  cf every  letter  written about  the patients to
   the officer  in charge.  It was found  that at the beginning there was
   no  possible  reason for about oOfo of the letters written, but only
   one half of  one percent of the letters produced harmful results.  He
   said  he was  inclined  to think  that owing  to the fact  that the Red
   Cross has  the  benefit of  a nation-wide organization that  for the
   present it is  very much better to utilise their services  than to
   establish  government  employees to  do  the  same work.

COL. BRATTON: said that  experience had shown him  that  the Red Cross is
   a great aid  in  carrying on relation to  the  outside world.   He told of
   the situation  in Atlanta,  Aaen the hospital was established he found
   it would be  necessary tc  satisfy the  people  of Atlanta that the
   wounded boys were  being properly taken  care  of, and was fortunate
   to secure  the  services  of a  first-class man  from the Red Cross.   The
   result  was that the people became very  interested in  the work and
   sent  committees  with  food, also provided  pictures two or three times
   a week  and ail  kinds  of entertainment.

SURGEON PAYNE stated  that  one of the greatest difficulties he had
   experienced had been  in sidetracking  the  people v/ho, though kindly
   disposed, brought  food and all kinds  of entertainment which were
   injurious to the patients.  He said he did not believe in any kind
   of athletics in a hospital, unless under  the Physiotherapy Depart-
   ment,  neither did he believe in dances in a hospitalc   He said people
   would  bring in  all kiiids  cf food and  the patients would eat it before 
 
Fifth  Session              Thursday, January  19,  1922

                             Page 27

SURGEON PAYNE (Cont.)

    going to mess^ and  then  of course would complain of  the hospital food
    furnished.  The greatest benefit from the Red Cross  had been the
    coordination  of those activities,

COL. BRATTON asked that seme of  the men who served in General Hospital #6
    speak on this subject.

SURGEON WWILIHITE; stated he had  served under Colonel Brattan, and agreed
    heartily with all he had said.  He stated also that  in his work in
    the hospital  in Phi lad ek hi a the Red  Cross had done  the finest kind of
    social service work, coordinating all the agencies that Dr8 Payne
    spoke of as so detrimental to aim, and lis believed had been a very
    great benefit rather than a  hindrance.

    Dr« Didman  took up  the work  of the Red Cross in taking care of
    relatives of  patients who come to the hospital.  Often these people
    spend all their money for railroad fare, and b.ave none left ./hen
    they reach  the hospital; and the hospital has to take care of them,
    He said he had arranged  that four or  five rooms be fixed up for
    such people as this and  believed some definite authority should be
    had from the  Veterans' Bureau to house these people  and furnish their
    mealsc  jre  stated that some  boys will ask for things and others
    will not.  He referred to an instance in which a patient had told
    a lady that he needed a  shirt., ana two days later when she brought
    his. one she yave  it tc him before the whole v/ard and the boy was
    ridiculed for a lent, time afterward.   He had had trouble in getting
    the v/ork done throw.gh the social welfare workers in  the hospital,  as
    the public wants  the individual tlory of handing something to the
    boys themselves*  The Red Cross has also been a great aid in invest-
    igating home  conditions of the patients,  especially  of tubercular
    patients who  want to go home to die*  Also, in the case of a man who
    asks for a  long furlough because his  mother or sister is dying,  the
    Red Cross will investigate ana get an immediate report,  and marry times
    it will be found  that the mother or sister is not sick at all*

SURGEON PAYNE: stated that he did not want to be misunderstood,  that he
    did not mean  to take credit  away from the Red Cross.

LIEUT. BOONS: 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 sep-
    arated  from social  service. 
 
Fifth  Ses^si^on          Thursday, January  19,  1922.
                              Page 28

 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 v/as consudered 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. KXaUTZ 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 DEDMA.N stated he had taken part .in the compilation of General
    Order #27, and that he found one flaw in it now.  This v/as 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 v/here they could
    sleep at night,  that before the redraft simply turmoil and strife,  like .
    the boy in France whose wife,  every time'she wrote to him,  nagged him,
    and he of course v/as 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 aisciplinary 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  natter 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 hosaital
    the patients  were willing to  pay their  own  transportation,  and v/ould go
    whether  it was paid  or not.

ADMIRAL  STITT: asked  that  those who wished  to  present resolutions be
    v/riting  them.

DHL GUTHRIE:  requested  that  the medical  officers  v/ho  have complaints in
    regard to General  Order 27  and do  not have  time to express  then write
    them  out and he would be  very  glaa to have  them sent to him. 
 
Fifth  Session
Thursday,  January 19,  1922.
                              Page 29.

 SURGEON WHITE  (Speedway Hospital): asked whether, if a patient stays away
       over night A»W.O»LM  paragrajhs 3  or 4  on Page 3 of General Order
       27A would a^ply*

 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 para-
       graphs referred to.

 ADMIRAL STITT: "The  next discussions v/ill be on  "The Relation of District
       Managers  to Hospitals".

 DR. WILLIAMS:  emphasized the point that v/hen 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 ob-
       tain advice v/hich facilitates the discharge and treatment of patients
      very raich.  The relation of the Naval Hospital with the District
      Manager has been one  of greatest cooperation,  that the Veterans1
      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 Veterans1  Bureau in place
      of 1934-B, that it was impossible to manifold this  form and it nec-
      essitated  just  twice as much work as before.  He  suggested that the
      Committee  on Forms consider the  feasibility of adoptin^ forms  that
      can be manifolded and thereby  zmfke 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 Vet-
     erans'  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  Command- 
 
Fifth  Session
Thursday,  January 19,  1922.
                             Page 30

 DR«  RAWLS: (Cont.)

     ing 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 must now  be
     viewed as  a much broader field than ever before,  that after discuss-
     ing the subject of an educational department and social service  work
     with people in contact with it it was decided to be  absolutely nec-
     essary to  enlarge the personnel of these hospitals so as  to take in
     these various .new things v/hich 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  hos-
     pital and  do not come in contact v/ith the Commanding Officer.  The
     whole idea of the social service relation is that these men shall be
     made more  resourceful and mors capable of earning a  living for them-
     selves.

 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  treat-
     ments per  day.   He stated that one might not take care of oyer 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:  s^oke on the value  of occupational therapy.   Hs  told how-
     after the  introduction of occupational therapy in his hospital in New
    York boys  who had been very  troublesome  before  became deeply  interest-
     ed  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
*» 
 
=- ± t 1 ~  Session              Thursday, January IE,  1922.

                              Page 31

SURGEON PAYNE:  (Cont.)

    the man makes, and  that  in reany  cases  the  men buy  their own material.
    He cited  the  case of  a man in his hospital who makes  all kinds cf toys
    out of tin  cans  and has  worked up quite  a  trade.   Public sentiment is
    all on that nan's side.

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

                           MOTION

                That the  Director  of the Veterans'  Bureau be
                requested to secure  legislation  so that the
                expenses  of  the patient's  transportation  tc his
                bona fide home, when he ha3  been discharged for
                disciplinary reasons,  be deducted from his
                compensation,  .when compensation  is being  given,
                or may  be given thereafter*

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

CAPT. BIACICTOOD:  "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 li3.ee to
      present  this resolution:"

                         RESOLUTION

                Be  it resolved that  it  is  the  sense of this meet-
                ing  that  the pay of  the rairoes of all  branches  of
                the  Government service  is  far  below what  it should 
 
Eihf_k   Se_s_s_ion           Thursday,  January 19,  1922.

                              Page 32.

CAPT. BLACKWOOD  (CONT.)

                       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 individual-
                        ization of treatment.
The meeting adjourned at 12:25 P. M. 
 
£ I * .£"£  Session                     Thursday, January  19, 1922.

                         Page 35.

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 discuss ion for bringing to the attention of the
   Conference any subject which you may have in mini
-Ar,A
 tie.,
        We have divided the work i n this way.  In order that v/e might have
 some leading thought from which to start and upon which to base our dis-
 cussions,  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 rssponsibility.

        Ue have learned by comparison month by month since taking over this
 v/ork 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.  W'e realize that in
 the general medical case ultimately we  must get to a place where wc shall
 have finished largely with that character of case.

        But with the n*^. case v/e 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 yea 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 littls strong,- I should
 say in 90 per cent of these cases you will find,  where the case is  genu-
 ine,  that you have some physical cause  at the bottom of the mental  trouble.

        Therefore  I wish to suggest that in the consideration of this'cease,
 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 v/ith  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  ap-
pear after fifty, but has some physical derangement the overcoming  of
which may  help  very materially in  the curing  of the case. 
 
J? 1 ± 1 k  Session                   Thursday,  January 19,1922

                           Page 34,

        So I .would like to emphasize this thought:  that you have not ex-
hausted 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 pre-
 liminary examination of these patients.

        And then I would l'ke to emphasize also that your preliminary exam-
 ination,  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 whit
 I believe:

        That many of these cases that come to #ou 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 Govern-
 ment does net 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 iq/ 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 v/here 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 real-
 ly  are  established in their homes.  There is no case  in the world that
 is  more unfairly treated than the neuro-psychiatric case.  No  all know
 that by many experiences and observations.   So let us give particular and
 special attention to this subject.

        They say to us v/e have no specialists in this  line.  I .am not so
 sure but  v/e 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  diag-
nosed tubercular when really they are  not,  - a very bad impression,  as
you can imagine,  tc  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. 
■>...; -.1  .. «  .
ie». V ■ a"  0 
^•1 * 1 k  ^essi^B                     Ehursday,  January/ 19, 1922.

                           Page 35.

     We knov/, 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  invari-
ab ry these men were the subject of the  toxemias  of fatigue,  and by re-
lieving 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 aiscovering wheth-
er or not, as the basis of their  mental or  nervous disturbance, there
may net be some physical  condition.

     The meeting is now in charge of Dr.  White.

WE, 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 v/ill feel free  to  get up  and briefly set forth such ■
   vital problems as  you  may have in mind.   In order  thatve  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 v/e 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 v/ith these  patients while  in hospital.   In making
   this examination we have on our staff a  number  of very competent at-
   tending 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 mini a case  diagnosed  neuras-
   thenia which v/as treated six months  ago,  which  was  aacase of brain
   tumo r.

           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  seriolo^ical and base metabollism.  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. 
 
Sixth  Session
Thursday,  January 19,1922
                           Paae 36.

      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 dis-
 orders originating purely in their mind, or because of some constitutional
 nervous defect and that the real fundamental condition from v/hich they are
 suffering is not an organic condition but is nervous or mental and must be ap-
 proached 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
 moans*  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 ana by
 that means prolong their functional disorders.

      Regarding occupational therapy.  We all know that this is a very im-
 portant 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 eef the other phys-
 icians v/hen 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  v/ho 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.  TREADNAY:   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-suraical 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. llolb did not say
 something about  the training  school he had started in connection with his
hospital." Xle  sent  seme young officers  over  to learn technique  and methods
 of liana ling  the psycho-neurotics.   We have also sent 3orae officers to the
Public Health  Service  clinic  at  the Psychopathic  Institute in Boston and
v/e 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. 
 
 1 1 * 111  S ess ion                  Thursday, January  19, 1922

                           Page 37.

 They are not interested in mental or nervous cases.   They want to go  in-
 to general medicine.  Last year v/e sent two officers to the  Southern Univ-
 ersity and to the Northern and Wrestern universities to meet  the graduating
 classes and the internes,  and from thatwe have been recruiting some
 younger men v/ho 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, war-as where patients of this sort may receive at the
 beginning of their treatment,  their preliminary examination,  where they
 may be e \acuated home with compensation or without compensation,  or  ev-
 acuated 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 ana v/e have attempt-
 ed to develop out-patient clinics with the old dispensaries maintained
 by the Public Health Service;  but the question of personnel again enter-
 ed 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  nust be worked out.  The man who believes he is seriously ill when
 he lias 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 v/hich has not met the
 neeas  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   neat  dea_  about these  convulsions;  some are epileptic and eome c.:e
 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 Compen-
 sation Act in  the  several  States,  has  interfered with  the  employment  of men
with an epileptic  past. 
 
Sixth  Session
Thursday,  January 19,1922
                             Page 38.

Tt is as hard for the man who has a  seizure once a month  to  get a position as
the onewith rkrur, 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 no* turned it into an institution for
feeble-minded.

    The question of vocational training is also a big problem in connection
v/ith 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 sit-
uation 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 v/as.  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 be-
come 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 bof
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 pyscho-neurotic 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  ajjplication of general orders,  hospital
regulations and internal regulation? as within the hospital,  is entirely dif- 
 
Sixth  Session
Thursday,  January 19, 1922
                        Page39.

 ferent from any other class of hospital under Federal control.

     The very fact that you attempt to apply certain regulations in a hosp-
 ital of this kind where the morale is naturally at a low ebb,  due to the
 mental phases under v/hich these men are suffering, sometimes results in
 disaster and the breaking down of the morale you havje 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 men have not reached probably
 the  shcool 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 communi-
 ties 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 hospitalization is out of the question.   I believe
 that that part of the Bureau concerned with the compensation of these men,
 from an economical standpoint,  mist 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 psycho-
 pathic 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 tc
correct;  that  is hospitalizing  pyscho-neurotics, - neuropsychiatric 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 cf  them
simulate very  closely  the  epileptic; many have  learned  to bite  their  tongues
as the epileptic does.  They  should not  be hospitalised;  about  25  $ of  the
cases are not  epileptic. 
 
Sixth  Session
Thursday,  January 19,1922.
                           Page 40.

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  therWahd 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 solu-
tion.  I third: 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 hospitali-
zation.  The solution covering that  is,  I believe, for the Government to formu-
late,  properly taking into consideration these districts, and build an epilep-
tic colony, under proper sapervision,  and I believe from an economic  stand-
point, it could be made almost self-supporting.

    In regard to  the medical  treatment,  we  have  been instituting at East
Norfolk a very carofua  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, pro-
longs the intervals betv/een shocks and in many instances effects complete  ces-
sation; 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, theee men immediately react  to  the lack of it.  I should say v/e have
had at least four deaths at Fast Norfolk due absolutely  to the  lack of luminol.

DR. WILBUR:  At Chicago we developed  a diagnostic clinic at the iferine Hosp-
ital and had two  departments: in-patient and out-patient departments.  We
had a capacity £or in-patients of  about  150.   The out-patient department was
unlimited ana 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  wcuxd 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 pos-
sible;

             3.  Hyper-thyriodisii,  following operations,  where  the pulse is
still  hivh.  When such  cases  were  sent to us,  an attempt was made to  stabili-
ze 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 cas..s. 
 
Sixth  Session
Thursday,  January 19,1922
                              page 41,

     I might say that out of every fifteen cases sent in v/ith diagnosis of
 epilepsy,  about twelve or thirteen of them proved,  after earful 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* IColb's at Waukesha,  The man was given
 complete physical, neurological, examination first.  We had a special consult-
 ant v/ho visited the hospital about once a week.  After a man had his exam-
 ination, 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 v/ard surge on 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 hosp-
 ital, — 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 v/ork, we had a committee at
 the district supervisor's office made up of one representative af 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 v/e would bring out?
 problem cases to this meeting,  where they would be taken up and such arrange-
 ments 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,  ac-
 cording to the need*? of the case.   If the man needed some special treatment,
 he  came into the hospitalnfor that treatment and at the same time he sav/ this
 ward  surgeon and talked the case over  with him.   Just as soon as that patient
 was  ready  for vocational training,  he  v/as put into  touch with out 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 wa3 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
 tv/o epileptics  out of the v/hole group.   These two were given positions  in
 factories  that  were  owned or governed  by  some relative or friend who had
 taken an interest  in them,  disregarding the  compensation laws and disregard-
 ing the inability  of the  men  to ,work when they  would have a seizure.  In two
 instances  only  have  v/e  succeeded in putting  men into training where  it  proved
a success. 
 
Sixth   Session          Thursday, January 19,1922.

                      Pome  <±2

DR. MC  LAKE:   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 150o patients.  Ihe present
Census  is 800.

    Now this institution v/as 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  <^>n  asylum.  It v/as not a place for merely
domiciliary residence or custodial care.  The needs of hospitalization,
however, this year,  have been  such that we have t^ken 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 v/hich  we  have.

    Up  to  the present time  v/e  have had no special accommodation what-
soever  for  n.^p,  - -  t.b. patients.  Out institution is built on the
cottage plan and in  the  preliminary survey and construction no pro-
vision  v/as  mode  for  t.b. patients.  However, at the present time I have
one v/ard which is filled with  eleven of these cases.  I may say in this
connection  that  v/e are expecting to build a t.b.- n.p. unit of eighty
beds and will start  construction in about five or six months, v/hich v/ill
be gratifying to you men who huve these comoined cases and would like to
unload  them and  as soon  as  we  can take these cases off your hands we v/ill
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 ^et many cases toward the end of
this t.b. condition, vvhich  present n.p. symptoms.  Now I know from ex-
perience at Fort Bdyard  and in otner t.b. sanitoriums, especially at
Fort Bayard,  where I was associated several years v/ith Colonel Burke,
tha  these  patients  become  exceedingly troublesome and exceedingly an-
noying.  However, if you are perfectly frank v/ith yourself and perfectly
frank with  the n.p.  man, you v/ill 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. hospi-
tals you should  set  aside a ward or tv/o or three v/ards where you can take
care of your terminal toxemias whose symptoms are principally mental;
they should not  be unloaded on the n.p. hospitals v/hich are build and
equipped for reasonably  curable cases of n.p. disease.

     As to  what  General  Sawyer said about many of these n.p. cases living
feutside.  I v/ant to  most heartily indorse that attitude, and I ^vill  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
v/e feel that  he  hus  come to the point where he should be giver * 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 com-
munication  v/ith  the  Veterans1 Bureau officer, or a Red Cross worker  in  the
District, in  which he is paroled. 
 
Sixth  Session
Thursday,  January 19, 1922.
                          Page43.

 In other words,  during the first thirty days I yet 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 tc make suf-
 ficient 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  cf 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 v/ould 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  build
 ing of special hospitals  for these men.  I personally am not in favor of
 such a scheme and I will tell you v/hy.   I  have  a considerable number of
 these men.   I believe that every complete n.p.  hospital should have a departs
 ment v/ith definite numbers assigned from the staff v/ho 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
 emphasise.   There are a certain number of these  men v/ho 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 per-
 sonnel.  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.  inen 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  to-day 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  a
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. 
 
Sixth  Session.
Thursday, January 19, 1922.
DR. FULLER:   T an particularly interested in the  question of person-
nel.   The  shortage of neuro-psychiatric  trained personnel and physi-
cians  Is a real and very acute problem.   T7e have  any number of vacancies  fur
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. I.'c Lake  spoke of is for the
Commanding Officers of those hospitals who have one psychiatrist on
their  staff> — and practically all the  large hospitals have one en
their  stafft — to insist that these psychiatrists interest ether
members  of the staff.  The fact that Dr. Treadway brought out, that
most young men are not interested an psychiatry is due to the fact
they do not  know anything about it,  I was one of the men v/ho visited the
schools last year.  I was suddenly confronted by  statements made by the
deans  or their assistants: n0h, neuro-psychiatry, I dorft 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 v/ill 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 yov.ng  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  ser-
vice,  who  are interested.

DR. MILLERS

           We ho.ve a specialist at Oteen who lectures to our entire  medi-
cal staff  Tues&^yand 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:  TThat «T?e you going to do w'ih the group the doctor describes
that ought to be in a colony:' What are yon going  to do with the mentally
deficient  v/ho will never be able to carrv 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 ic 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-Dine cases 1 didn't have a chance to speak of  the
other  morning.   I supgsstea .there in just a word  that in connection
with these disciplinary measures  such as have recently been promul-
gated  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 iViea I  wanted to  make v/as that
discipline should not be used as  discipline  per  se_  but  that we should
seek for all  of  the  possibilities  that are  incorported in disciplinary
measures which can be  brought to bear upon the ptient for his -welfare* 
 
 .§.i£!^Se£Si juo 11             Thursday,  January 19,1922

                        Page 45.

 In other words,  if we can make out of discipline a therapeutic tool.

     Now we are dealing fop the most part, in these border-line cases
 and in the delinquent group, v/ith types of individuals that are more
 cr 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 discip-
 linary pressure brought to bear.

     I have in mind a fellow who is a high-gre.de defective,  who has
 passed through a praecox attack, who has come back to comparative nor-
 mality.  He is a reasonably useful citizen around the institution but
 he can11 get on outside the institution and he has periods  of not get-
 ting on well in the institution, because every once in a v/hile he will go
 out and ~et drunk.  Now what are you going to do with that  sort of  fel-
 low?  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 v/e 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  out."  You
 have constantly to shift between severity and almost lack of discipline v/ith
 these epople to keep them at their level,  and you have to realize all  the
 time it is a Latter 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 judgement 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 an 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 en 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 hip
 and make him a public charge.   I developed some time  ago a  method of deal-
 ing 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 v/hile,  and v/hen ho 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  ingenu-
 ity how best  to  meet  it;  and  one  of  the  agencies at out command is  the
disciplinary measure,  which,  if wisely  enforced,  can be used tc push the
 patient to  the highest possibility  of his  adjustment. 
 
- 1 ± 1 it  S e s . s i  ) n

                       P-ge   46.
Thursday,  January 19, 1922
     lken,m  that connection,,  as to our friends,  the morons and epilep-
 tics.   I am fond of saying that practically everybody,  no natter how
 defective ae way be,  has a certain capacity for usefulness.  There is
 almost nobody who is,  under prober arrangements,  a total loss socially.
 A moron,  oi six or seven years of a;e,  nay be ten aer cent efficient.
 He may be ten per cent efficient under one set cf social conditions,
 naybe  fifteen ..cr cent efficient under another set.   He way be total loss
 unaer  other sets of conditions.

     Now a lot of these peoyie.  like the young fellow I  spoke of a while
 a c, are very useful citizens  in the hospital community.   They would be  a
 total  liability outside th.t corauinity.  We have  always had these people
 m the^ community .and we always shall have them probably.   It is perhaps
 a worth-while endeavor to try  to get the coraamity,  through these various
 -social agencies,  to appreciate them for certain values.  One of the medical
 officers of the Amy was discussing with me,  a while ago,  this problem in the
 the  South,  in eke cotton mill  districts,  v/here there is a large number of
 mentally deficient people.  They do not do much of anytain ;,  except.  forhapS,
 drink  whiskey,  treed and make  trouble.   They go into the  mills end either
 get  injured or discharged.  A  lot of that Laterial is really capable of
 utilization.  The mental defectives,  as a v/hole,  are fairly good natured and
 tractable.   There were lots of mental defectives  in  the Army,  enlisted men,
 who  aarried on and made good soldiers.   Sold youn. fellows went into  the
 Amy from the School cf Feeble Minded,  in Massachusetts,  and had excellent
 records.  The Superintendent there kept track of his feeb-.e-minded boys  in
 the  Army, and they made excellent records because they  belong to that ty^e
 of individual which bias a very strong leaning upon i.er»ons in authority
 and  v/ill follow his officer like a Newfoundland do g  his master,  .."ill obey
 orders to the letter end they  name most valuable  persons.   So this offi-
 cer  suggested to me that these feeble-minded groups  runnin • around  might
 be assenbled 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 _ roper social conditions end placed under the eye of a
 neuro-psychiatrist; and where  there ./as an immense shortage of labor,  perhaps
 factory owners would be pleased to get  these men.

     In other words there is a  lot of this defective  material which exists
 in our society tc-day which has absolutely lost motion,  v/nich could be put
 to a gmat  deal of use if we were wise  enouji to  do  it,  if public senti-
 ment would  support us  and assist.  It is easy to  talk of that here.  It  is
 another tiding to  aet public sentiment to help us.  There is no Ion er hosp-
 ital organization than this in the world and perhaps the hundre^ hospitals
 represented here  mi ht do something to  bring about that  public sentiment.
 So J   am disposed to look at people not fro:.: a strictly diagnostic  point of
 view to  look at them from the  social point of view as to the possibility of
 their  bocominn useful  to a certain decree as social  units and the possibility
 of society  metabolizing them.

    Just  one more word.   There has been an anormous  amount sai^ the last few
years  on  heredity,  and there is a  gr^at deal of feeling that there is a
^•reat  deal  due  to heredity. 
 
~ i 2S. i il  §. £ 1 B.L 2 Hl                 Thursday,  January  19,  1922.

                            Page 47.
that there is a great deal due to heredity. The  study is very  interest-
ing, scientifically very important, but the only attitude v/e should as-
sume is to practically throw out of consideration the whole question of
inheritance.  Ifyou are going to say this fellow has got a certain dis-
ease ,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 per-
centage of salvageable material is to  endeavor to make the adjustment •
If wq put them down as hereditary, our inclination will be to  throv/ them
out of the possibility of consideration.  w"e should rather stress the
possibilities to the utmost and find some solution or partial  solution
of a great many of these problems.
* 
 
Sixth  Session.
Thursday, January 19, 1922.
                            Page  48.

DR. CHRONQUEST  (U.S.P.H.S.):  So much has been  said that I shall not go
   on with the  problem.  I v/ould mention the Compensation side. I have
   been wondering for seme  time, especially among the neuroses, if by our
   present system of compensation we are not tending to make crystallized
   neuroses.  I do not pretend toanswer the question.  Take, for example,
   a chap v/ho has been in the service, v/ho has  done good work, irhose so-
   cial 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 condi-
   tions that 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
   ^ith all, but it is with some  of the cases.

        I have  wondered whether or not our present system of compensation to
   that type oof individual  was the best,or whether the system of Canada or
   England v/ould 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 v/hen
   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 v/hich 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  tv/o men in the  same  hospital,v/ith the same
   disease - -  that one will draw his compensation without a guardian, the
   other is  required to  have one.

DR. GUTHRIE:  It v/as our understanding that a man v/ho 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. IT. A. *3ITE:  I think the man v/ho 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, v/ho have a diag-
   noais 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 wen's disr-M Titles-  At times*'it may  be the fault of the  ^r^runinc 
 
Sixth  Session.
Thursday, January 19, 1922,
                             Page 40.

DR. CHRONQUEST:  (continued)

   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, v/hich
   are seen every onoe in awhile, 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 histor-
   ies and get them complete, detailed and accurate.

COLONEL IIATTISON: (acting for General Geo. Uood)  The Tuberculosis Section
   has to deal v/ith a group of patients, - the largest group that the Vet-
   erans1 Bureau has to handle.  I am sure that we have many men here v/ho
   are interested in this subject, and I hope we shall have a very free
   discussion of the subject.  vTe shall begin by having each subject opened,
   and then the program will be given to general discussion.  Tie shall ask
   Dr. Stites to open the session on "The Segregation of Cases".

SURGEON T. H. A. STITES (R) U.S.P.H.S. J 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 visita-
   tion from Heaven, and looked upon as a disgrace to the family, on down
   to the period v/hen 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 publid and to
   compel them to accept the proposition of its infectiousness, that v/e
   went to the extreme of leading everybody to the idea that it v/as a viru-
   lent infection; that it v/as 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 gen-
   eral.  Then the pendulum began to swing back, and we came to a sensible
   conclusion, - that while T.B. is an infectiousdisease,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. wcilc today*  I  have often heard it said that any benefit that
   comes  to  the individual is necessarily more or less incidental, and \hr.t
   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 T7orld Uar is the actual care
   of the  sick. 
 
Six th  Sessi_on.          Thursday, January 19, 1922.
                              Page 50.

STITES: (continued)

        The question of prevention of T. B. must be dealt v/ith, first, upon
   educational grounds, - to educate the public and the individual to tho
   point where we can more or less limit the spread of the infection; second-
   ly, 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.
   Ue know that when the good Lord made us, he put into us a certain amount
   of quality which, for lack df a better term, we have called natural re-
   sistance.  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 hygenic 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 build-
   ing 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 re-
   sistance.

        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,  Tt 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, "He are
   here alone;it is hopeless".   Uhen we are all here together exchanging ex-
   periences,  there comes the inspiration,  "Ue 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 workfor the  patient,  not be segregation,  but by classes.

       In  your  T.B.  sections,  have  your  sub-divisions;  have your places  to
  which you are going to  Bend  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. 
 
ixth  Session
Thursday, January 19, 1922.
                            Page  51r

STITES:  (continued)

         Perhaps a little outline of the organization of at least tv/o of the
    hospitals v/ith v/hich 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 chesa
    and sticking your ear to his heart.  Have somebody who understands neuro-
    logical 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, i?
    found to be a T.B,case, he is apt to say, "I caught it here".  Put aim
    where you can answer, "You did not get it here.  You have not been in
    sufficiently close contact v/ith the disease to catch it."

         Have your surgical ward; and then yourstrictly 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
    v/ill disgust him.

         Then have yourambulant section and sub-divide it into the section
    in v/hich 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 ^et away from the everlasting com-
    plaint,  "You let the fellow in ,ths nsxt 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  oases, 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 under-
    stood 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. 
 
Sixth  Session^                 Thursday, January 19, 1922.

                              Page 52.
DR. ELAUTZ (IMH.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 con-
   nection with the psychology of the ex-service man, v/hich has been re-
   ferred to a number of times.  He is apt to misunderstand and to be re-
   sentful 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 com-
   plaints on the part of T.B. workers not only in government but in civil
   institutions as well.

        r*e still find relapses occurring after the patient has been dischargee
   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, v/hile 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 v/ith its application in the treatment of T.B.
   One very important feature brought out this morning is the psycho-
   therapeutic object, - the point of view of relaxation or recreation,
   that is, giving the man something to occupy his mind and improve his mor-
   ale, helping him to forget his home anxieties and anxiety about compensa-
   tion.

        The second point,  or 2 A, deals with muscular reconstruction, -
   conversion of recently  acquired adipose tissue into working force by re-
   building 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 im-
   portant. Me  do  Im?" that in the  recently toxic stage, exercise  or v/ork
   does  produce a  reaction v/hich is  shown by a rise in pulse rate.   Me  know
   that  if  exercise  id begun in small  doses and gradually increased, the time
  will  come when  the  patient can be made to take a fairly  large am-runt of
   exercise continuing over a fairly long period of time, without  manifest-
   ing the  symptoms  of reaction.   Formerly we  gave Tuberculin in gradual
   doses until we  reaohed  the point where tho  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. 
 
£ i * 1 ll  Ses_s_i^2ilL             Thurs day, January 19, 1922.

                            Page 55.

KLAUTZ:  (c ont inued)

        The third point deals with applying occupation as a means  of train-
   ing 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 rehabilita-
   tion if we are to get  permanent results from sanitarium treatment. I
   donTt believe we hove  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 ef-
   fort should be made to bring him back to some  medical unit for re-examina-
   tion 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 v/e have
   this afternoon and discuss some of  our  real problems, and I mean by that
   problems that v/e as command ing 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 otherr you v/ould be able to
   solve.  I believe it v/ould be worth more to tell how to get rid of some
   of these problems.

        I believe that the  success of  running a hospital rests fentirely
   upon the confidence that your patients  have in you.  If you are sincere
   they knar 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 be-
   cause 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 tv/o 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 v/hich 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 conies made of
   those  letters  and placed one  of them on the bulletin board of the hospital. 
 
Sixth  Session.
Thursday, January 19, 1922.
                                Page 54,

 STANLEY:  (continued)

      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 v/ith 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 ishould 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 entertain-
   ment.   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 v/ould compare our institution with some of
   these other institutions.

      For many years I have been conneoted v/ith 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 v/ere entertained to death.   These
   men afterwards got out and were not satisfied unless they were placed-in
   an institution v/hich 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 v/ere a better class to handle because they v/ere not
   so much entertained.  Once in a v/hile  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 v/here 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 v/hile.
   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,   T have heard men criti-
   cize entertainments at Fitzsimmons; they v/ould swear and. walk out while
   Madame Schumann-Heinck was singing, because they v/ere dissatisfied; they
   were saturated with entertainment.   I  am against entertainment for tuber-
   culous 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 
 
- i * i !l  §. £ 1 £ * 2. £i.             Thursday,  January 19,  19220

                             Page  55.

WALLACE:   (continued)

   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  f ifty WerRisk  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 oh
   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  any-
   where.  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 wfcld 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.  Dont speak to them in scientific terms, let them under-
   stand 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 v/ho want to entertain them. Your  men will be  just as
   well and  better satisfied v/ith  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 v/hich he has blanket authority to  send him, Oteen or Fitz-
   simmons;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 v/ill 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 un-
   suitable  in the usual  sense of  the word for transfer. 
 
Sixth  Session,
Thursday, January 19, 1922,
                                 Page 56,

 SMITH:  (continued)

         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 tuberculour patient and wants to effect his discharge  to
    Fitzsimmons, he first asks the district manager for permission to trans-
    fer the patient.  The district manager in turn asks the Director of the
    Veterans' Bureau; the Director of the Veterans' Bureau advises the  dis-
    trict manager, who in turn advises the officer in charge ofwthe Navy  Hos*
    pital.   Now it will  be necessary to watch and pee 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 inter-
    pretation of Order 59 be discharged without  invoking the same  authorities
    who sent Mm there.   *n 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  recommenda-
    tion 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 frcm/iall  hospitals concerned, as  to whether this  order will not
   need modification.

SURGEON F. H. MCKEON, USPHS:  Some have stated  that they v/ere in ignorance
   of the existence of G, 0. 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 v/ho 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 
 
§. L * i h  S e_ s  s_ i  o  ru_              Thursday* January 19, 1922,

                              Page 57.

MCKEONt  \fcontinued)

    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  pos-
    sibly 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
    syiiltem which the Veterans' Bureau is putting into effect now will  result
    in a more careful  supervision of the traineets 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 break-down occurs.

        This afternoon  the subject of hospitalizing the  tuberculous veteran
    in n. p,  hospitals wss 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 hos-
    pitalized in an institution for the treatment  of tuberculous*  But to
    my mind that does  not  hold where the disability is clearly a mental dis-
    order; 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 to-day  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 an-
    noyance 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*  BURE£U:This matter affects us adminis-
    tratively 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  tuber-
   culous institution,  and they  refuse to  go,  shall we turn them out  or
   shall fre 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
   v/ho are  not  compelled to do so.  The pass  privilege is another  thing. Some
   patients  hatfe but one pass  a week and other patients  get passes  frequent-
   ly. 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. 
.'  ■ *.
ft ■-/ 1
.-, -   " ^ :/-, ,.
0 ."•■»• •
;> > .

■  Off
/.*,.

            *.••<*■>  •       "a.'. ..




'  \  'i->  '^""  ■•■/   '{',"■■




  -aw '    ::  ■; a'         '  '  ■

'.'•   V'W 'J/"
' t ' . v •
' V''.'
lfoa
>-..
'.^V.N

" •" «' >'
■y;«y
'<1. 
- i * 1 2l  i£ ill °Hl               Thursday, January 19, 1922.

                             Page 58a

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 v/hat 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 v/hat they want
   in the way of food.

         When I went to Greenville it was the custom to give the men break-
   fast at about seven o'clock; luncheon at 10:30; noon meal at 12 o'clock;
   at noon the men v/ere not hungry and v/ere generally dissatisfied with the
   food; at 3 o'clock, after the rest hour, they would have another nourish-
   ment; 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 v/as 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 v/e 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 hosritali-
   z at ion 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 bonder how
   you can get an accurate record of a man's condition v/hen 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 5:45 I told the men
   it was for their good and although they objected at first, it appealed
   to their reason, after they v/ere told v/hy 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 6end 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 hos-
   pitals.   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 ar-
   rived  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 v/ill not  have  a claim against the Federal Employees Com-
   pensation  Commission by  saying that he was working in  a tuberculosis 

■-. '.)<■■■ 
- i * t !i ?_ 1 i s L°Bjl             Thursday, January  19,  1922,

                             Page 59.

DEDMAN:   (continued)

   hospital and  contracted tuberculosis v/hile  in the hospital.

        There  are many things  I would  like to  speak of,   I v/as very much
   impressed with trhat 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  th& 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. SATCYER:   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.   There-
   fore 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 Appro-
   priations Committee*   If you have not heard him I am sure  you will be
   «ry 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 v/ill agree,
   after  you have heard  General Dawes, that if you have had no other ex-
   cuse 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 v/ould be to the interest of a good
   many if they  might bring up some subject that they are particularly in-
   terested in.  So we are going to have in the morning a question box, and
   if any ofyou  have questions in v/hich 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,

       Prestaeixv 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 a» you
   have not contemplated. 
■ • •'-. s
a  *  fc^-i'w
■'ww   '  ''     "■
i'Mr-.M"!
■■*'?. la
>v  -A*,
:  •.*!)•  cf
'">  '\V'i ;'
» I..- ■ l'l ■
■  ,;.i.
v;',-.-  .
••a-:,-"-  ana .  ,
'■''.A'-r *<'}.   .1-./  '■ •    \.x*j\
 ■'.    *  .,  -A: taw  War  'A-  v> .1
 h-n .-  ■: •■!'; -a a « a»'>a:a«.a-
■'.   /.;:«■.,';  'ft.:  .•-•.'*  *..■:...   f"    .;
 •''..'"'■'.ft* Ol  " 'V:  •• :■•■'  >■'.       >
'i  : : ••■
.?■■>-*>.  ■■  ■■ i .a
V.'J\tv- 
Seventh  Session
Friday,  January 20,  1932*
                             Page  1.


 GENERAL SAUYER:  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 v/as  changed.   I told you also that
    you would not be disappointed  in  today's program, and nov/ 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 kinas of men.  For instance, from V/yoming we get
    out stock men;  from Iowa,  our  farmers; from Indiana,  our authors,  par-
    ticularly cur fiction writers; from Ohio,  of course, we  %et our presi-
    dents;  from  Illinois, a  thousand  miles from Wall Street, we get the
    greatest of  financiers.  It is tiue 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 expendi-
    ture,  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, v/ith institutions opera-
    ted as  economically as they can be*

        I  only relate this that ail of you may know  and. may  carry this mes-
    sage 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
    tho 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, Chair-
    man of  the Appropriations  Committee of the House.

CONGRESSMAN MADDED: -

       "Mr, Chairman,  ladies and gentlemen:

       The  most sacred obligation  we  have  today imposed upon the Govern-
    men is  the proper care of  the  men v/ho  caite back  from  the brar less
    physically fit  than they were  when  they went away. Provision is being 
 
Seventh  Session           Priiay, January 20,  1922.

                             Page 2.

SAWYER (Cont.)

   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 v/e must provide, and v/e 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 weil cf other things as of the men themselves.
   I think the American people would  be willing to make any sacrifice for
   the comfort of the raen who served  the nation either in the late war
   or any other -arar; and tho best evidence of their willingness to do that
   and of the willingness of tho Congress  to cooperate is the fact that
   we are spending out of the public  treasury for the allotments,  allow-
   ances,  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 nay be doing somo things in connection with this expendi-
   ture that are not for the best interests of the men,  and I sometimes
   have dcunt as to whether v/c are wise or unwise.  I sometimes have doubt
   as to whether we are managing this expenditure as it ought to be mana-
   ged,  - whether we are giving the proper care to the moral situtation
   surrounding the hospitals where these imn arc being treated.  We have
   evidence before Toy committee in the record testified to by those in
   charge of hospitals in v/hich 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 tc see  that proper care and proper
   attention is given to every nan that  served the nation; but I believe
   that  in the payments  v/e make to these  men who are  being hospitalized,
   we ought to have  some control over v/here that money goes, v/hile  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  v/ith those in  charge,
   and be  allowed to expend  only a limited  sui^  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.   Wow,  we  have
  an obligation  greater than  the  obligation to  care  for  the men, and that
   is to see that v/hile v/e are  caring  for them we  do  not  destroy them.
   (APPLAUSE). 
 
Seventh  Session
Friday, Januaiy 20, 1922.
                              Page 3.
MADDEN (Cent.)

   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 con-
   victions;  there is nobody in the world that people hate so  much as  the
   man in high public place v/ho has not the  courage  of his convictions.
   The man in high public place has got to have sufficient courage to  pro-
   tect the  rank and file of those who are being protected by  the Govern-
   ment from the folly  of their ov/n deeds; and that  applies  as v/ell to the
   Legion and all /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-foxd,   Ws
   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 v/hich  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  v/hile 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 v/e the
   courage?   I think v/e 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 v/ill  nave
   it anyhow. Far better  to have  the  grumbling v/hen the men are sober thai.
   otherwise.  Far better  to have  the  grumbling v»hen 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 v/e  get  through with
   the treatment v/e are giving  him he  can look forward  to having a bank
   account somewhere.

           You know v/e  are  liable  to destroy the usefulness  of this man.
   The citizenship of  the  future may depend  upon  our actions,  and v/e  must
   be careful.  The obligation  is  ears 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 thiw
   work ought to be transferred, because he  is not fit  for his job.   Publi.'
   office is just an opportunity to  serve; that  is all.   'The man v/ho  is  i
   public office, who  trims his sails  to meet every passing  wina is  not
   fit for the job.  He  must have  courage, integrity,  purpose in life; ana
   the man v/ho cannot do the things  that are dictated by conscience  and 
 
Seventh  Session          Friday, January ^0, 1922,
                            Page 4.

MADDEN (Cont.)

   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 v/ho 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 arny of patriotic men that have
   come back, eyeless, legless, armless, and sick in many other v/ays; but
   v/e must also depend upon you to  cooperate v/ith us in an effort to pre-
   vent 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 theza.  You need not be afraid
   to criticise; 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.  I.Iost  doctors do not know/ne¥pecially Amy
   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,

       Nov:  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 appro-
   priated beyond the  revenue, and  I don't care from whom the estimates
   come.

       Our job  is to  represent the  tax-payers.  Somebody must visualize
   the nation.  You men  visualize  the thing before you; you see  the  local
   picture.  We  see more  than  that; we  see  the whole picture; and  our  job
   is not only  to see  that  the  rights of  those under our care are  pro-
   tected and preserved, but  that the rights of the  people who are not
   under  our care and under ./hose care  ve  are,  are  protected.  We  repre-
   sent  the  tax-payers of  the  nation.   They have  been  mighty  patriotic;
   they have been  liberal;  they  have not  grumbled;  they have  paid  the
   price;  they  have paid iw with courage;  and  they  have shown their
   patriotism.   'They  have  shown their unselfish devotion to  liberty.   Theg
   are willin-  to meet any expense £hat may be imposed for the  proper car..
   of  those who fell before the bullets of the enemy;  but  they want and
     ill  insist  upon proper supervision  of the expenditures.
w
    They have a right to that.  They have a right to relief from the
burdens of taxation to the extent that we can help to  :ive them that
r^lief; and it is your job and mine and that of every  other nan
reiiei; am j^ j-3 /uuk* «j-~ ~— ---             *,
in the -overrent service, - ..hether he be a uollar-a-year man  or
.;hether°he"be given  fifty thousand dollars a year  for  the privilege  of
service, - to do everything in his power  to make the people  of  America
fael that *^ey a*e not misrepresented  in  anything  v/e may do. 
 
Seventh  Session
Friday, January 20j 1922«
                               Page 5.
MADDEN (Cont.)

            The expenses of the Government for  1919 were nineteen billions;
   for 1920, seven billion, five hundred; for 1921, six billion, five hun-
   dred; for 1922, four billion, thirty-four millions; but a billion,, eight
   hundred and forty-five millions of that are  in three fixed charges, i.e.,,
   nine hundred and seventy-five million dollars a year for interest on tho
   public debt,  v/hich did not exist before the war; three hundred and
   eighty-one million dollars a year for the sinking fund,  v/hich aid not
   exist before the war; four hundred and eighty-nine million dollars a year
   for .the care of the men that you are here to represent,  for their hos-
   pitalization,  allotments,  allowances, insurance,  and so on; so that v/e
   have that fixed charge in these three items  that never existed before.
   Our Government in the future is bound to cost twice what it ever cost
   before,  and so we have eveiybody in the United States watching every
   dollar of expenditure.

            We have seven million tax-payers now that pay out of their in-
   comes,  - seven million people watching what v/e do.  Before the war we
   did not have any of these people.  They did not care what you did;
   how much money you spent,  or v/here you got it.  They did not have to
   pay it; it v/as not being paid directly*  How it is paid airect,  and
   the more tax-payers you have got paying into the Treasury,  the more
   account you have got to have of v/hat you do v/ith the government funds.

            I am just here today to say to you,  gentlemen,  that I know you
   can help a lot both in effecting econoiqy of expenditure and in creating
   a better condition, from the moral standpoint, in all of the surround-
   ings v/here our men are being treated and cared for.  You can cooperate
   by suggesting to our Committee on Appropriations how v/e can best meet
   the situation that will prevent extravagant waste of money by the men
   qho are being cared for, while they are in the institutions, and how v/e
   can preserve the funds for them and their families; ajLso, how we can pre-
   serve the moral standards of the institutions.

            Why,  the statements that come to me are appalling about the low
   moral standards around some of these institutions.  I heard a good deal
   about the Army camps during the war,  but it was not any worse than now.
   It is for you men to say v/hat v/e shall do to prevent it, and we want you
   to cooperate fairly,  loyally, actively, unitedly and promptly, because
   we must at any hazara and at any cost prevent any condition that will
   bring stench to the institution that we are  trying to preserve.

            We must not under any circumstances allow the fund that is
   being used to preserve the health to the limit and build up the men who
   served  us during the war,  to be used for any purpose that will create
   scandal in the nation; and it is bound to create scandal if v/e do not
   watch out for the moral standard in every community.

            Now,  pave the way.  Show us how we  can tie the fund up, and
   help us to help the people of the nation to preserve the men who are
   the wards of the nation.  V/e must not demoralize them; we must not
   make them mendicants; we must not encourage  them to leave their normal,
   legitimate employment to become v/ards of the nation; but v/e must en-
   courage  these  men in every way that v/e can to become so useful that  they 
 
Seventh  Session
Friday, January 20, 1922
                              Page 6.

MADDEN (Cont.)

   v/ill be able to help themselves and be willing to do it, and not de-
   pend upon the nation.

           If I have been able to express a thought at all here that will
   be of any value in the long run, I shall feel well repaid for having
   come,  I know of no more patriotic men than those v/ho confront me,  and
   no more patriotic v/omen than those v/ho devoted themselves to the service
   of the nation during the war.  There are ho more patriotic men and
   v/omen than these anywhere.  They made the sacrifice during the darkest
   hours,  llhny of you men could go out and,  as far as dollars go,  be much
   better off; but you prefer to do a service to the nation.

          Now, couple v/ith your medical service the two suggestions that
   I made.  Let me repeat them,  - the u-buiiding of the moral standard,
   and the maintenance of an economic expenditure of the funds that may
   be placed under your charge.

          Thank You,

GENERAL SAWYER:  "Fellows, as an expression of your appreciation of
   the presence of Congressman Madden this morning,  I would ask you
   to rise to your feet, that he may know we believe in him and are
   for him,"

The assembly responded by standing up.


GENERAL SAWYER: I would lose a great opportunity if I did not talce
   advantage of this particular moment to say to you that I should
   like - being a doctor myself - that v/e relieve ourselves of the
   charge of not being business men.  Certainly in the administra-
   tion of your affairs you have the greatest opportunity that can
   come to men now to demonstrate that you have some business sense
   as well as professional sense, and to me it is a great pleasure
   to have this program this morning because it gives us a new idea
   of v/hat it means to think in the language of dollars and cents.

          This administration has great ambitions to develop within
   the Government a business organization.  The President of the
   United States believes that the machinery conducting the affairs
   of the Government of the United States is about as complete,  is
   about as capable as any machinery that could possibly be devised,
   providing it has a perfect system of organization and business
   operation of these affairs.

          The experiences of the past have shown that v/e have
   gone on in our governmental affairs without uue regard to where
   v/e were to get out.  We have dependou upon deficiency bills tc
   help us in our extravagance or our over-expenditures.  The time 
 
Seventh  Session              Friday, January 20, 1322.

                              Page 7.
SAWYER (Cont.)

  has come v/hen that policy is a matter of the past3

           Realizing that it v/as only possible to carry on  the affairs
  of our Government along business lines, the President sought v/hat
  be regards - and I know this personally because I have heard him
  express it many times - one of the biggest and best and most potent
  business men of the United States of America to take charge of
  the direction of the budget; and j now have great pleasure in in-
  troducing to you,  follows, my dearest, closest friend,  General
  Charles G. Dawes,  of Chicago,  Illinois, 
 
 "Mr,  Chairman and Members of the Conference:

          The trouble v/ith most of the Government meetings is that
 they  do not assume the nature of a business meeting.  We have
 something that is entirely different from the atmosphere v/hich
 surrounds the meeting of any private business organization*

          In ny .work down here for this year, I look upon the Gov-
 ernment simply as a business organization and unless I get
 formality out of my mind, I do not get close to the poeple v/ith
 whom I do business.  So this morning I just simply want to ex-
 plain - because  when you can give the reasons for the imposition
 of discipline and rules of action, you make these rules of action
 doubly effective.

          I want  to explain, and grasp this opportunity to explain
 something of the working of the machinery v/hich ha3 been set in
 motion by the President,  creating by Executive Order for
 the first time,  a machine for the imposition of an Executive plan,
 and a pressure upon Governmental business*   In other words, the
 President,  for the first time,  has assumed his responsibility as
 business head of the organization.  He has established certain
 agencies for the imposition of executive policies and I wanted to
 explain •' :  something  about them.

          This meeting, itself,  is the result of the creation of
 one of these coordinating agencies by Executive Order*  And v/hat
 is  involved in this meeting?

          Suppose a private corporation was spending,  apart from
 the interest it  paid on its debts,  about one-fourth of all its
 expenditures along one certain line of activity.   That is what
 this  Government  is doing  through the Boards represented here,—
Arny,  Navy,  Veterans1  Bureau,  etc.   Supposing that business had
run along for a  hundred years  and somebody would  come in and say
 to  the head of the business,  "How much money are  you spending on
 this  particular  activity?"

           "Well,  so much,  one-fourth of all v/e spend,"

           "Have  you ever  had a meeting of the heads of the agen-
cies  for the expenditure?"

          "No."

          "Well,  how do you know you are not duplicating facili-
ties?  How do you know there is  any  coordination  between the es-
tablishments you are building in the securing of  supplies,  in
the hiring  of men?"

          "We don't know.   We never  have had,  in  this business or-
ganization,   even  a meeting to discuss the  question of proper expend- 
 
DAWES: (Cont,)
  iture of money upon the standpoint of one corporation as distinguished
  from five separate departments of a corporation"

            Now what a ridiculous situtation that is and yet  that
  is what has pertained from the beginning of Government.  We have
  forty-one independent governmental departments and establishments
  and each of them has been going on its ov/n way and the result has
  been chaos in business,  absolute chaos.   It is a  remarkable sthing
  that here for the first time in the history of the Government you
  have got together the elements to determine the proper administration
  of this most important matter cf the care of the  sick and the disabled
  among the veterans of the war,   For the first time it is possible,
  by this juxtaposition,  to properly consider policies  to prevent
  duplication,  to devise ways and means and it is a  comment upon the
  terrible conditions under which the business of this  Government has
  been transacted,  and tk&t is the first instance where  you could get
  them all together to discuss a coordinated  policy.  'That has been so
  with everything.   The meeting never v/ould have  gotten  together,
  you never could have gotten together physically in connection v/ith
  this thing unless you had been ordered together by  the use  of the
  Executive power of the President of the  United  States,  Now don't
  get  that out of your head,  — that  underneath  this  reorganization of
  government,  v/hich is not  to  be effected,  but which has been effected
  in  this  routine business,  there  is  the  idea  of  force,  and if the  idea
  of force  was not  there we v/ould  not have  gotten anywhere in connecticn
 with  the  securing of these  results, which small as  they are, represent
 an immense advance upon the  old  situtation.  I  speak now from the
 standpoint of  the accomplishment of these coordinating boards,  -  not as
 predicting something that is  going  to be done, but of the result  of
 that which has been done during  the last  six months through coordinat-
 ing agencies such as your Federal Board,  established by the  President
 of the United States  through  the use of his authority and running the
 routine business of  the Government for the first time upon a business
 basis.

            I make this distinction (for Mr,  Burke,  for instance)  as
 some misapprehension may be had in connection with this matter  of
 policy*   The Budget Bureau,  is not concerned v/ith  policy save  that  of
 economy and efficiency.  V/e are concerned v/ith the routine expenditure
 of  money,  of proper conduct of routine business,  It is our  business
 to  see that when money is appropriated by Congress along a certain
 line  or policy v/ith which we have nothing to do, that that money  is
 spent as  economically and as judiciously and carefully as possible  in
 order to  secure the greatest results along the line of the policy
 imposed by Congress,

           If  Congress as a matter of policy should pass a lav/  to  put
garbage on the  White House steps,  it becomes our duty,  regrettable  as
 it might  be,  to advise Congress and the Executive  as to how  the  larg&g^-
amount  of garbage  may be/expeditiously ahd economically spread  en tSo  v .
White House steps,   And that is why v/e are safe in demanding what i$
absolutely necessary,  in every business,  in routine matters, - a  cen-
 tralized  authority.   There is no democracy in a properly organized 
 
DAWES (Cont,)
business so far as routine business  is  concerned.   It  is  a monarchy,
and if  the sense  of  responsibility on the  part  of  the  agent to  the  man
at the head of the corporation, who  is  responsible for the policy,  is
lost, the business goes  to pieces, and,  if a private business,  you  go
into  the hands of the sheriff.

           The trouble  is that  in the past the  Presidents of the United
States  have not done their full duty and assumed the control of the
routine business  organization of  Government.  The  result  is,  as is  always
the  case, with a  private or  public organization, that  when the  money is
spent by parties  interested  alone in spending the  money,  the  plan of the
unit  over which the  spending head presides takes precedence over  the
plan of the  organization as  a v/hole.

           Now  that  has  been exactly the situtation in the United States
up to this  time,  and in dollars and  cents,  to say  nothing of the matter
 of the  use  of facilities,  there has  been a waste that  is  incalculable
 in the  past.

            Now,  for instance,  take this.  All this is  preliminary but it
 is very important.   Let me talk about human nature in  connection with
 this matter of taking order, —  this  matter of jealousy of prerogative.
 I sometimes think we ought all to take a course of study  in human nature.
 I sometimes think that while in the  A.  E.  F.  charged by the Commander-
 in-Chief with this same job of coordinating separated  services, the in-
 dependent services of the Arny  in connection v/ith  the  unified business
 plan of the A,  E% F.,  and afterwards in trying  to  couple  up the allies
 in the same line  of endeavor,  I had  a better chance than  most people to
 see in its  full majesty, - if you choose to look at it that way —  that
desire for absolute independence, -  that willingness to subordinate
practically everything on earth to hold power which is characteristic of
human nature.

            When you have to approach independent powerj to induce volun-
 tary surrender,  I have found you might as  well  give it up in advance.
There is nothin a man holds to  like  this right  to  exercise power, and
 the  best illustration of that is shown by the fact that the greatest war
of all ages was  fought for four years without a central command.
Napoleon's  44th maxim in war was  that nothing is more  important c<  .  .
 in war than a unified command,  under one chief. Everybody knew it, but
it was  not  until the unnecessary loss of hundreds  of thousands  of lives
and billions of dollars worth of material that  Great Britain bent its
pride and accepted that plain,  conmon-sense provision of unified  command
of the  allies under Foch,  Not  until the fourth year of the war v/hen  the
allied  cause  faced annihilation was  such a plain,  common-sense  provi-
sion as that  for  central compand  possible  to be made for  the allies, ani
the  certainty of  annihilation alone  aad.e it possible.

          Now do  you think it is  any different  in  connection with the
independent  jurisdiction of these Government Departments, from the  in-
dependent services  of the Ampl 
 
DAWES (Cont.)
          They talked  in the past about  Interdepartmental Boards,  to  cor-.
re ct this old chaos, when  they had no Executive  leadership*  An  effort
v/as made from time  to  time by Interdepartmental Boards, acting as  a com-
mittee without relinquishment of the  independent authority represented
to undertake some of these reforms, the  necessity  of which everybody  saw.
Nothing was ever done  to amount to any thing.  W&y?  They would  meet
together and talk and  outline the situation and necessity for action until
some question came up  v/here somebody v/as going to  lose control of  some-
thing or a part of his jursidiction by some coordinated action for the
benefit of the *hola Government.  Then immediately  the whole thing died
out and nothing v/as accomplished practically by any Interdepartmental
Board, where anything  vital had to be given up by  one of the independent
members of it, whose jurisdiction and power would be cut down in the
interest of the common plan of the Government,

          When the  President of the United States  assumed this central
control of routine business, he did what any man would do in connection
with a private corporation; he called together in  conference the business
administration, - everybody connected with the business of the Government
as head of department  or independent establishment - Cabinet Officers
correspond to Vice  Presidents in a business corporation.   Of necessity
they had allowed  this  disgraceful system of chaos  and extravagance to go
on.  It was not their  fault any more  than it is the fault of you gentle-
men, who have been  running along independent lines, because you v/ere not
joined together in  a system operating under a central authority.  We all
were properly subject  to the indictment  of loose business methods because
the President of  the United States had not imposed a unified plan and
system over us nor  had he  created the machinery by v/hich this plan would
be carried into effect, as he has since  done*

          In connection v/ith surplus  supplies, every department  formerly
v/as selling its supplies in the open-market, and other departments were
buying the same kind of supplies in open market.   In a number of cases
speculators would come and buy ar public sales material from one depart-
ment to sell it to  another department at two or  three times the  price*
Real estate was being  leased in cities right along from private  owners,
when the Government had vacant property  to rent.   This was the custom
also in connection  with motor transport. If any Department wanted some-
thing moved and did not have motor  transport, it v/ould go out and hire
motor transportation.  There was no machinery by which the empty motor
trucks and idle men of the other departments could be used*
                     were
          When goods/to be shipped, everybody would route them as  they
pleased.  There rcas no unified central authority v/hich could deal  with
the services as a whole as regards the classification of freight and  the
v/hole transportation question.

          The same  thing existed in the  making of  contracts* 
 
DAWES (Cont.)
            The same thing existed in Government purchasing.   There was
  competition betv/een the Departments,  the Departments themselves not
  being coordinated*  In the Treasury Department alone we found 18 separat
  points of purchasing activity.  Evexything was run in Government busi-
  ness as if it v/as composed of 41 separate corporations.  How were things
  changed for the better?  It is all simple enough.   It all depended on
  the President because he alone had the authority to impose  the methods
  of coordinating and controlling this great general business,  just as  he
  is coordinating these great activities here today  through this Board,
  presided over by his appointee,  General Sawyer,  a  co-ordinator.

            The plan which the President adopted v/as simple enough,  - just
  what would be done in any business organization -  without asking  for
  any additional legilsation for additional employees,  but  by  simply
  taking from the body of the employees,  officials of the United States,
  those pen especially qualified by knowledge and experience to  act  as his
  agents,  and then creating the machinery through which they could  trans-
  mit his  policy and plan of unified business to the general organization.

            It is the simplest thing in the world, and  the  only  possible
  objection I have ever heard was urged the other day where it was said
  that the detail of Army and Navy  Officers for  this central work by  the
  President might not result in giving  him the benefit  of absolute im-
  partiality of judgment because of their former connection v/ith  the War
  and  Navy departments.   What nonsense J

            For instance,  in my bank, - supposing  I  wanted  to take a man
  from the Discount Department,  from the  Foreign Exchange Department, or
  the  Real Estate Department,  - what  folly  to say  that  I would be justly
 afraid that he  would  not be my loyal and  faithful agent in the imposi-
 tion of  a plan  for  the  interest of  the  institution as a whole because of
 his  former connection with  those departments of  the bank.  V/hat folly
 to say that  the President of  the United States v/ith all his  power over
 personnel can not receive from men detailed for co-ordinating v/ork the
 same loyalty as he would receive from U3n appointed
 from the outside to come into this complex machine.  And I say now that
 the plan must stand or fall upon that proprosition.  Regarding Colonel
 Smither,  the Chief Coordinator, or Commander Stanley,  or any  of these
 men who have been connected v/ith the Ariry or Navy,  - so far as this work
 is concerned,  as agents for the President of the United States,  they are
 as independent as if they had never been in the Army or Navy,   If any-
 body thinks they are not,  let us  give him an example.   We  have  not
 found anything but cooperation from the  heads of these departments  and
 the heads of these services because their personal  interests  lie parallel
now with  the unified plan of the  government since the  President of the
United  States to whom they are responsible,  is  behind  that plan*

           If the President becomes indifferent,  - if he loses his  eyes,
and ears  and  fingers in matters of routine business in the shape of
the Chief Coordinators  of the Boards,  -  if he  lets  them drift,  imne- 
 
DAWES (continued)
diately there will  come  the  effort  from you and  everybody  else  to  pull
to  pieces this  coordinating  machinery which alone  is  able  to  impose  a
unified plan upon the  governmental  business.

          Now why is it  necessary for you to accept,  without  mental
reservation, the necessity of the existance of this coordinating board
under which you aot and  the  authority  of  the Chief Coordinator  of that
board as representing  the President?  Let me say in connection  with  this
that the rights of  the independent  departments and establishments  are
jealously regarded  under these executive  orders.

          What  I v/ant  to impress upon the minds  of all  is  the necessity
of  these co-ordinating boards to enable you to do  your work properly.

          Take  it in ships.   In coordinating shipping transportation,
you have got to have Mr, Weeks, Mr. Deriby and Mr.  Lasker in contact  in
connection with a decision involving the  economical use of ships. How
can anybody get them together without the authority of  the President?
Suppose I was expected to call them together without  the authority of
the President.  I v/ould  go to Mr* Weeks for example and wait  until the
Senators were through  seeing him, and then  perhaps because of his per-
sonal friendship persuade him to go over  with me to see Mr, Denby. When
we  had seen Denby how  could  v/e get  the  two  together v/ith Lasker?  You
could not get anywhere in this co-ordinating work  without  a delegated
authority from  the  President to compel  contact between high officials.

          In connection  with this great v/ork of  yours in which  you spent
last year three^JBurths of a  billion dollars, you cannot have  it run
right without the existence  of this co-ordinating  Board, - without that
authority to make a bird's-eye view of  the  whole situation, - without
that authority  to say  why this building,  for example, is unnecessary,
because there exists a superfluity  of this  sort  of building in  another
department,  TTha^s the  use  of endeavoring  to catalogue those activities
in  which there  is duplication, in which you have got  to have  the bird's-
eye view, and would never get proper action taken, unless  you have in
existence this  Board created by the authority  of the  President!

          In connection  with the rights of  your  department, for instance,
there is preserved  for you at all times in  connection v/ith the  coor-
dinating order  of the  Federal Board of  Hospitalization, a  right of ap-
peal to the President  of the United States.   If  this  Coordinating Board
interferes to such  an  extent with the plans of your unit that you think
the disadvantage so great that it counterbalances  the beneficial effect
to  the government as a whole, the right of  appeal  to  the President is
with you* But for the  first  time in the government, as you know, there
will be presented to the President  by the Chief  Coordinator the interests
of  the government treated from the  standpoint  of the  Coordinating Board,
so  that the President  of the United States  in  making  his decision on
your matter has the strongest possible  statement of the needs of the
unit from you,  and  the strongest possible statement of the needs of the
government as a whole  from the president  of the  Board*  But the final
authority# of course„  is in  the President of the United States  and he
will exercise it.   In  all of these  order* the  right of the head 
 
of the independent unit to a proper examination, by the supreme author-
ity, of his plan is preserved, and it has been  so  in connection with
all of these coordinating agencies and with the Director of the 3udget.

          Let me tell you something as to the spirit of cooperation shown.
I have never had a contest before the President v/ith a cabinet officer
or head of a department in connection with a coordinating action. I have
never had one for this reason.  Take in connection with the transfer of
ships, - we have independent agencies for the examination of conditions.
We have the right, as agents of the President,  of  obtaining informa-
tion^from any bureau chief or head of a department.

          Tie have, through Colonel Smither's wonderful organization of
course, the means for securing essential knowledge about these things.

          Regarding ships , - we asked the Navy  the other day for a couple
of mine sweepers for the Coast and Geodetic Survey.  They refused. That
was always the case in the old days.  Of course,everybody looks out for
the interest of his ov/n department.  Well I called over one of the
Assistant Secretaries of  the Navy, and gave him a  bird's-eye view of the
situation.

          They had 49 mine sweepers; and they were going out of com*  .
mission.  If they went to the Coast and Geodetic Survey, they would be
kept in commission and would not deteriorate so rapidly.  What is more,
if they didn't go to the Geodetic Survey, the United States v/ould have
to ask for a million dollars to build new ships.

          That matter was taken back and proper attention given to it
with this knowledge of the whole situation and  the Secretary of the
Navy joined in the request that the ships be transferred.

          It was not the  Secretary of the Navy who had really been
responsible for the first decision.  It v/as some fellow along down the
line, without the bird's-eye view, who has been safe for a hundred years
from the eye of a central authority, thinking in terms of the v/hole
government - doing v/hat he believed his duty, I admit, in directing
things for the best interests of his unit, but who, without the bird's-
eye view would have thrown the Government into  an  unnecessary expense
of a million dollars.

          It then developed when the Coast and  Geodetic Survey people
went to get the mine sweepers, that they were in process of repair;
that the engines were disassembled. Now the Coast  and Geodetic Survey
had no appropriation available for repairing work  and so the Navy said,
"T7e won't spend our money on those ships."

          "Uhy?"

          "Because the President of the United  States told us to be
economical.
          Nov/ supposing there had not been in existence an agency acting
under the President, such as the one here presided over by General
Sawyer which could see what v/as really involved in that action on the
part of the head of that  subordinate unit of the Navy.  Because the Navy
wanted to save a repair bill of $10,240,00 the  Government would have
spent unnnecessarily $1,000,000 for new ships.  Do not  think that v/as  an 
':  '  .* ;'<■
v   r.:.' - 
 DAWES (Gout.)                 ,                 ,,  ,
 unusual case!  It was almost always so in the old  days.
          Now nobody has  been more  anxious than the Secretary  of  the
 Navy  to cooperate  in these  matters but he must have  information,~
 and you must have the information,- to enable one  to  cooperate.  All
 that  v/as necessary for me to do was to write  tc the Secretary of the
 Ndvy, that unless these  ships were repaired out of the Navy appropri-
 ation at a cost of $10,240 v/e v/ould huve  had  to ask for  a million
 dollars appropriation for new ships.   But what if that  information
 h^d not been given?

     The existence of these agencies is necessaiy to enable this Govern-
 ment  to be run on a business basis.  I have ^iven  you a  simple illustri-
 ~tion in connection with tne ships.  We transferred thirteen ships v/ith
 the acauiesence of the heads of the departments concerned by simply
 developing the birds eye view of the situation without ever taking the
 matter up win the President, except for tne issuance  of the Executive
 order by oggreement.

     The patriotic head of a unit really welcomes this system by v/hich  he
 is toiven the information vvhich enables him to run  the activities   of his
 particular institution in the interest of the Government as a v/hole.

     I repeat you must have that bird's-eye view of the necessities  of  the
 Government as ^. whole, v/hich «,lone you can secure  through the authority
 of the President as exercised throubh tne Coordinator of the Board  you
 have  here.   It is absolutely necesscJgy that there  should be no with-
 holding of the spirit of cooperation  and  loyalty to your Co-ordinator.
 There should be no fe3ling that your independent jurisdiction is  going to
 be unnecessarily curtailed md interfered v/ith.  There is the right of
 appeal,  and it is just as important to the proper functioning of  the
 whole governmental business  machine that  you have courageous defense of the
 department unit as  you  have courageous defense of the policies of  co-
 ordination.

     There  is no proper room  for friction; and  so far as the Budget  Bureau
 is concerned and  the coordinating  agencies headed by Colonel Smitier,
 v/e have had  a minimum of  friction v/ith the departments,There  have  beenr
 transferred over $112,000,000 dollars worth of property between these
 departments  aithin the last  six months.  $100,000 per year is being saved
 in the comparatively small tiling right here in the District  of Motor
 transportation.

    Anybody v/ho stands against the principle of this thing is a man, in
 the first pl~ce, v/ho is not intelligent.  He is a man  in the second place
 who is not loyal; and he is a man,  in the third place, v/ho is in  d^n^er,
 in view of the accomplishments of  this coordinating v/ork. What excuses
 are there for anyone not  to give his loy^l cooperation to the  President
 of the United States, who, for the  first time, has undertaken to  be
 responsible for a correct system of routine business?

    One other thin^ in connection v/ith the spirit  of economy:- the
President of the United States has  asked it.   He <*sked it here in the
first  meeting of the Govt. bU3ino3S  organization  last June  at which  some
of you v/ere jrcsantJEhat request of  his has received response.   I  find  over
the country tnat for the  first time in government,  economy has become
fashionable,  and extravagance dangerous; and all over  the country,  in the
post office service, 
 
DAVESCCont'd)
     the  Army service- in all Govt activities.   There is the  spirit  of
 loyal cooperation under the leadership of the President in the  matter of
 economy.

     We know,  too, v/hat you have been trying to  do in that way in your
 ov/n service is resulting in an immense saving to the GovernmeJ&t.

     V/hat  we need are men in authority to help us find out where savings
 can be mode.   We have only scratched the surface* but it is possible now*
 as we toet the business of the Government in the proper,  organized  shape»
 to determine where the limit of economy is. We do not knov/ yet* because our
 reorganization of routine business methods has  not gone on lon^ enough.
 We have only been in operation four or five months.   It v/ill  be a  year or
 two possibly before the extent of economies can be determined.

     But in directing the prevention of duplication,  etc., in  the general
 attitude of being desirous to save, as opposed  to the old attitude o£
 being desirous to spend,- all that means that the Government  of the United
 States c«n be run more economically than at present provided  the President
 Of the United States gives his attention to the business organisation
 end he v/ill."

     General Dawes concluded liis remarks, and as he walked from  the stage
 General Ireland made a suggestion that he say something in connection vvith
 coordination within the limits of a department  itself.  General Dawes then said
 said:

     "General Ireland asks t iat I speak about a  most  important mat-er.  V/e
 cannot get general coordination among the departments unless  each  depart-
 ment is coordinated within itself.   For instance, we found that in the
 Treasury  Department there v/ere about eighteen separate points of purchasing
 activity.   No one man v/^s in touch v/ith all these agencies.   The represen-
 tative of the Treasury department on the coordinating board,  therefore,
 could not speak for the eighteen agencies.   Therefore,  e^ch institution
 must coordinate within itself in order that its representative  can proper-
 ly speak  for  it on the coordinating, board,  to say nothing about the desir-
 ability of coordination from the st*-ndpoint of  the business of  that parti-
 cular deportment,  Therefore, get yout units coordinated.

     In connection v/ith this whole matter of hospitalization,  the eyes of the
 country are on you,  v/ho are charged v/ith this great  responsibility.   No
 body of men in Government  service has more  complexing situations to meet than
 you  hove.   You «,re surrounded by every embarrassment.   In these days, when
 the  pinhuad denugotues a^re  flourishing;  when the  mere  politician is willing
 to  capitalize  <*rything,  even  a wounded soldier,  to catch votes, you know
 that  you  are  liable  to have your constructive work unjustly attacked,  To
 get  into  the  lime-libht many  men v/ill Sacrifice right principles,  and it is
 distressing to see tne antics of the puny men in  public  life  seeking  to
 ingratiate themselves in public favor in connection v/ith soldier relief.
The  demagogue   has no hesitation in attacking those things which are  right
 only provided  they happen  to  be unpopular.  His mind, unlike  yours,  is not
on the  real good  of  the  soldier*  He is  thinking  v/hat the newspapers  may
 say about  him.

    Tou must be courageous; you must worto for the  real  good of 
« ..■.*., c;
io   a
.;•  i;
v J., v; k



'„'    1-5 J
.'..'  ,f   ■.-. ;  ■'.'-   ,1 ?.. a  *  •'•
V.:  '   } 
DAWES (Cont,)
the soldier; you must v/ork for  the  real good of  the Government^ and
I will tell you something^  There is no privilege so great* which
comes with jublic  lifef as to courageously stand for that which is
right, and in so doing take castigation from demagogues for doing
one's duty*  It all comes out ri^it in the long ruiw

          In the midst of your  discouraging embarrassments, when
carefully thought  out measures  of sane relief for v/ounded veterans
are often attacked by unscruplous men, who thereby can advertise
for a little time  their insignificant personalities;if you some-
times are/ompted to take the easy v/ay and join the yelping pack
of destructive critics, be comforts! in the thought of that ever-
lasting truth that in the long  run  the man who fearlessly does
right in public place survives, and the man v/ho weakly takes the
wrong way because  it is easy receives only ignominy." 
i 
      G e -  -nth   S o j s i o n         Friday, January 20, 1922.
                                      pagG  18
      GET. SAV/YER:   It seems unnecessary for me to say, still it is only fair
         to  General Dawes, that he has injected into the affairs of Goverreaent
         the greatest enthusiasm and the most interest that has been euxwn in
         Government affairs in all the history of the Republic,

              His idea of coordination, v/hich cane to him out of the trying ex-
         perience of the war on the other side has certainly served him a wonder-
         ful purpose in the effects that he has brought about in this new plan
         of conducting the affairs of the Administration on a business basis,
         and I certainly hope that each of ycu, as you go back to your fields of
         activity, will  carry with you tho idea that you have^ a most resp.on.sir
         ble position.   No matter how small your institution^y^h^l^iaoiliTiies e
         and tho needs are all the same.

              It may interest you to know that in the few weeks this present
*         Board has existed, we have been able to turn over to tho various hos-
         pitals of the country in which we have been particularly and necessar-
         ily interested, in a hurry, several million dollars worth of property.
         Arrangements are now in operation whereby in caring and preparing for
         nearly 11,000 new beds, we have in mind to avail ourselves of the
         great resources of the Army and Navy in supplying these needs;  and I
         must say out of fairness to the heads cf those Departments,  as repre-
         sented by the medical departments,  that core hearty cooperation could
         not bo obtained.    To give you an evidence of something of the differ-
         ence of to-day and yesterday,  early last summer an appeal  came to  me
         to provide some cots for one of your institutions.    It was impossible
         for me to locate cots that I could make accessible for the purpose, and
         one day one of cur own representatives from this Board looking about
         found SO car-loads of these cots at Des Moines,  Iowa.    Now when we are
         in need of cots,  we know where to find them and know how to get posses-
         sion of them;  and this is true of all the  things that  are  really necesr
         (Sary in the conduct of your affairs.

              I am here to say to you without any fear of contradiction that
         this Hospitalization Board has already accomplished some very  helpful
         things,  and we have many more  things in mind.    One thing v/e do not as-
         sume,  and that is authority.   We have  no  idea or desire of being  auto-
         cratic in our administration but we have  a firm determination  that re-
         gardless of any sentiment or any emotion which may be  brought  to in-
         fluence  the affairs of this Board,  we will  go  on with  what we  believe
         to be  the best thing for the men we are  trying to  serve.

              I believe that  the  service  v/e  should render and that we must
         render,  and the only service that is worth while  to the veteran, is to
         make him well  if  possible,  and,  if  not,  to make him as nearly well as
         he can bo and  as  resourceful as  he  can be  and put him  back  into life
         again with confidence  in himself, with respect  to his  Government and
        with ambition  to  make America  the leading Government of all the govern-
        ments  cf  tho world.

             I am here tc  say to you that while you are talking tc your pa-
        tients about the  affairs that arise with you each day,  do not forget
        as a part of your responsibility and  your duty that you help to create 
 
S_EJ/-_EJ>LT_H   SESSION    Page  29  Friday, January 20, 1922.

a spirit and a determination on the part of the man you are serving to
get back into life again.   Discourage in every way ycu possibly csn the
idea of his becoming   -..a barnacle upon this great Ship of State.  En-
courage him to believe that the responsibility of the debts that are in-
curred here now are debts his children and his grandchildren will have tc
pay; and so, while we are talking economy to you, I would impress upon
you this one thought: that economy is only the assurance to yourself
that every hundred cents buys a dollar's v/orth.  We do not mean by the
economy we are trying to preach here economy that might be regarded as
penuriousness.   We want you to have all you need in the best way that
it can be provided for you, but we want you to have concern enough in
the property that is turned over to you/felatJ£t is v/orth v/hat you pay
for it and that it is used to the best advantage possible.

     Yesterday, v/e decided, I believe, that v/e would devote an hour
this morning to the answering of some miscellaneous interrogations.
Dr.  "Hhite,  have you received any?

DR.  WEITE:    No.

SURGEON W.  H. SANFORD (R):    Having spent the  last year and a half in
    the Inspection Division,  the subject of this excessive amount of
    money in the hands cf the sick soldier has impressed itself on me
    more and more as I inspected the hospitals-    It  v/as the  cause of
    great trouble, and is in my opinion doing  more to hinder  the patient
    than any one factor.    Without this $80.00 or $157*50  & month,  the
    vice and crime and drinking around the institutions could not exist,
    and therefore I believe that one of the greatest  things that could
    be accomplished at this Conference would be  for tho Committee to
    promulgate some way of preventing these men from  using that  money
    in the  way it is being used to-day.

         I  have inspected Ft.  Bayard,  Ft.  Stanton and other large in-
    stitutions in the West,  and I know these men in charge v/ill  agree
    v/ith me v/hen I say that the thing that hampers the recovery  of  the
    patients is their right tc  expend the  money  the way they want.   If
    they didn't have it,  the  rum-runner and the  other vices that  come
    would not be there.    I think it  is one of ihe most  important  sub-
    jects we could settle,  and suggest  that  it would  be well if  tho
    Committee would recommend that  v/e give these  men,  say, $15.00 a
    month,  and take care  of the rest  of their  money until  they are
    ready tc  go  back to  their homes.

SURGEON J.  E.  MILLER (R):   At our hospital we have  a canteen.   I  sup-
   pose most hospitals have canteens.  V/e have had $3,000 paid  into
    the hospital -$3>000  a  year profit  on  sales  tc  soldiers.   I  think
    such money  could  be turned  in for the  benefit  of  the soldiers,  for
    entertainments, Christmas dinners,  etc., as  that  seems the proper
   place for it.

MR.  M. SANGER  (St.Elizabeths Hospital):   With reference  to these
   funds of the beneficiaries v/ho  are  in hospitals,  a similar condition 
 
Seventh   Session.    Page 20    Friday January 20,  1922.

existed for a v/hile with reference tc those drawing pensions.   That
proposition had to be met.  Congress passed a law whereby these people
receiving pensions, v/ho entered soldiers homes or hospitals had tc pay
that money either to the superintendent of the hospital,  the President
of the Soldiers Home, or tho Governor cf the Home, to be  cared for for
the benefit of the pensioner.   Those v/ho had beneficiaries at home re-
ceived the benefit of their portion cf the pension under  supervision cf
the Pension Office, the Pension Office having machinery t;  find out v/hat
beneficiaries had dependents, etc., and v/hat proportion of the pension
should be paid to them.

     The only thing in connection with these funds paid to the hospitals
v/hich led to complaint v/as the money paid to heads cf hospitals or Sol-
diers Homes for deposit in the Treasury, but v/hich v/as not drawing in-
terest.  This needs corrective legislation.  Precedents are at hand.
Moneys paid into the Treasury by beneficiaries or enlisted men of the
Army or Navy are drawing interest.  The money from these  pensioners
should be drawing interest.   These funds, whether from the pensioners
cr beneficiaries of the War Risk Bureau should be used as a sinking-fund
possibly to retire the debt of the Government and in that manner tc drew
interest.  It would help the Government in becoming part  of the  cinking-
fund; it would help the veteran in that it v/ould perr.it tho money re-
ceived tc be deposited for his benefit, and would give an opportunity
for regulations to be made to safeguard him; to prevent these  people
from coming around the institutions by preventing his having excessive
money to spend.   Then v/hen the man is discharged, he would have an es-
tate with v/hich tc begin life and tc provide for the future.

     I think this organization should give some consideration  to this
matter.   I refer to Acts of February 20, 1905 and February 7,1903, and
similar acts in regard tc Soldiers Homes.   I think the one thing tc bo
considered is a means of investing these funds for drawing interest.

MAJOR GEKERAL H. W. IRELAND:   The question cf patients having money
   while in the hospital is one cf the most demoralizing  things that can
   happen.   It has been recognized in the Army for man;'"  years.

        In the Philippines v/e hod a sy.wpathetic commanding officer and
   we received permission to v/ith-hold a certain portion  of tho funds.
   Then we received word from the Secretary of War that it was contrary
   to law; that the money was earned by the soldier, and  had tc  be paid
   to him.

        I think ycu are going to find the seme is true cf compensation.
   If you are going to held the compensation cf the man v/hile  ho is in
   the hospital, ycu will have to get an Act cf Congress.   I  think,
   therefore, that you should consider the amount of compensation the man
   should get v/hile in the hospital; consider the proposition  cf maybo
   reducing his compensation v/hile in the hospital, being cared fcr by
   tho Government.

 SENIOR SURGEON  J. E. DEDMAN (E):   I am glad this subject came up.
    A year and a half age, a committee of T. 3. oxgerts came tc  cur 
 
  Seventh   Session.    Page 21   Friday .January 20,19.-72.

hospital and v/e discussed that question.   I" made the statement that many
cf the men in cur hospitals were getting tec much money.   It was immedi-
ately taken up by the American Legion, and they said all kinds of unkind
things about mo-   I said that men v/ho never had any money in their lives-
single boys, etc. , were getting $80.00 a mouth and that this was too much
money.

     I cited the instance of where a lady came into my office, weeping.
She said she had been dependent upon her son; that he had go I;ton that
day a check for $1:200; had bought an automobile for $1500; and had gone
$300 in debt.

     The greatest  set of vultures we have to contend v/ith are the auto-
mobile salesmen.   For instance, they come and sell tc our boys for $700
cars which would  sell for $400.   If the boy has $500, they charge him
$750 in order to get notes and keep him in debt.

     I am in favor of getting an Act of Congress to put the man's money
at interest, so that when he is rehabilitated he v/ill have something to
talce care of himself.   As it is now the boys are spending their money
for hootch, automobiles, etc., and instead of rehabilitating them we
are ruining them.

MR. M. SANGER, St. Elizabeths Hospital:   In regard to the question of
   General Ireland, the pension regulations include a provision that one
   part of the pension shall be devoted to reimbursing the hospital for
   part of the care.   I think that would serve in a way tc admit of
   those in hospital getting less while there than when outside-

SENIOR SUPGEON G. B, YOUNG, U.S.P.H.S.   While on the subject I offer the
    suggestion that something might be done along this line in connection
    vvith the disciplinary regulations, which provide that v/hen a man is
    discharged for disciplinary reasons his compensation will be with-
    held for a certain period.   V/e all know that we sometimes v/ill have
    to discharge people for disciplinary rea,scns, and it may happen that
    the offense is of such a character and the man of such a character as
    to make you feel that the sentence you have to impose upon him as
    compared to that which you have to impose upon a flagrant offender
    is lacking in elasticity.   It seems to methat it v/ould be well in
    this connection to consider whether tne regulations could provide
    for the with-holding of compensation by the Veterans' bureau for a
    greater period as an incentive tc better conduct, so that the man
    might be returned to the hospital v/ith the incentive that if he beharw
    satisfactox'ily that Lais money v.-hiah had been wii.h-h.eld would be re-
    stored.   As it is a man has to be discharged and he goes out penni-
    less, because he hasnJc anything coming to him for several men-hs.
    If he could lock forward to a suspended sentence, I think that would
    save some of the better element among these possible unintentional
    offenders and get them back into a line of good behavior.

 COLONEL JAMES A. MATTISON, N„HoD,V„S.   This question which was brought w
     by Congressman. Madden, General Ireland and others is a ver.r  • 
 
Seventh   JH c s s .i o n    Page 22     Friday, January 20,  1922.

pertinent one.   This method of handling the funds of men of former wars
has been in effect in the National Home service for many years.    The
matter just spoken of in regard to handling this money in a disciplinary
way has also been a feature.   In regard tc the men v/ho have been offend-
ers, who have been continually guilty of getting drunk, the commanding  of-
ficer of each hospital had the authority to with-hold, as a disciplinary
measure, any part or the v/hole of a man's pension until such time as he
saw fit to turn the mony over to the man or apart cf it.    Of course
the matter of with-holding pension money in the case of men cf former
wars is of much less importance.   Formerly, these men v/ere getting $10,
$20 and $25 a month, and when Congress passed a pension la>v providing
$30 a month, they saved money.   That does not compare with the pensions
our soldiers cf the recent war are receiving, $S0  $100 and $150  a month,
and, as has been stated by  several men already, it has been and is going
to continue to be one of the greatest factors in preventing these men
from being restored to an active state in life again.

     In the matter of the corrupt conditions which have been described
as existing around these hospitals, it is something that cannot be pre-
vented.   Every effort has been made.  The civil authorities have been
appealed to and in most cases they have given undivided co-operation.
Personally, I feel that it is an exceedingly important matter.

SURGEON J. B. ANDERSON (R):   If I have interpreted the regulations
   correctly, we are not permitted to have a canteen around the hospital.
   If I am in error, I should like to know it.

LIEUT. COL. W. H. MONCRIEF, U.S.A.:   Contrary to the impression  given
   here yesterday afternoon, revelry does not maintain at Fitzsimmons
   Hospital.  I think we have a well-ordered institution.   The matter cf
   compensation does give us  some concern.

        We have four classes of patients,- Army, Navy, beneficiaries of
   Soldiers Homes and of the Veterans' Bureau.   On the day I left, v/s  had
   a total of 980 patients, 719 of v/hich were Veterans' Bureau beneficiar-
   ies.   These are officers, ex-nurses ar.d ex-enlisted men.   I  will say
   that the behavior of  these people during my tour of duty at the hos-
   pital compares favorably v/ith that of any other institution.   Wc heve
   our troubles; if we didn't have them, I don't suppose the institution
   would need a commanding officer.

        But the question of compensation is one that is not easily adjuster
   unless it is adjusted at the source.   It is impossible to give ycu  an
   idea-unless ycu have charge of one of these institutiens-of how much
   trouble the commanding officer is going t: have if the responsibility
   of withholding this compensation is put on him.

        We are near a large city - not too near and not tco far - but we
   are surrounded by people who want to offer at all ti.mes every  inducemeit
   tc the enlisted men to spend this amount of ccrmpensaticn in the most ad-
   vantageous manner.   This class ranges from the pedal or of tin toys  to
   the most reliable banking firms in the city of Denver.    'These bank
   representatives wait onus.   Since I have been there,  I have  had tc 
 
 Seventh   Session.    Page.  -3-    Friday, January 20,1922.

 pursue the policy of excluding from the reservation all solicitation
 whatsoever, my argument being that it v/as my duty,tc protect the T. B.
 patients; that if one solicitor wore allowed, ethers must bo allowed;
 and that I had no time ncr inclination tc pass upon the merits of the
 various propositions offered.   I have not had a*great deal cf trouble;
 and since I have bc\i:i able tc get the representative people to understand
 this situation - and I take particular pains tc inform all my personnel
 that reputable firms and others are aware cf this prohibition - it is as-
 sumed that anyone soliciting en the reservation is not reputable.

      I think a great deal can be done in regard tc taking care cf this
 matter by the social service v/crk in the hospitals.   The good people cf
 Denver have been very kind in every xtcy*


 DR. BUTLER:   In view of the fact that economy seems tc be the order
    of the day, and to have economy the bird's-eye view has been pointed
    out tc organizations this morning, I suggest that as a fitting slogan
    for this body, the words: "Cultivate a bird's-eye view11 be adopted.


 GIa3S.lL SAV/YER:    I don't know just v/hat authority ycu gentlemen have  in
  ,  regard tc the matter of solicitors, but at White Oaks Farm if inter-
    ruptiens such as these attempted to exist, somebody would get hurt.
    I would not tcierate the existence of such affairs.  There is no reas-
    en why you should, and if there is any reason vfny you shouldn't, this
    Beard can help you tc bring about seme regulation or some rule whereby
    it will be possible fcr you to protect yourselves and your people
    against such imposition as this.   Be assured that this Board is going
    tc pre viae it; but I really think that if gou will exercise your au-
    thority as commanding officers and net allow these people tc intrude
    upon you, you will be able to cure a lot of your difficulties at
    heme.


SURGEON J. M, UHEATE (R) , U.S.P.H.S.:    A year ago v/e v/ere swarmed with
    agents, and I sent out a hospital regulation prohibiting that.   It
    is easy to issue regulations, but hard to  put them into effect,  so
    I have made it a. rule tc make my regulations as few as possible.  This,
    however, I found tc  be a necessary regulation, and I prohibited agents
    of all kinds  from access tc the hospital. 
 
 Seventh   S.es.sion     Page 2^.    Friday January 20, 1922.

 ,,fffl^8 a^^^ed-acre field, which is approachable in a hundred
 thf ZZJ^S' andTthoro is «> way of keeping such agents out of
 StUf SrV^1?n*  x1 had ^ °a^tain of the ^tch «*» a Deputy United
 States iferahal.   I had my head orderly made a constable for the
 county.   They helped me to maintain order outside the reservation.

      The matter of compensation has been a big problem v/ith all of
 us.   l recall that about the first time I got "in bad" with my pa-
 tients was early in the game.   I was waited on by a delegation of
 patients m my office one morning, who asked if I were properly
 quotea in the morning paper.   I had not seen the paper.

      A day or two before, a committee of Legion men called at my
 office (we had most happy relations v/ith the local Legion heads).
 One of this Committee was the editor of a local paper.    Among the
 general things we discussed v/as the abuse of compensation.   I said
 I wished we had some law like Canada, whereby all but one-fourth of
 the compensation could be withheld, as I believed that  ten dollars
 a month was enough for a sick man in the hospital.    This was dis-
 cussed and it sounded reasonable.

      The next day, to my surprise, the editor of the local paper
 printed the story of my recommendation; and the young chap,  thinking
 I suppose to give me the credit for the thought,  quoted me freely.

      The soldiers appointed a committee to wait on mo.    They wanted
 to know if I thought it fair to the United States soldier.    They said
 it was their money and that they proposed to spend it as  they saw fit.

      Out of this controversy grow consideration by the  Legion;  and in
 course of time that Legion Post sent a committee man to Washington, who
 had a long conference with Mr. Sweet; and indirectly I  may be much tc
 be condemned or praised for introducing into the Sweet  Bill the  measure
 of withholding compensation.   Our committee man who went  up  there statec"
 that it was a rather new thought to I.Tr. Sv/eet and that  he  v/aved it aside
 at first,  but that later he showed interest and finally said he  was going
 to rewrite his bill, incorporating that idea.

      But it did not go nearly as far as I recommended;  that is,  the
 adoption of the Canadian form of withholding all but one-fourth.  There
 is no  need to discuss tha,t.    Mr.  Sweet said it was illegal;  that com-
 pensation is a wage; but he compromised by saying we could fine  the men.

     Regarding my drastic order,  I might add that I do  allow the  agents
 of the banks to  come in,  and I am proud to  say that we  do  handle  much of
 our  trouble  by depositing money either for checking accounts  or  savings.
 I  think that about  forty per cent  of our men are  carrying  savings ac-
 counts in  the  local  banks.

     We have at  least  l60 N.  P. cases in my hospital,although it  is of-
 ficially a T.  B. hospital.    As you know,  the  regulation provides that if
 a man  is not capable of handling his money,  his compensation  check v/ill be
 sent to the  Commanding Officer, who  is held responsible for the  money.
I out  the money  in the bank,  giving  to  the  man,  after conferring v/ith tk >
Chief of the N. P. Section,  such funds as he may  need. 
 
Seventh  Session
Friday, January 20, 1922.
                               Page   25

SURGEON M, J, WHITE:  Early  in 1919, when I first  opened  Palo Alto,
   I made recommendation  for the amendment of the  Act,  so that  the  Com-
   pensation of a  patient might be held until he had  completely recovered,
   and I see no reason why there is  a  legal bar to it.  I thirkCongress
   can say that Compensation is payable  ./hen a man has completely  re-
   covered and is  discharged from the hospital,  V/e cannot undertake to
   protect the patients from sharks.  For instance, we give a man a pass;
   he goes down town and  spends his  money.  As  long as he has money in
   his pocket,  he will spend it*  I  think it v/ould  be legal for Congress
   to say that Compensation  will be  payable v/hen the man has reached max-
   imum hospital treatment or when he is  properly discharged.  Otherwise,
   if a patient has accumulated, say, $160, he  starts a disturbance and
   you have to give him the  money.

CAPTAIN F, W. Uieber, U.S.N.: - I am glad  to say that we have had very
   little trouble v/ith our Veterans1 Bureau patients.  We have,  however,
   had trouble occasionaly ■  but I have always been able to attend to
   these matters myself,   for I have a good understanding with a U.  S,
   Attorney,  v/ho helps me out.

         Regarding money,  it v/ould be the best thing if most of the Com-
   pensation to the men could be withheld.  They may have dependent fam-
   ilies,  so no uniform rule  could guide us in our action,  I do not
   think it should be left to the Commanding Officer,  for in the first
   place,  we do not knov/ how raich money the men should receive*

         Uith regard to the matter of smuggling into the reservation,
   I  sent a request to the Surgeon General to be allowed to pat  up a
   fence but I  have never heard from it.   I am going to recommend to my
   successor that he call attention to that matter again.    The  reserva-
   tion at Fort Iyon covers  1100 acres,  and a portion should be  enclosed
   v/ith a fence.   There has been much stealing there,  and  we have often
   found the stolen articles  in houses arouna the  reservation.   The build-
   ing of a fence would be expensive, but it v/ould counter-balance  the loss
   of government property.

         For the  benefit of the gentlemen v/ho may  succeed  at Fort Lyon soon,
   I  might say  that v/hen I was  ordered to Fort Iyon I was  very much grieved,
   I  knew it was  in a desert, and everybody v/ho had been there gave such a
   discouraging report,   I/fcr sentiment in that matter has changed to such an
   extent  that  if the place had remained  in the hands of the Navy,  I should
  have  liked to have remained there.  We are a happy family of  about
   fourteen  commissioned  officers  and v/e  have formed a little community of
   ourselves, being independent of the outside world to  a  large  extent,
   Ue have our  power house,  ice plant,  community house,  social meetings,
   and  in  fact we are as independent  as can be.

        During the flood,  we were able,  for about  two weeks to  attend to
   our ov/n things,  and after  that we  were  able to help the outsiders.   So,
   to those gentlemen I v/ant  to say  that  they need  not be  disconsolate upon
   receiving orders to 30  to  Fort  Lyon. 
 
Seventh  Session          Friday, January 20,  1922,
Page 26
WIEBER (Cont.)
         I  think it  is  ideal for the  T, B.  patients.  We have  the dry
   climate,  constant sun-shiny  days,  cool nights,  and everything con-
   ducive to  the proper treatment of  T. B.   Everything  is  complete, and
   the people are  greatly benefited by  their stay  in  our vicinity, as  can
   be attested by  the fact  that many  former Navy People, v/ho had been  in
   the institution,  are nov/ living there  and are as strong as  any person
   in the East*

         I  might say that the people  who  have had  T.  B. and who are doing
   well out west had better make up their minds to stay our there for  fear
   that change of  conditions might bring  about activity again  in their
   cases*

         Regarding a uniform system of  treatment as suggested, I do not
   believe  any strict rules should be set.   We can have a  sort of general
   system,   but no  uniform method as to  the  hours of rest,  food, etc.
   At Fort  Lyon, rest is nov/ being enforced,  and every patient gets tv/o
   rest periods, i,  e.,  from 9  to II  A.M* and from 1  to 3  P.M.  Liberty is
   allowed  only once a  week;  and overnight,  once a month.  Those v/ho would
   be discontented anywhere have left,  and  those v/ho  have  stayed feel  they
   have our sympathy and support and  are  doing well;

GENERAL SAWYER asked for resolutions  from the Resolutions  Committee.

GENERAL IRELAND: "Your  committee has  gone over the resolutions that have
   been presented, and  v/e find  all of them  in order,  with  the  exception
   of one submitted  by  Colonel  Bratton with reference to transportation
   home.  We v/ould inform you that there  v/ill have to be legislation to
   carry out  that  resolution.   We have  changed the resolution  to read  as
   follows:
             'That  the Director  of the U.S.  Veterans1  Bureau be requested
             to secure legislation so  that the expenses  of  the  patient1s
             transportation  to his bona  fide home,  when he  has been dis-
 .:.          charged  for disciplinary  reasons, be deducted  from his com-
            pensation,  when compensation  is being  given, or may be given
            thereafter.'

   As changed, I recommend  that the resolution be  adopted  by the meeting
   as read."

   This M o t i _o  n  v/as  seconded,  and carried.

CAPTAIN N.  J. BLACZWOOD, U*  S.  N.:- The Committee  on  Forms has held tv/o
   meetings at which the general subject  of this work was  discussed and
   plans agreed upon.   This work is so great  that  your Committee finds
   it impossible to  report more  than  progress at present.  The whole
   matter must be  gone  into  carefully and thoroughly  in order  to avoid 
 
Seventh  Session          Friday,  January 20,  1922,

                              Pa°e  2 7
BIACKW00D  (Cont.)

    mistakes and duplications  of the  past.   The v/ork,  to  be  a success,
    will require frequent meetings, careful study  and cooperation*
    Therefore, it seems wise  that all members  of the Committee be officers
    on duty in Washington, and j recommend  that the  present  chairman,
    Captain Blaclrwood, be relieved, and  that his place be filled by
    Captain M, S. Elliott, Commanding Officer  of the Naval Hospital; also,
    that all Commanding Officers here present  shall,  as soon as possible
    after  returning to their  respective  commands,   take up the subject of
    forms and paper v/ork regarding Veterans* Bureau  patients, and as soon
    thereafter as possible submit to  the Veterans1 Bureau, Washington,
    recommendations and suggestions for  the elimination, provision and sim-
    plification both of the forms themselves and their numbers*

            Upon receipt of these letters, your Committee v/ill then
    take up the whole subject in a more  comprehensive v/ay and will,
    as soon as possible,  submit its recommendations  for your con-
    sideration and approval.

    The M 0 T I 0 N  was seconded and carried.
Meeting adjourned at 12:30 P. M. 
 
     Eighth  Se.§_§ion             Friday, January 20,1922.
                                  Pa;:e  28.

        Honorable Charles H. Burke presiding.

        The roll v/as called by Dr. b.A. Vhite.

     MR. BURKE: "V/e will proceed v/ith  the afternoon program.  Hie first
        subject is "Foreign Relations  of the U.S. Veterans' Bureau in care
        of ex-soldiers of the former allied countries".  It will be dis-
        cussed by Dr. F.D. Hester of the Veterans"* Bur3au".

     DR. HESTER: read as follows:

        "FOREIGN RELATIONS OF THE U.S. VETERANS1 aUT^AU

                          IN CARE OF

         EX-SOLDIERS OF TFE FORMER ALLIED COUNT! IES.

         Mr. Chairman, Ladies and Gentlemen:

            As I note tbat the program upon which I hove been placed refers
         to foreign relations of the U.S. Veterans1 Bureau in care of ex-
         soldiers of the formel- allied countries, with your permission I
         v/ill add to that, the care of U.S. ex-service men in foreign coun-
         tries.  Ihe core of U.S. ex-service men in this country aas been
         discussed from every an^Ie, and it would seem proper that v/e should
         also refer to his Cjtg in foreign countries from a medical stand-
         point, as v/ell as to the c^re of the allied ex-service man in th%£~
         country.

THE L^i pROVID*-  As act of Congress, Public ±u<±, Sixty-si^th Con6reSs, ap-
ING FOR THE proved December 3-i,i»19, provides that the Bureau of Var Risk
C^RE OF U.  Insurance, now the Veterans' Bureau, is authorized, to furnish
S.EX*Ser-   transportation, also medical, surgical, and hospital services
VICE i/IEN IN to discharged mem'eers of tne military or naval forces of those
FOREIGN     Governments which nave  )een ^ssoci^toi in war with the United
COUNTRIES   States since April u,lai?, ^x^i come within the provisions of
            laws of sucn Governments similar to the \.»»r Risk Insurance Act,
            at suck rotes and under euch regulations as the Id rector of the
            Bur 3^1 of War Risk Insurance may prescribe, etc.

                  You will note that this provision of the law stipulates
AUTHOR IZ ATI ONat such rates and under such regulations as the Director of the
FOR         Bureau of War Risk Insurone2 may prescribe.  The regulation
SERVICE     that has been issued by the Director of the U.S. Veterans1
            Eur 3au provides that m all cases where application for treat-
            ment is male '.y ex-members of the military or navd forces of
            the allies, such treatment will be furnished only on the
            specific authorisation of  the Director of the U.S. Vet arms'
            Bureau upon authority obtained from the Government concerned,
            to incur the expense of tre-tment in '?«*ch cise.  V/hen tr^t-
            ment is so authorized, the same procedure is to be followed
            as in cases of application nude by ex-member3 of the Canadian
            forces,  which is as follows: 
 
£jkgh.thS£_s£i.ori                FRIDAY  January 2d 1922
                             Pa-e 29.

RECIPROCAL AGREEMENT V ITH CANADA:

        An agreement entered into betv/een the Canadian and this Govern-
   ment upon reciprocal lines provides that when an honorably discharged
   member of the military or naval forces of the Allies, resident in the
   United States or its territorial possessions, requires medical or
   surgical treatment for a disability contracted in, due to, or increased
   by his military or naval service, he shall apply to the nearest medical
   representative of the U.S. Veterans1 Bureau, "if such representative
   is not available, information regarding the address of the nearest
   medical representative of the U.S. Veterans' Bureau may be secured
   through any local representative of the American Red Cross, the American
   Legion, the Y.I.LC.A., the Salvation Army, the Knights of Columbus, or
   other volunteer agency.

METHOD OF PROCEDURE WHEN APPLICATION IS MADE FOR TREATMENT:

        V/hen application for treatment is made by an ex-member of the
   Canadian forces, the medical representative of the U.S. Veterans1
   Bureau to Whom such  application is made v/ill communicate v/ith the
   District Manager in  order to obtain particulars regarding the man's
   military or naval status and medical history, and the District Manager
   will communicate v.ith the Bureou(Assistant Director, Medical Division,
   Attention Foreign Relations Section), which v/ill obtain from the Gov-
   ernment of Canada the necessary information.  If additional information
   is  required,  the District Manager, if speed be necessary, will request
   such ad fitional information by telegram.  In no case should treatment be
   undertaken pending receipt of authority from the U.S. Veterans1 Bureau,
   unless the call be one of emergency, and in all emergency cases the
   medical officer in the field is authorized to ^ive prompt service.

LEITTER OF INSTRUCTIONS:

        The articles of agreement with Canada have been supplemented with
   a letter of instructions that clearly sets forth just how service is to
   be  given by representatives of this Bureau to beneficiaries of the
   Canadian Government.  This letter cf instruction is a guide for the
   representatives of this Bureau in the field as to proper procedure when
   any doubtful  situation should arise, an* has been sent tc the District
   Managers in such numbers as to furnish each medical officer v/ith a copy.

        It is possible  that some of you gentlemen are not in possession of
   these instructions;  should such be the c&.se, a number of copies are at
   your disposal here,  <*nd may be obtained from the stenographers1 table.

NUMBER OF CANADIAN EX-SERVICE MEN CARED FOR BY THIS BUREAU:

        It may not be out of order to mention at this time that the U.S.
   Veterans1 Bureau through its Foreign Relations Section, Medical Division,
   has cared for over 9,000 Canadian ex-service men.  When I say Canadian
   ex-service men, please know that these are not in reality Canadians,
   but that 95/b  of the  number are American boys, v/ho, through their valor
   and enthusiasm, rushed into the breacn in the early stages of the con-
   flict, having crossed the Canadian border in 1914.1915, IS lb and  1917, 
 
Eighth  Session              Friday, January 20,1922
                              Page 30.
   Their services havinb been rendered under the English flag in Canadian
   organizations, these boys are properly beneficiaries of the Canadian
   Government, and ore being cared for by that Government throufeh the U.S.
   Veterans' Bureau, Foreign Relations Section, Medical Division, by  co-
   operation with the Department of Soldiers1 Givil Re-Establishment,
   v/hich is an organization of the Canadian Government, similar to:tie U.
   S. Veterans1 Bureau.  The personnel of the Department of Soldiers1
   Civil Re-Establishment is something over 6,000, divided into 10 medical
   units, or districts.  The Foreign Relations Section, Medical Division,
   of the Bureau is constantly in receipt of requests for service from
   allied ex-service men v/ith whose government this Bureau has no recip-
   rocal agreement.  These cases are promptly referred to the representativ
   of that government located in Washxngton vvith a view of giving service,
   if the Government under whose flag the man served v/ill authorize the
   service.

REPORTS TO BE MADE UPON CANADIAN FORMS 346,399 and  76.:

        Your attention is particularly Called to the necessity of forward-
   ing to the Bureau reports required by the Canadian Government regarding
   the hospitalization of Canadian ex-service men; and I desire to stress
   this point, that, when a medical examination is made of a Canadian
   ex-service man, the report of your findings should be furnished on  S.
   CR. Form 346(S.C.R. meaning Soldiers1 Civil Re-Establishment), this
   Form being  similar in requirements to the Bureau Medical Division Form
   2545.  It is upon the findings in this report made upon 0.C.R.346 that
   the Canadian Government gives its approval for hospitalization. S.C,R,
   Form 399 is a Progress Report, and should be rendered monthly during the
   man's stay  in hospital, for the reason that until tnis report is re-
   ceived no pension v/ill be paid to the man or to his dependents.  V/hen  a
   Canadian beneficiary is hospitalized his compensation is reduced, but
   the f family  allowance, should he have dependents, is increased.  $40
   is the maximum pension poyaole to «u man vAiile in hospital, $10 of v/hich
   is eaid to him and $30 hela in reserve, which is accumulative, and is
   given to him upon discharge from hospital.  The family allowance is
   increased according to the number of his dependents, and is paid to his
   family direct.  S.C.R. Form 76 is a discharge report from hospital and
   should be rendered promptly in triplicate, as all these reports should
   be.  If you are not in possession of these Canadian Forms,346,399 and
   76* they may be obtained from the District Ivlanager in whose district you
   are located.

EX-MEMBERS OF THE MILITARY AND NAVAL FORCES OF THE UNITED KINGDOM:

        At this time the Veterans1 Bureau has completed agreements where-
   by s-rvic« is b3in-g given to British ex-service men, which includes 3x-
   msmbers of the military and naval forces of the United Kingdom of Great
   Britain and Ireland, New Zealand and South Africa, as well as those of
   Canada.

RUSSIAN ALLIED EX-SERVICE MEN:

        In addition to the above named may be included  the Russian  allied
   ex-service men,  an agreement having  been entered into with  the Russian
   Ambassador now located in Washington, v/hose ofiicial status has  not 
 
— X £ ~ ± h  S.s.s_§.i.on                Friday, January 20,1922
                             Page 31.
   When medical, surgical, or hospital treatment is requested for a
   Russian ex-service man, it must be approved in advance by the Russian
   Ambassador, who certifies that jny expense incident to tins service
   v/ill be reimbursed by  the Russian  Ambassador.

CZECHOSLOVAKIAN EX-SERVICE MEN

        Through an agreement v/ith the Czechoslovak!an Minister,  this
   service is also furnished to the Czechoslovak!an allied ex-service
   men upon  request from  the Minister of that country, accompanied by a
   statement that any expense incident to service v/ill be reimbursed by
   his Government.

RECIPROCAL AGREEMENT V/ITH THE BRITISH GOVERN! ENT:

        An agreement is pending at this time v/ith the Britisn Government
   to provide  service for all U.S. ex-service men v/ho may be permanently
   or temporarily domiciled in tho United Kingdom.

CO-OPERATION OF TEE STATE DEPARTMENT IN GIVING SERVICE TO U.S. EX-SERVICE
MEN IN FOREIGN COUNTRIES.:

        All  medical, surgical, cr hospital service that may be required
   for U.S.  ex-service men  nov/ in foreign countries is provided for by
   this Bureau through co-operation v.ith representatives abroad of tne
   Department  of State, this Bureau authorizing  such service upon receipt
   of information that the man is in need of such service, and upon the
   establishment of his identity and the fact that the disability for
   v/hich  treatment is requested was due to or aggravated by his U, S.
   military  service.  Any expense incident to this service is provided for
   by this Bureau and is  paid for through the State Department by trans-
   fer of appropriation.  This procedure has been found very satisfactory,
   for the reason that it expedites the service to the man and simplifies
   the accounting problem by the prompt payment of any expense that may
   have been incurred.

MEDICAL EXAMINATIONS IN FOREIGN COUNTRIES TAPE EY PHYSICIANS DESIGNATED
BY U.S. CONSUL:

        For  the past six  months a ruling has been in effect that where a
   Bureau beneficiary in  a foreign country was ordered for examination,
   he must appear before  «* physician designated by the U.S. Consul only,
   and that  unless a report was received v/ithin three months from the date
   of the letter directing him to appear, or to furnish satisfactory evi-
   dence to  the Bureau as to the cause of his inability to report, his
   compensation, if he received such, would be held in suspense pending
   the report of his medical examination.  The result of this procedure
   in securinb an examination by competent physicians has been that more
   satisfactory reports <^re received. 
 
Hi£h£h  Session              Friday, January 20,1922


CHECKS SENT TO BENEFICIARIES IN FOREIGN COUNTRIES:

        The records of the Bureau for the month of December show that at
   this time there v/ere 5,977 beneficiaries of the Bureau to whom checks
   were sent, totalling in value $489,71^.  These beneficiaries are resi-
   dent in foreiyi countries located in all parts of the earth, as is
   shown by the tabulated statement submitted.

SOME CASES OF INTEREST:

        In order that you may have a. slight conception of the far-reachin^
   effect of the strong arm of this Government in giving aid to its ex-
   service wen wherever located, v/hich means that ttaey are scattered all
   over the earth, I believe that it v/ill serve ray purpose if I cite a few
   cases that may prove of interest to you.  I shall withhold the names  of
   these men and refer to them by numbers only.

CASE NO, 1.

        In this case a member of Congress came to the Veterans1 Bureau and
   stated that he had been excursioned around from department to department
   in his effort to obtain assistance in coming to the rescue of a boy who
   had beai discharged from the U.S. military service against medical ad-
   vice, suffering from melancholia, and v/ho was sent to his home at the
   earnest request of his parents, as it v/as believed that his return to
   normaloy would be more quickly effected in the environment of his home
   and under parental care,  than in a hospital.  The Congressman went on to
   relate that after remaining home for about four months, the boy was one
   day reported missing.  Diligent inquiry and searching parties failed  to
   locate him, and a river nearby suggested the possibility of an accident
   or suicide.  We will drop the curtain on this distressing situation,  for
   we know by the law of the universal heart of the suffering that must
   have followed in that afflicted home.

LOCATED IN SYDNEY, AUSTRALIA:

        After a lapse of fourteen months a letter we-s received from Sydney,
   Australia, addressed to a small town in a Southern State,  sibned by the
   Christian name of the writer, Henry, we will call him.  The letter was
   a rambling, disconnected communication, addressed to no one, not even to
   the Postmaster, but simply to the town.  The Postmaster, beint, the self-
   appointed recipient of the Communication, incidentally mentioned it to
   the father of the missing boy,   The father did not associate the  iettei
   in any v/ay with his lost son, but that evening upon returning home, he
   told his wife of the letter which the Postmaster had mentioned-  I Con
   almost see in your faces nov/ that you have read the sequel to my story,
   that the mother's love quickly put the question:  "Did you see that
   letter?1'1  and when the father said, "No", the mother insisted that the
   letter must be from  her lost boy.  A visit to the Postmaster v/as made
   immediately, the letter v/as produced and identified by the mother as
   having been written by her boy.  Tne letter was then tv/o march a old*
   The Congressman had come to see v/hat could be done as to Iccatin^ the
   boy in far away Australia. 
 
Eighth  Session            Friday, J«nuory 20,1922
                             Page 33.

   Although the distance between the yearning mother and her lost boy was
   over 12,000 miles, I do not think I am exasperating v/hen I state that
   within  thirty minutes after learning  the facts a cablegram v/as under
   the vat er, requesting that  the Consul  General at Sydney cause a thorough
   search  to be made,  in the hospitals and other institutions in the city
   with a  view of finding the boy whose  personal description was furnish-
   ed, and to hospitalize if  necessary and cable results.  Within tv/o days
   a reply was received, stating that the boy had been found and placed
   in a hospital.  He has subsequently been returned to the United States,
   where he is now being cared for as a  beneficiary of this Bureau,  and I
   am glad to say that he is  progressing satisfactorily.  Is it strange
   that the Congressman and the Bureau should have the gratitude of these
   parents?

CASE N0„2a:

        A  medical officer of  the U.S. .army while traveling in Northern
   Africa  stopped over night  at a hotel  in Algiers and there learned of
   the presence and illness of a U.S.Ex-service man.  This youn^ officer
   was out of funds and in need of hospitalization.  The attention of the
   Surgeon General of the Army v/as called to the case, who in turn ad-
   vised  the Veterans' Bureau of the nun's distress.  The State Depart-
   ment v/as call 3d by telephone and requested to c«-ble the U.S.  Consul at
   Algiers, d^iectir.g him to  give immediate service to this American boy
   and report aci.io..i  tjksn. with the result that the boy was promptly
   cared for and sent by f5 rst available transportation to Marseilles,
   France, v/here he was hospitalized.

CASE NO. 3.:

        This case is  that of  a navy man whose disappearance v/as a mystery
   to his  family.  The first  information as to his location v/as obtained
   through the U.S. Veterans' Bureau, Medical  Division, as the result of
   a telegram received from the Director Medical Services, Department of
   Soldiers' Civil Be-Establishment, Ottawa, Canada, which stated that a
   man hod been arrested there as a vagrant; that he v/as apparently a
   mental  case, and had been  in the U.S. Navy,  His name was furnished
   and his identity established through  the Bureau of Medicine and Surgery
   of the  Navy,  He was promptly hospitalized by the Bureau through the
   co-operation of the Canadian officials and returned to t.ais country
   with an attendant, v/here he is under  treatment  at St. Elizabeth's
   Hospital.

PURPOSE OF THE BUREAU'S ENDEAVORS:

        I might go on to cite many such  Cases, but my time alloted is in-
   sufficient.   My purpose is simply to  inform you that it is the wish of
   the Director and his associates in the Veterans' Bureau that it and
   its co-operating agencies may give to each case a human touch, reflect-
   ing personal interest and I can think of no better maxim for our guid-
   ance tian the title of Charles Reode's book,"Put Yourself In His Place,"
   -  - -  and bive service as you v/ould na.ve it ^iven unto you." 
 
Eighth  Session,
Friday, January 20, 1922.
                              Page  34.

MR. BURKB:  stated that in the absence of Major Fraser his  subject v/ould
   be taken up by Mr. Milliken*

MR. J. B. MILLIKEN, of the U, S. Veterans6 Bureau, discussed the  subject
   "Relation of U. S. Veterans8 Bureau to other existing bureaus in caring
   for its beneficiaries", as follows:

        "Ladies, Mr. Chairman, and Gentlemen:  The subject of my twenty
   minutes talk to you might more appropriately be termed the relation
   of the U. S. Veterans1 Bureau to all the Executive Departments of the
   Government, for indeed, there is not a Department of this government
   with which the U. Si Veterans* Bureau does not have  a vital and immediate
   contact.

        Probably there are three Executive Departments of the Government
   with v/hich the Bureau has more contact than with the other Executive
   Departments - that of the Treasury Department,  the T7ar Department, and
   the Navy Department.  Inasmuch as the U. S. Public Health Service is
   a part of the Treasury Department  our contact v/ith this Department of the
   government is immediate and vital, and is of more immediate importance
   than our contact v/ith the other Executive Departments,

        As is appreciated, ho hospitals are operated directly by the U. S.
   Veterans5 Bureau, and all hospitals v/ith the exception of contract hos-
   pitals are operated by the other independent establishments of the gov-
   ernment, the Public Health Service of course having the lionfs share in
   providing facilities, and prior to the Act of August 9, 1921 creating the
   U. S. Veterans' Bureau, the U. S. Public Health Service had charge of the
   various fourteen district offices v/here was stationed at each district
   office a Supervisor.

        The Secretary of the Treasury's order of April 19, 1921 transferred
   the functions of the District Supervisor's Office to the then Bureau of
   U*ar Risk Insurance,and the Act of August 9, 1921 transferred by law the
   activities of these offices to the U. S. Veterans' Bureau, but left un-
   hampered the jurisdiction and authority of the U. S. Public Health Service
   concerning matters of hospitalization.

        Without the work of the facilities afforded by the U. S.  Public
   Health Service it would indeed be impossible for the U. S. Veterans'
   Bureau to function and discharge its obligations relative to the hospitali-
   zation, medical care, and treatment of disabled ex-service men and women.
   Co-ordination of their v/ork has lead to the fullest cooperation on the
   part of every agency, to the end that the disabled ex-service  man is
   receiving the best treatment which a grateful government can provide.  You
   have, of course, before you all the data and information relative to the
   extent of the work carried on by the U. S.  Public Health Service as it
   relates to the beneficiaries of the UV S.  Veterans'  Bureau. 
■■-.- 
§. 1 1 i 1 ° !li.            Friday, January 20, 1922.
                               Page  35c

MILLIKEN:   (c ontinued)

        The relation of this Bureau to the T,rar and Navy Departments is
   fundamental, for the reason that before any person can be accorded
   the benefits provided for under the act creating the U. S, Veterans'
   Bureau, a record must be obtained from the Vjrar or Navy Department showing
   the military or naval record of the person seeking benefits either
   for compensation, insurance, vocational training, 'or medical care and
   treatment.  Something over 900,000 requests have been made to date on
   the TTar and Navy Departments requesting a transcript of the military
   or naval record of the person while in the active service and there
   has been no dimunition in the"number  of reports requested daily, in
   that our average number of requests each day is about 1,000. The matter
   of furnishing adequately the transcript of record of an ex-serv5ce man
   or woman, showing whether or not they received any medical treatment
   while in the active service is indeed a most difficult problem.  It must
   be remembered cases are now arising where a given individual has been
   discharged from the military or naval service for a period of approximate-
   ly three years, and that in all probability they did not recei7e medical
   care or treatment while in the service, but their health has become
   impaired subsequent to their discharge from the service.  Quite true
   they might have had some Slight attack of influenza v/hile in the service
   or some other disability, but did not report for medical care and treat-
   ment.

        The most of these individuals believe that the TTar or the Navy
   Department should have had a record of such indisposition on their part.
   and that, in turn, it is up to the U. S. Veterans' Bureau to secure
   such a record upon which to predicate the service origin of a given
   disability.  Certainly not in the history of this government has the
   military and naval establishments been called upon wo complete and
   compile the records of statistics and facts comparable to that resulting
   from the late war. and v/hile there have been many mistakes made both
   on the part of the U. S. Veterans' Bureau in requesting the information
   and on the part of the TTar and Navy Departments in submitting information,
   the great bulk of vrork has been performed in a most satisfactory manner,
   and great benefits have been accorded to those applying for the same under
   the beneficent laws passed by our Congress.

        On January 1st, 1922 there had been filed v/ith the U. S. Veterans'
   Bureau 81400 claims for compensation.  In each and every claim filed it
   was necessary to request the TTar or Navy Department for the military or
   naval record of the person applying for compensation benefits, find in
   many instances it v/as necessary to make duplicate requests because of
   inadequate identification given or of additional evidence which the
   claimant submitted v/hich would make it possible for the TTar or Navy De-
   partment to make  a more exhaustive search of their records.  To show the
   promptness with v/hich reports have been received from the Uar and Navy
   Departments  for  no claim is either allowed or disallowed without a
   report  from the TTar or Navy Department - out of the 814,000 claims
   filed,  51$ have been allowed, 41$ have been disallowed, and B% are pend-
   ing awaiting information either from  the VTar or Navy Departments or from  +
   the claimant himself. 
 
§- 11 1 i 2. Hi           Friday, January 20, 1922.
                             Page 36.

MILLIKEN:   (c ont inued)

         Also to December 15th, 1921, 486,884 former service ipen had
    requested vocational training.   It v/as necessary for the Rehabilitation
    Division of the Federal Board for Vocational Education, (now a part of
    the U. S.^Veterans  Bureou;, to  request the military or naval record
    from the TTar or Navy Deparcment, and out of that number 299,000 had been
    declared eligible for training;  135,000 had been declared ineligible for
    training; and 51,000 cases ware  pending to determine their rights to
    vocational training.  These figures also represent a tremendous v/ork
    required of the TTar and Navy Departments in that the records of each man
    must be obtained before final disposition was made of the case.

         TThen viewed from the stupendous task, the results accomplished are
    indeed commendable.

         The great assistance of the TTar and Navy Departments should also not
    be overlooked when it is remembered that at the date of the signing of
    the Armistice there were approximately 040,000,000,000 worth of insurance
    in force which had been written through the service of the TTar and Navy
    Departments in providing insurance officers to make contact v/ith every
    man v/ho was a member of the military or naval forces.

         The TTar and Navy Departments have always been of tremendous assis-
    tance in the matter of hospitalization of ex-service men and women.  On
    December 1st, there were 1<410 beds occupied in Army Hospitals, and
    2,032  beds occupied in Naval Hospitals.  Certainly then from this resume'
    of facts the contact v/ith the TTar and Navy Departments is  most vital.

         Th& contact of the U. S. Veterans' Bureau with the Post Office
    Department is apparent.  It need only be mentioned that to date the  U.S.
    Veterans' Bureau, representing the consolidated agencies since their
    organization have received approximats^OjOOOjOOO incoming pieces of mail,
    and have dispatched approximately 105,000,000 pieces of mail,  and the
    daily  average receipt of incoming mail in the Bureau,  even under decen-
    tralization, is  approximately 41,000 pieces  of mail per day and the  out-
    going  pieces of  mail  from the Central Office 6f the Veterans'  Bureau is
    approximately 58,000  pieces  of mail per day.

        The  Veterans1  Bureau as you have been informed relative to the  care
    of  ex-service  men of  foreign allied countries and of American  soldiers
    residing  in  allied  countries has a vital contact v/ith the  State Department
    in  addressing  their communications to the  various foreign  countries  and
    in .the utilization  of the various U.  S. Consuls.

        The Department of Justice has charge  of all  suits  filed against the
    U. S. Veterans' Bureau xvhere suit is  brought on an insurance contract.
   The department of Justice also handles  all  prosecutions v/here  irregular-
   ities are found under the act creating the  U.  3.  Veterans'  Bureau. 
 
- 1l i. h 1 £  §,_e_s ill Hk_             Friday., January 20, 1922.

                              Page  37.

MILLIKEN:  (continued}

        Under the  Interior Department  vou know  of the use made  of the St.
   ElizabethJs Hospital  ana  of  hospitalunder the'jurisdiction  of the
   Commissioners of  Indian Affairs.

        The  contact  is also  quite vital  with the Department  of  the  Interior
   in  obtaining various  information from the Pension Bureau  as  a person
   may be  filing an  application for compensation and also an application for
   a pension.

        The  Department  of Agriculture  has been  of very  great assistance
   to  the  Bureau  in  rendering advice relative to the training of disabled
   ex-service men  with  a vocational handicap v/ho desire to take up  agricul-
   tural pursuits, and  at  the present  time  the  Department of Agriculture
   ts  rendering most valuable service  in mapping  out agricultural courses
   for the first Vocational  School  of  the Government located at Chillicothe,
   Ohio.

        Many disabled ex-service men taking vocational  training have been
    assisted by  the Department of Commerce in mapping out their  careers for
   v/ork incident  to that cf the Department  of Commerce.

         The Depax-cret\'i of  Labor has been of very  great  assistance in aiding
   the Bureau -co  fiad employment objectives for disabled ex-service men
    undergoing training or who have  been rehabilitated by the U. S.  Veterans'
    Bureau,.

         This will give  you a general view of the  relation  of the U. S. Vet-
    erans'  Bureau  to the Executive Departments  of  the government.  The U. S.
    Veterans7 Bureau naturally must have a close contact v/ith the Congress.
    Congress continually calls upon the Bureau for  data  and  information which
    can only be  obtained from the other Executive  Departments of the govern-
    ment but which immediately relate to the v/ork of the U.  S. Veterans'  Bu-
    reau.

         Inasmuch as you Gentlemen are  essentially interested in hospital
    administration, I should like to speak briefly on the question  of'hospital
    records, and «rhat data the Bureau is required  to have when  it  is called
   before  Congress relative to Appropriations.  As you  knov/,  Congress  makes
    one apnropriation to the U. S. Veterans' Bureau for  Medical  and  Hospitals
    Services,  Sums from this appropriation are  in turn allotted to  the  U.S.
    Public  Health Service,  the TTar and  the Navy  Departments,  the Interior
   Department,  ano1 the  National Homes  for Disabled Volunteer'Soldiers. Then
    the U.  S. Veterans'  Bureau is called before  Congress for every  appropria-
    tion it must show specifically how  the money has been allotted,  for what
   purposes it  has been allotted, and  the result accomplished. 
 
  i. £L 3l t !i  Session.                Friday,  Tanaurp 20, 1922.

                              Page  38.

MILLIKEN:  (continued)

        It has become imperative for the IT. S. Veterans' Bureau to have
   available comprehensive records  concerning all hospitals  in v/hich there
   are being treated its beneficiaries. It  is not sufficient that these
   records be only those concerning the admission and discharge of patients
   and the physical examination report in each instance, but equally funda-
   mental data concerning the results of treatment,  periodical turn-over
   of patients, the hospitals*  administration, and  of equal  importance, but
   from a different ar.gie, the  cost of operation with the resulting per
   item cost per  patient.

        A considerable  part  of  the  records  on patients, their flow in  and
   out of hospitals and similar data are available  or can be made available,
   the value of these  data  so derived, of course, v/ill be proportionate to
   the accuracy  or thoroughness v/ith v/hich  the records of admission and
   discharge are  prepared and transmitted.  The report of admission and dis-
   charge of patients and the report of physical examination are at present
   the only reports commontto all Government Hospitals.  The necessity for
   the prompt rendering of  accurate admission and discharge  reports and
   physical examination reports in  all instances is  apparent.  Such reports
   are of very great  importance to  the U- S. Veterans* Bureau, for upon
   them  is determined the medical rating of the hospitalized beneficiaries
   and any delay or omission in the rendering of records of  this character
   reflects upon the  administration of the  U. S. Veterans' Bureau.

         In  regard to  the individual hospital operation costs, until very
   recently the  U. S.  Veterans' Bureau has  been operating  in the dark  on
   unit  costs.   It is  demanded  that the U.  S. Veterans' Bureau have complete
   knowledge  of  the cost of operating  all government hospitals, not merely
   as  a  gross  item, but classified  by purpose of expenditure and by depart-
   ment  of hospital for which spent. The reason for  this point is made
   tv/o-fold  - First,  that the Bureau before it con  allot money to the  several
    services for  hospital' expense, must be in a position to know for what
    purpose the money  should be  disbursed; and second, because the Congress of
   the ^nited States  is holding the Bureau  accountable for all moneys
   appropriated  to it and unless this Bureau can tell Congress in detail bow
   this  money has been spent,  or  is to be disbursed, our hospitalization
   program will  be jeopardized  until  such information can be secured.

         The per  diem  rates  for  hospitals of the several services very
   materially  so far  as our estimates are concerned. The degree to which
   such  a variation in rates is only an apparent variation due to the  dif-
   ferent bases  upon which  they are calculated is  not at present ascertain-
   able, but it  should  be.   Not only should this Bureau know what it costs
   for its own patients at  any  one  institution, but  it should know the per
   diem  cost over a given period for all the patients hospitalized there. The
   cost  to this Bureau affects  not  only our appropriation; the cost to the
   service operating the hospital,  including this Bureau's share, but  it
   affects the U. S. Treasury.  If  the cost of maintenance of certain  hos-
   pitals is excessive, it would be poor business  not to evacuate that
   hospital, if  other conditions made it practicable,  or if  impracticable to
   attempt to reduce its operating  cost. 
 
~ i £L !l *L *L  §.llli£Hi.             Friday,  January 20,  1922.

                               P-ge 39.

MILLIKEN:   (c ont inue d)

         Recently the U.  S.  Public Health Service inaugurated a system of
    cost accounting by individual hospitals.  TTith the  perfection of this
    procedure the U. S. Veterans1 Bureau will be  in a position to talk in-
    telligently about operating costs with these  hospitals whether by depart-
    ments of hospitals, purposes of disbursement, such  as salaries, repairs,»
    etc., or by unit costs.

         The U. S. Veterans1 Bureau looks forward to the time when similar
    data are available and regularly submitted by the War Department, the
    Navy Department and the  National Homes for Volunteer Disabled Soldiers,
    not merely as reimbursements due certain  appropriations,  but by actual
    disbursements of detailed purpose of not  only for this Bureau's share,
    but for total operations.

         The U. S. Veterans' Bureau also maintains contact v/ith the various
    miscellaneous Departments and institutions of the government.  Time v/ill
    not permit of going into any details or of mentioning these contacts.

         The U. S. Veterans' Bureau when viewed from its huge task of running
    an  insurance company  with over three and  one-half billions of insurance
    in  force, of making payments on 149,000 insurance claims  each month,
    making  payment on 204,000 compensation claims each  month, with approxi-
    mately  29,000 ex-service men and women undergoing hospitalization, and
    having  caused to be made over 1,000,000 medical examinations and respon-
    sible for 104 .,000 disabled ex-service men undergoing vocational training,
    representing a task v/hich calls for  the closest cooperation and assistance
    from every department of the government and only by having the closest
    cooperation possible  will the government, through the U.  S. Veterans' Bu-
    reau, be able to discharge its obligations to the host of disabled ex-
    service  men and v/omen of this country.

         The Bureau has always enjoyed the fullest cooperation from the
    various  departments of the government and knov/s that the  same cooperation
   will be  extended with unstinted measure in the  future, to the end that
    §very pledge  will  be  redeemed concerning  the  care and treatment of the
    defenders  of  this  Republic,  and to the  end that this administration will
    go down  in history as an administration that  did not forget its sick and
   wounded  soldiers,  and brought peace  and contentment to everjr fireside
   where assistance  on the  part of the  government was  requested and v/as due."

COLONEL JAMES A. MATTISON,  N. H.  D.  V.  S., gave  the following discussion
    of "Economy of Administration in U.  S.  Veterans7 Hospitals":

        The subject  is so broad  that we  can  only consider certain phases
   of it within  the time  allotted for this paper.  TTe  all recognize that
   there are certain  fundamental  essentials which must  of necessity be
   provided in every  hospital regardless  of the  number  of patients cared
   for.  This necessarily means that overhead expenses  of an institution
   hospitalizing small numbers  of patients will be out  of proportion to
   those of a hospital caring for a  large  number. 
 
Exghth  Session.
Friday, January 20, 1922,
                               Page   40*

MATTISOF:  (c ontinued)

        The general business management, the purchasing of supplies and
   equipment, the conservation and dispensing of the same, the elimina-
   tion of v/aste, etc.. will bo considered only casually for the purpose
   of emphasizing the  importance of adhering as closely to strict busi-
   ness methods as is  dene  in the case  of every successful business man,
   whether he be a hospital executiveta merchant, or a man in any other
   line of business.

        In this connection, it might be said that a mistake v/hich is made
   in many government  institutions, and one which is not made by the most
   successful business men, is to attempt to start on economy at a place
   where  one can least afford to economize, that is in the pay and allow-
   ances  of the personnel immediately responsible for the management of
   the  institution, the responsible heads of departments, etc.  In other
   words, we are not always willing to  pay for brains, a price commensurate
   with the business responsibility involved.  Again when v/e have been for-
   tunate enough to secure the right man the right place, v/e do not always
   recognize his value by paying him  a  price commensurate with the value
   of his work.  Furthermore, v/hen we have made the mistake of getting the
   wrong  man, who  in reality  is receiving a greater compensation than his
   services are worth, and one who, in  reality, is a very expensJTe employ-
   ee, we oftentimes make the mistake of not recognizing inefficiency and
   promptly correcting it,

        In case there  is  any decided  handicap along the lines of ineffi-
   ciency in the responsible personnel  in the administrative, utility, ser-
   vice or professional departments,  it should be promptly corrected, as it
   is to  those  in  such petitions to whom we constantly look to be on the alert
   in recognizing  the  short comings of  all subordinate personnel.

        In visiting our own or other  hospitals v/e promptly recognize the
   presence or  absence of evidence  of the proper vigilance or efficienoy in
   every  department.   In  case of a tour of inspection of one of these insti-
   tutions there should be found spurting steam valves, leaking water faucets,
   extravagant  use of  electric lights,  overheated buildings, garbage and
   swill  tanks  running over wr\h v/aste  food supplies, evidence of lack of
   organization and co-operation on the part of the personnel, professional
   or otherwise, v/e should immediately  recognize the fact that there v/as
   inefficiency existing  in the personnel of such an institution, and as
   a result of  this, a decided lack of  economical and efficient administra-
   tion.  Finding  such conditions  in  other departments, we should expect
   to find unsatisfactory conditions ^jjhen the patient population was reached.
   TTe should expect to find histories^poorly written or not written at all,
   patients waiting over-time for special examinations or special treatments,
   lack of accurate laboratory and X-ray records, etc.  The matter of such
   inefficiency and consequent poor administration on the part of the person-
   nel  in any institution would naturally lead to great dissatisfaction on the
   part of the patients of such an institution and Jto the greyest lack of
   economy on the part of the administration, of the hospr^al. 
 
 — i & *L Ji ll  5. 1 1 1 i. £ £•.               Friday, January 20, 1922.


                               Fage    41.

MATTISON:  (continued)

         In connection with the professional  department proper,  again the
    attainment of the most satisfactory  results  from the standpoint, both
    of economy and efficiency, is dependent upon the capacity and co-op-
    eration of the responsible personnel.  There has been much discussion
    in regard to the number of professional personnel doctors, nurses,'at-
    tendants, etc., and  on this subject  there has been apparently wide
    differences of opinion.  However, these differences have been based
    upon differences of viewpoints  of what the actual conditions to be met
    were.

         A definite agreement has been reached in regard to the  required
    personnel, nurses,  doctors, attendants,  social service, workers, etc*,
    to each tv/o hundred patients in a hospital caring for all acute patients,
    whether they be major surgical,  acute active neuro-psychiatric, active
    tuberculosis,  or other type of  acute condition requiring active, construc-
    tive treatment.

         As a matter of fact, however, v/e all know that in none  of our
    Veterans5 Hospitals, especially the  larger ones of 500 to 1000 or
    more beds, are all the natients  or even a majority of them represented
    by this type  of patients, on the contrary v/e have a large group of
    convalescent patients vaio require professionally ver}/- much less attention
    from the standpoint  of active constructive treatment, dietetic attention,
    etc., and hence require vastly  less  personnel, and the expense of their
    maintenance in the hospital will be  very  greatly reduced from that of the
    acute type.  A^ain, v/e have another  group which represents the semi-
    domiciliary type, many of whom  require very  slight constructive treatment,
    and yet they belong  to a type of patients who are capable of being
    finally rehabilitated ano1 restored to an  earning status in life.  This
    group requires still less care  than  the former, and naturally less per-
    sonnel and proportionately less per  capita cost to the institution caring
    for them.   Lastly, v/e pass to  a purely domiciliary group v/ho are to a
    large measure permanently disabled and are,  therefore, many  of them,
    to be permanent charges oh the  Veterans' Hospitals.  The great majority
    of tho latter  group will require little or no special treatment, but will
    require only general care and maintenance.   In this group v/e are dealing
    with a type who will represent  the minimum per capita cost.

         As time goes on we shall realize, especially in our larger hospitals,
    that the above condition will exist  to a  larger and larger measure and
    tho necessity of a very close checking system and a very careful classifi-
    cation of the patients along the lines indicated above v/ill  be a matter
    of the very highest importance,,

         This does not mean that as  long as special treatment along any line
    is needed that each patient will not have such expert examinations, care
    and treatment as his condition  calls for. Quite the contrary, the most
    careful and competent examinations should be directed by hospital units
    composed 
 
5. 1 & k_ t h  S e £ s i. o m         Friday, January 20, 1922.

                             Page 42.

JETTISON:  (continued)

   of the most competent staff  of men  including  surgical;"medical; ear, nose
   and throat; X-ray., etc., at such intervals as the-condition of the
   patient calls for.  It v/ill  be by this system alone that v/e are to keep
   a check on the progress toward recovery of each individual patient and
   prevent an untfue accumulation of a domiciliary group. By proper coopera-
   tion of such a group v/ith the rehabilitation  section, many men may be
   selected as suitable persons for rehabilitation in the vocational schools.
   The  importance of this we all realize as there is a certain percentage
   of natients v/ho v/ill be quite content with their state as long as they are
   receiving complete maintenance and a liberal  compensation of from 080 to
   Ol50 per month and no cares  and no  responsibilities to assume in life.
   That is we should be constantly on the alert  to prevent making permanent
   residents or charges of any  man v/ho can be restored to an earning status
   in life.

        Contrast, if you please, with the conditions in our hospitals the
   the patient in private hospital, v/ho is paying from OlO to C>50 per
  day for private nursing, hospital accommodations, etc., and a correspond-
   ingly high rate for special  professional services, and who in addition
   to this is losing heavily because of his absence from his personal bus-
   iness.   In the latter case  there is a much greater incentive for getting
   well, a greater incentive for requesting that special nurses and other ex-
   penses be cut off at the earliest moment it is found that they are no
   longer needed and for the additional request that they be discharged
   from the hospital as early as possible after the maximum benefits from
   hospitalization have been received.       In the one case, the private
   patient is paying freely a large sum of money to get well-   In the other
   case, the patients of our Veterans  hospitals in many cases are paid lib-
   erally for being sick.

        In making the above statement,  we do not wish to be misunderstood.
   we all know that v/o have among our patients in the Veterans' Hospitals
   some of the best type of men anywhere to be found; some of the most am-
   bitious; some v/ho are exceedingly anxious to have their health restored
   and be returned to an earning status in life at the earliest possible mo-.
   ment; but, unfortunately, this does  not apply by any manner dfmeans to
   all the patients whom v/e are hospitalizing.   Out of the disabled arising
   from an army of nearly five  million men, naturally there v/ill bob up
   representative types of every manner of man in existence.   As representa-
   tives of Veterans'  Hospitals we owe  to our Government as well as to our
   patient our best efforts to help,  not only toward the rehabilitation of
   every soldier who can be rehabilitated but we are also obligated to help
   develop this  program upon the most economical basis without sacrificing
   efficiency and the  most satisfactory constructive results." 
 
Eighth  Session                 Friday, January 20,1922
                              Page 43.

MR. BURKE:  stated that the  subjects v/ere now open for discussion, and
   called on Colonel Patterson for _ few vaords.

COLONEL PATTERSON, of the U.S. Veterans' Sur^u,: stated that it had been
   a. gre^-t pergonal loss to  hem th-^t he bad been unable to at:end -ii of
   the m«etin6s.  He  then spoke on the policy of the Veteran^' Puz.au with
   respect to  the utilisation of contract acspitals and Government, institu-
   tions.  He  stated  that the Bureau has been for some months on.deavoring
   to  take the beneficiaries of the Bureau out of contract institutions
   a.nd put them into  Governmental institutions for several reasons - first,
   the law says wo must utilize to tne maximum extent the Gpv eminent facili-
   ties  in existence.  .Another reason is that the majority of contract
   hospitals are unsatisfactory from the treatmant standpoint, if from no
   other reason, as many of  these contract hospitals ore purely boarding
   houses v/hich originated merely for the purpose of making money out of
   the Government, by talcing care of beneficiaries of the Veterans' Bureau,
   Of  course there are many  contract hospitals in which this is not true, but
   it has been determined that better treatment at at least eiual cost can
   be  obtained "fen the Government hospital.  Another reason is that the
   civilian hospital  is not  particularly interested and does not desire to
   make  the necessary reports.  He also mentioned discipline.   The contract
   hospitals do not  like to  discipline a man because it may lead to the
   loss  of that p'-itisnt,  He stated that every time the Hospital Section
   of  the Medical I>iv3 .-.ion recommends the closing of a contract hospital
   the Bureau  i~ bamedi^ielv bombarded by letters from Congressmen,  Senators,
   the American Legion, United Veterans, and other organizations,  but the
   Veterans3 Bureau, has beea trying to stand firm.

         The next subject he  took up was the fact that a tenef iciary gets
   more  compensation  while he is in a hospital*  This, however,  cannot be
   changed except by  Act of  Congress., and the Medical Division has recom-
   mended to the Director that the man's compensation be reduced while he
   is  in the hospital.

         He took u p next disciplinary regulations.  With regard to pay-
   ment  of transportation, he stated that this money could not be deducted
   from  the man's compensation without Congressional action.

         He spoke also on the fact that under the Vocational Sehobilitation
   Act a man discharged v/ith a disability not connected with the service,
   who has been denied compensation, can get training even if his disa-
   bility is the direct result of his own misconduct, and that he is en-
   titled to treatment for any disease contracted while taking training
   if it  interferes v/ith the continuance of his training.  The Medical
   Division recommended some time ago that Section 3 training be dis-
   continued and. that no man be given training unless his disability is the
   result of service  or aggravated  thereby.
      He said he hoped  that  the gentlemen present would  express their
opinion as to whether or not meetings  similar to this  one  should  oe
held  annually. 
 
JJigjath  Session            Friday, January 20,1922
                              Page 44.
     V/ith  regard  to  the  attitude  of the Veterans1 Bureau towards the
various Services, he stated  that  v/hen allegations are made all the
Veterans1  Bureau  can do  is to send them tc  the Head of the Service,
yoking  him  to  take  the  usual steps to find out whether or not those
things are true.  On the : tb-er hand, if there is a charge a man is ris-
treated, the Veterans' fiareau mast investigate it.  It is a very peculiar
situation  for one Department to investigate something conducted in another
Department.

       Regarding complaints, he cited one case.  A letter was received
from an insane  ran. :-n the va3St Rcxbury Hospital, v/ho signed the letter
''All the patients in the hospital", and complained about everything in
the institution.  A  letter v/as immediately received from a Congressman,
then another, and one from a Senator.  The institution had been inspected
only ten days previous and the Veterans1 Bureau was sure the allegations
v/ere not true,  but sent  out  another man to investigate the matter. Later
the Bureau received  copies of similar letters v/hich the insane man had
sent to President Harding, Kind George and the Prince of V'ales.  He men-
tioned this  as  an illustration of v/h«t the Veterans'  Bureau has to put
up v/ith.

       Speaking  about coordination and cooperation, he mentioned the fact
that the Public Health Service is represented in the Veterans1 Bureau by
Dr. Guthrie, Dr.  Lloyd and Dr. Lon^,, the Navy by Commander Garrison and
Commander  Boone-,  ond the Army by  Colonel Brooke and Colonel Hutton.  In
this way the Bureau  benefits by the advice of these men, and friction
between the  Departments  is avoided.

       Another thing  he took up was the situation in  Arizona.  Attempts
have recently been made  to get the Bureau to put hospitals in two towns,
Phoenix and  Tucson,  both of which he stated v/ere so hot that everybody
would  have to get out m the summer.  There are 431 Vacant beds at
Prescott,  within  «±0J miles,  ai:d in a fe.v months 422 more^ will be avail-
able.   Transportation has been offered these men to these hospitals but
many have  refused to go.  He believed that the Veterans' Bureau could do
more than  this, but  wanted on expression of opinion on the subject.

MR.  BURKE, asked  for further discussions on the questions raised by
Colonel Patterson.

DR.  KLAUTZ:  stated  that  he would like to ask Col. Patterson whether the
question of  furloughs has been token up in connection with disciplinary
regulations.

COLONEL PATTERSON*   informed him  that length or frequency of furloughs
had not  bean determined,   but permission to be absent v/ill be obtained
from District Managers under policies issued by the Central Office from
time to time.  He asked for an expression of opinion on this subject. 
 
lightfe  S^jsi^n              Friday,  January 20,1922

                              Page 45.

DR. KLAUTZr  stated in regard to the situation in Arizona that  probably
   all the hospitals available there v/ere situated in an altitude of
   5000 ft.

COL. PATTERSON:  informed him that Camp Kearny is lower than this.   He
   stated that the policy of the Veterans' Bureau in regard to  tuber-
   culosis has the backing of the National Tuberculosis Association,
   and that the men asking for hospitalization had been offered trans-
   portation to Kearny or Prescott..

DR. KLAUTZ:  offered the suggestion that somewhere in the mountains
   North of Tucson there might be places v/hich were not too high and
   would be good all the year round.

COL. PATTERSON; reported that there are already at Prescott 131 vacant
   beds and within four months will be 432 additional.  Why should we
   $o to additional expense when we have these other hospitals?

DR. LONG: took up the subject of the speeding up of patients in hospitals,
   which is necessary for two reasons - - first, in the interest of the
   man himself, and, second, in the interest of economy.  The average
   man was about 25 years of age when he entered the service, and it
   should be taken into consideration that his character had not been
   formed, and that keeping him in a hospital tends to destroy  still
   further his initiative, so the sooner a man gets out of the  hospital
   the better it will be for him.    As for economy, it costs about $240
   a month to keep a man in a hospital.  He stated that dispensaries are
   now being established in the district and sub-offices, v/here treat-
   ment can be obtained, thus a man should be discharged as soon as he
   has reached the maximum improvement.  He cited the case of Palo Alto,
   where arrangements had been made with Dr. Wheate that when a man had
   reached the maximum hospital improvement such furt ier treatment as was
   needed should be obtained in the out-patient office.  In about six
   weeks the total number of patients was reduced from 540 to 417.

DR. ELLIOTT, took up the question of furloughs, stating that qX the Naval
   Hospital*in Washington at Christmas time many Veterans1 Bureau patients
   asked for leave, and pursuant to advice from the District Manager
   they were given the same amount of leave that the other Naval patients
   received, frc-xn  5 to 10 days.

DR. DEDMAN; spoke on economy.  He said he understood a certain  rate per
   diem was to be established for the e&re of patients, and wonted to call
   attention to several things in this connection.  First, the  environmen
   Some hospitals have central heating plants; others have stoves.  He
   said that his hospital was an old cantonment hospital, v/ith  a unit
   heating system which required the employment of about 45  stokers. 
,f   i 
■Si-SllJik  § e 3j i 5 n             Friday,  January 20,1922

                               Page 45.

KLAUTZ(Cont.)

    Another thing, some hospitals are a great distance from markets;  also,
    prices may be higher.  All these things make -Suite a difference in the
    average cost of the care of a patient per day.

         With regard to General Order 27, he called attention  to  the  clause
    which gives the Medical Officer in charge the privilege of giving the
    man his transportation back to his home, and mentioned the case of a man
    who came to the hospital from Oteen, where he had been discharged f^r
    disciplinary reasons.  The hospital could not admit him, but  authority
    was obtained from the Veterans' Bureau to admit him for examination, and,
    if active, to hospitalize.  The man was examined and found to be  inactive
    He then complained to the American Legion because they did not  hosp-
    italize him, and he had no way to get home*   However,  in this particular
    case, transportation v/as later received from the veterans  Bureau.
    General Order 27a now gives the Medical Officer wuthority  to  pay  trans-
    portation.

         He then asked whether a man who hod been discharged for  disciplinary
    reasons and v/as very sick should be hospitalized.

COL.  PATTERSONS  informed him that General Order 27 has ample authority for
    emergency cases,

CAPT. BLACK700D: expressed his appreciation of  the opportunity to  attend
    the conference, and of the great value it had been.

          He mentioned the fact that the word "discipline" oarrie-s v/ith  it a
    feeling of dre&L.   Discipline is purely and  simply  obedience,  and
    when you have obedience you have discipline.  Orders should be  issued
    in such away that no antagonism will be created.   He  gave an example:
    In the Naval Hospital the patients are all supposed  to  stand  at attention,
  ,  if able,  when the Commanding Officer comes thru the  v/ards.  The Veterans1
    Bureau patients objected most seriously to this,  so  an order was issued
    that}; they should  sit down,  and nov/ you couldnH make them sit down.

          He  stated that  with regard to the question of  absence of a patiant
    over leave  for seven  days, under G.O.  2? a man  can now stay  away six
    days without  any action other than  minor punishments, v/hich he said is
    absolutely  ridiculous.  He thought  some other form of punishment, should
    be devised, as reduction  of compensation would not affect many of the
   patients who are not  receiving compensation, and believed  the Commanding
   Officer should  be allowed to assign these minor punishments.   He did
   not believe the patient should be discharged, as in  that case he would0^
Ly  go to another hospital.

         Another thing he suggested, v/ith reference to medical records
  was that a skeleton record, at least, of the history of a man's treat-
  ment,  his  examination and diagnosis, should be made to follow him aroiJftl
  from plac'e  to place.   This would save a great deal of v/ork and give th
  hospital a line on v/hat has been done for the man in the past* 
 
S 1 jg h t iJers.sion               Friday,  January 20,1922

                               Page 47.

CAPT. BLACKW0OD(Cont.):

   He said patients had been hospitalized anywhere from one to thirty-
   five times prior to coming to his hospital, and it was impossible to
   get a history of their previous hospitalization.

HON. CHILES H, BURKE:  I happen to be, as some of you may know,  at the
   head of the Bureau of Indian Affairs.

        In listening  to  the discussion this morning by Mr. Madden and
   by General Dawes,  I have had brought to my notice that there are some
   things in connection with hospitalization that compare in some respects
   with some of the things I have to come in contact with in connection
   with the administration of the affairs of the Indians,

        Mr. Madden referred to the politicians and the harm they may do
   by  criticism and comment and so forth.  I donH think he meant when he
    said politicians,  the men who may participate in politics,  I think he
   had in mind these  demagogues and agitators and  sources of propaganda
    that  are doing more harm in the Government service,— I know it is
   true  of  the Indian Bureau?— than, anything else or everything else
    all put  together;  and I  thirk  something of that applies to the hosp-
    italization question.   Agitators, I  coll them.  Some of them ore perhaps^
    interested in the  Indians  and  in  their purposes,  supersensitive, possibl
    Others have selfish motives  that  they desire  to serve; others are just
   ordinary trouble makers*

         So,  in the Indian Service, one of the things that we  are handi-
    capped by is this  aggregation that  I have  just  describedf  that  are
    criticizing and finding fault  v/ith  practically  everything  that  is being
    done.   One of the  things that they  contend for more  than  anything else
    is that the Federal Government,  in  supervising and administering the
    affairs of the Indians should,  before they put into  operation any
    policy for their uplift and their advancement,  have  the consent of  the
    Indians.  What an absurd proposition*  When you contemplate  sending
    your boy to some educational institution,  &re you going to permit him
    to dictate and say to you what you shall do,  or,  when he  selects a
    certain institution and tries it for a few weeks, say that he does  not
    like it and is going to try some other institution^  How far would  a
    father get with a  son if he permitted him to dictate and dominate  the
    situation.

         So it seems  to me teat this question of hospitalization and caring
    for the ex-service man is very largely a medical question and it ought
    to be administered with a view to v/hat will be most productive in
    rehabilitating and restoring  these men to full health; and so it oc-
    curred to me that  before this meeting adjourns, and because possibly
    the impression may have been given this morning that the principal
    question was one of economy, that we should, just for a mo mint,
    consider this other uuestion of v/hat can be done and v/hat shou3.& be don
    for the best interests of these ex-service men. 
.A 
J£ i £ h. .t h  ±L e s. .s i. o. n              Friday, January 20,1922

                              Page 48.

   It will require regulations; it vn.ll reiuire legislation.

         If you hove not been repaid in the  other  sessions of this
   Conference until this forenoon, I think  every  one of you who has
   come  from scbg* distance will feel that he has  been fully compensated i!
   in  listening  to  the discussion by General Dac/es and Mr. Madden with
   reference to  what  the Government, unde?  our present Chief Executive,
   is  endeavoring to  accomplish in the matter  of  administering Govern-
   ment.  And so v/e have this hospitalization  proposition and «-ll of  the
   Departments having to deal with that  subject.  We have this Federal
   Board of  Hospitalization made  up of representatives or "the heads of
    these different  departments.

         Now  what I  v/ant  to ask you gentlemen,  and I am talking to you
   now as experts,  as men  v/ho are in the field in charge of hospitals,
   in a position to see  this question from every  angle,- what can you
   do nov/ that v/ill help ths situation.   This  is  v/hat I v/ant to bring
    to your attention: that is, that each and  every one of you, through
   your proper officers,  communicate freely and from time to time what
   you believe  ought  to  be done to strengthen and improve this service;
    and then, these  suggestions coming from every  part of the country
    and all of these different institutions and services will be con-
    centrated and ultimately hove  consideration by the Federal Board
    of Hospital! eat ion,  stnd a regulation v/i II  be prepared where needed
    and necessary legislation will be  suggested to Congress in  ihe
    interest of better caring for  and administering these different
   hospitals throughout  the United States.

         My opinion,  gentlemen, is this:  that when a man goes into a
   hospital he is presumed to be  ill and should be governed by such
    regulations and b.v such control as will best enable him to recover
   from his disability  at  the earliest practicable time; and if he
   ought to  have considerable money and  if  he  ought to be permitted to
   go his way,  let  him go;  but if,  on  the contrary, he should be re-
   quired to live within certain  reasonable discipline as to his
   personal  conduct,  if  he should be limited  in the amount of money
    that  he should have  to  spend as he desires  he  should be limited by
   you,  who  are  expert and vvho have no possible thing in mind except  the
   welfare of  these men.

         Now  don't get the  impression that  you  can get all the leg-
   islation  that you  think perhaps you ought  to have.  I *rn not going to
   speak of  the  Congress as constituted now, because a person in the
   administrative  side of  the Government  and in a bureau is not sup-
   posed to  talk about  tie Contoress and  so  I am not going to say any-
   thing about the present  Congress; but up to about six years i^o and for
   a period  of many years,  I happen to know that  there were men in
   Congress  that don't measure up to what my friend, Mr. Madden , said
   a member  of Congress ought to  be0 
 
   EIGHTH   SESSION               . Friday, January L0,1922.

 There used to bo members of Congress'who kept their ears N/ery close to
 the ground listening constantly for any criticism, for any comment c#
 any part of the Government service, .perhaps through a magashne or news-
 paper; and they rose on the floor in their might to denounce seme policy
 or administrative action on the part of the Government simply because
 they lacked the courage of their convictions.

      Mr. Madden does not come within that class of members of Congress.
 He is a man who has always been known to have the courage of his convic-
 tions.   Perhaps the entire bedy is now made up of that type of members,
 but such was not the case up to 1915-

      These agitators that I have spoken of, these demagogues, have
 learned v/hat you can do with a scared member of Congress, and we used
 to say that the thing that emphasized mostli scared Congressman was
 two.   T7e don't have them I think any more.

      % friends, let us hope that Congress is so constituted at the
 present time, and we will assume that it is, that it v/ill courageously
 and fearlessly and without any regard as to what the results may be to
 themselves, rise up and respond to what you gentlemen,  through the
 heads of these various Departments and the Federal Board of Hospitali-
 zation may indicate and will enact into law such legislation,  and if
 there are any in the Congress who may have any. fears about  the  results
 if they do so act, I would say to them they have less to  fear by keep-
 ing courageous and standing for what is right,  regardless of the comment
 at the time, or the criticism that may come from certain sources.

      Gentlemen,  I thank you for the privilege of these  few  words and
 I hope that all of you and each of you will be  generous and diligent in
 cemmunieating,  whenever ycu have any suggestions to  make  with reference
 to bettering this service,  in order that they may have  the  consideration
 of these co-ordinating Departments that v/ere so  ably described  this
 morning by General Dawes.    I thank you.

 GEN.  SAV/YER:    General Ireland,  have you anything to  say?

 GEN.  IRELAND:    I  don't believe  I have.    I think it  is time  well spent
    and I  trust  that  there will be further meetings of this  kind.

 ADMIRAL STITT:    I can only repeat what  General  Ireland has said.   I
   have learned  a great deal  from this  Conference and feel  sure  that
   everyone  agrees that v/e  should have  a similar Conference, possibly
   every year.

 GENERAL CUlt/IING:   I have nothing  to  say except  to express  v/hat  I  know
   is  the appreciation cf everybody here  to  you  as Chairman of  the
   Board for having inaugurated  such  a  Conference, and,  secondly,  I
   think we owe  something to Colonel  Forbes as an agent for having brought
   us all together.

COL. MATTISON, N„H.D.V.S.:   I can voice  tho sentiments just  expressed. 
 
E i  -h  th    Session       Page  50. Friday, January 20, 192-?.

   I expected  this meeting to be  exceedingly valuable and it is vest3y
   more  so than  I had ever anticipated.    I am very glad indeed ic have
   had this opportunity.

DR. UHITE:   I want  to express my personal appreciation for having had
   the opportunity of coming intc personal contact with all cf you men
   who are engaged in this work.    I have  long felt that one of the
    very great values of  a congregation of this  sort is that resulting
   from  personal contact  with men who are  doing  the same v/ork.

         I have listened tc all of the discussions.  I don't knew v/hat
   I have learned, but I  feel, as I go back to my desk, that during
   the coming  year I will, in my  various decisions, hark back to some-
   thing that  has been said here  that v/ill help  me solve the questions
   of the day.   The real things  that one  learns on occasions of this
   sort  it is  almost impossible to  formulate in  one's mind at the mo-
   ment  but they are always brought up and proven valuable day by day.
   Thank you very much, gentlemen,  for the privilege of meeting you and
   I am  going  tc ask you  to come  out to St. Elizabeths and visit with
   us.

COL. PATTERSON:   I  have  already  occupied  a great deal cf time and sc
   I can only  voice  the sentiments  expressed by  the previous gentlemen.
   I knew those  of us in  the Bureau have learned a great deal and I hope
   that  it will  be possible to let  us have tho benefit of a similar
   Conference  next year.   T7e in  the Euroau will be in a much better
   condition to profit by your suggestions than  we are this year and
   we will laiow  better where v/e stand than v/e do at present.   I-bst of
   us are rather new to the job and are in a very receptive mood.

     In  passing  I would like to tell Captain Blackwood that the new
   order, G.0.2|, covers  most of  the things he brought up.    Some of the
   other suggestions as to the way  patients get  into hospitals I fear
   will  take seme time to rectify.   Ue are in the hands of our agents
   in the field.   Many of them arc not up to the standard.   "Jc hope
   tc rectify  that.    As  far as the hospital question is concerned, I
   think: ycu understand that tho Medical Bureau  is v/ith you and I hope
    you  will take tc heart what Commissioner Burke has said and give
   us in v/riting the benefit cf your opinions and send them in through
   your  chiefs.   I hope  ycu will give that your attention and let us
   have  the benefit of your advice.    TTo want constructive criticism
   and v/e need your help.

GENERAL  SAT7YER:   How many cf the Coriander s present are accompanied by
   their wives.   Those that are, please stand.    (Six stood up)   I
   want  to  say furthermore that tho reception at tho Thite House is at
   8:30;  entrance by the North Portico.     I feel sure that I can predict
   for you a very pleasant evening.

        In  summarizing, just  in a few words,  I would like to give ycu
   something  of an idea of tho impressions that have come to me and I
   believe  that ycu will agree that  they arc fair and that you should
   accept tho  same  impression for yourself. 
 
Eighth   Session
Pago 51.  Friday, January 20,  1922.
      First,  it has been a great delight tc me,  personally,  to  meet you
 Commanders of these various hospitals.   I have a very much better idea
 of the kind cf men that arc caring for these institutions and  v/ish to  say
 to yen that I am more than pleased v/ith the capacity and tho efficiency
 that ycu demonstrate.   Your contact here with each other has  helped you
 very greatly.   To me the whole hospital question is visualized in a
 much broader way.   I thought I had a fair conception of what  this propo-
 sition meant, but I must say I have enlarged my horizon very materially.
 As for myself I have received an inspiration such as I have never had  be-
 fore tc malic of this hospitalization subject a matter for consideration
 and of engagement of aomuch higher typo.   Tfith tho idea of its immen-
 sity, with a better understanding cf many of tho details and requirements
 and difficulties, I myself go forth to the undertakings I have before
 mo as the Chief Coordinator cf this Board v/ith much more determination
 than ever before, v/ith an ambition that has never quite possessed mo
 before, so I feel that I myself have been very greatly benefited.

      There arc some things you will take back with you out  of  this
 crowded program.    As the days come .and go you will have the experience
 of referring to this Conference as having given you new light  and as hav-
 ing given you an assistance ycu hardly record tc-day.

      It is my own v/ish that we may be able to put in the hands of each
 of you quite extensive minutes of all of those  proceedings.  If I can
 bring that about in tho course of a reasonable  length of time,  you shall
 be possessed of such a record.

      I wish to thank the speakers for c enforming so regularly to  the
 suggestion as to  time limit.    I wish tc thud:: ycu for the care with which
 ycu have prepared your papers and presented them.    j v/ish  to  thank those
 cf ycu who have participated in tho discussions.    I want to express my
 appreciation of these of you who have listened  so  intently  and apparently
 v/ith such interest.

      I would bo unfair to the occasion if I did not express  my gratitude
 for the assistance that has been given us by the  nurses in  their  associa-
 tion with us hero.

      One thing I  would have ycu do.    You arc but  single representatives
 of the institutions  from which you come.

      It v/ould be  somewhat selfish if you v/ere to  go  homo and bottle up
v/ithin yourselves the  experiences that  ycu have had hero and the observa-
 tions  ycu have  made.    New,  fellows,  let  mo tell you what to do:   Go
back to  your various  fields.   Call in your associates  and your  assistants,
take up  your whole administrative family  and try  to  inject into them a
little of  tho enthusiasm, a little  of the spirit,  a little of  the  deter-
mination;  give  to  them scrae cf the  ideas  you take  away from here.

     I v/ant ycu tc gc v/hile you are  still under the  influence cf  the in-
spiration of  tho occasion,  and I  v/ant tc  urge that  cock  of ycu, as  scon
as ycu get home, take up with  your  administrative  family the various things
that have boon  discussed here,  and try  tc  instill  in them the  some  renewed 
 
Eighth Session                 Pago  52,       aFriday, January 20, 1922

earnestness and enthusiasm that you possess this evening, and Convcy
tc them for us, this Board of Hospitalization and tho great President
of this United States of Aeoericas VJarron G. Harding, the assurance
that he appreciates every effort that you arc putting forth.

     Coming from a doctor's family, ho realizes more fully than you
can possibly guess tho difficulties that are  confronting you every day;
and be assured that when ycu act upon your best judgment that you will
find him  standing by whatever you may have regarded as necessary to the
bringing  about of the end-results in this war veteran's case.

     Lot  me emphasize once more that the concern that the Adm.inistration
has is not how you may entertain them v/hile they arc in tho hospital,
is not how easy and sympathetic you may be v/ith them, but it is how ycu
engender  in them a spirit cf determination tc get back into the world
again as  productive citizens.   That is your  job.

     In closing, let mo say that at the suggestion cf Colonel Patterson
and tho Veterans' Bureau which v/e are serving, that v/c arc hoping that
somehow before another year shall have x->assod around that we will have a
real place to v/hich wo may invite ycu to participate in the most inter-
esting program that could possibly be produced.   Fellovvs, I thank you
for your  presence.

COMMANDER BOONE:      I am sorry we are not able to raise our glasses
   tc a toast to the Chief Coordinator and the members of the Federal
   Board  of Hospitalization.   The least v/c can do is tc stand for a
   rising vote of appreciation.

          All stood up.

     The  mooting adjourned at h:k$ P.M. 
 
 
 
 
 ^=3l     ?       £=^
ATIONAL LIBRARY OF MEDICINE
NATIONAL LIBRARY OF MEDICINE
-=\
-^
NATIONAL  LIBRARY OF MEDICINE     NATIONAL LIBRARY OF  MEDICINE
nqiq3w jo Aavaan  tvnouvn     3nidiq3w >■.;-. -,-vaan tvnouvn     3noiq3w  jo Aavaan ivnoiivn     ^-.okjsvv jo Aavaan  tvnouvn 
SRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL L I BR A R Y  OF ME DICI N E     NATIONAL LI BR A R Y OF M E DIC I N E     N AT ~. \:Al I i " - A ;
                  o
                  a.






                                                                %
o Aavaan ivnoiivn     3nidiq3w jo Aavaan tvnouvn     3noiq3w jo Aavaan  ivnoiivn    3nidiq3
w jo Aavaan tvnoi
                                                                                                                   ■■•a' -■■'■•   /' 2 %



                                                                                                                    \jA ^\ « /

IBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY  OF MEDICINE     NATIONAL LIBRARY (
io Aavaan ivnouvn    3nidio3w jo Aavaan tvnouvn     snoiosw jo Aavaan ivnouvn    aNoiaaw jo  Aavaan tvnouvn     3noici3w jo Aavas


                                                                "D
                                                                s   y \c\>aa o  ^^na^x    5   y\n%K  o  /-^u^\   5
IBRARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE    NATIONAL LIBRARY C
o Aavaan ivnouvn     3nidiq3w jo Aavaan tvnouvn    tndiqjw jo Aavaan tvnouvn     3noiq3w jo Aavaan tvnouvn     3noiq3w jo Aava
BRARY  OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF  MEDICINE     NATIONAL LIBRARY C
o Aavaan tvnouvn     3noiq3w jo Aavaan  tvnouvn     3nidiq3w jo Aavaan tvnouvn     3noiq3w jo Aavaan ivnouvn     3nidiq3w jo  a -i ■
BRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY C

/  „ V  /A.     5    yV W ~ V  //K    5     y*v -q/  ^ \* /A.     -     yV  „y  • \,


                                                                                                                              <
3 Aavaan ivnouvn     3nioic3w jo Aava8n tvnouvn    snidiosw jo Aavaan tvnouvn     3nidio3w jo Aavaan tvnouvn     snoioj1.

                                                                                                                    -=--1
L1 1
1RARY OF MEDICINE    NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY OF MEDICINE     NATIONAL LIBRARY O

' -; \.  A      I      >V  ~S I \^  VS.     I     y*V  V 3  V  A      I      A   -./  -■ \.   A      §     w    s 4 \
■ Tfi->>*'  <o Aavaan ivnouvn    3nidio3w jo Aavaan tvnouvn     3nidiq3w jo Aavaan tvnouvn     aNioiasw jo Aavac 
. ■•w&iA

'A%£


A*'
v.
>At


MA
'r*AlA<<&A
NATIONAL LIBRARY OF MEDICINE
NLII 00076257 b
  A^%k
j^HT' a - f 'a1 -*^o t-vjc






          lots
NLM000782576