J USE OF BEPKESENTATIVES. (Document 1 No. 481. U. S. PUBLIC li^L-Ti-. %„ k SAL hospital facilities for dischargeb^oldiers, SAILORS, MARINES, AND ARMY AND NAVY NURSf ' / y £ r.-- % Ql!dings for 23,400 beds within next two years................................. 78, 425, 000 Furniture and equipment, 23,400 beds, at $300 per bed................ 7, 020, 000 Total for buildings, furniture, and equipment.................... 85, 445, 000 The experience of the Public Health Service shows that for the 28 weeks ended October 8, 1919, there has been an average increase of 137 patients per week in Public Health Service hospitals. The ex- perience for admission of patients in civil institutions has been approximately the same, or a total increase of 274 patients per week. If this ratio of increase should continue for one year, there would be approximately 23,000 patients in the hospitals of the service or in civil institutions under contract with the service. It is not possible for me to state whether or not the estimates as submitted by the Surgeon General of the Public Health Service are even approximately correct, but I feel sure that there is an urgent necessity for the enactment of some legislation providing additional hospital and out-patient facilities for the Public Health Service in order to meet the obligations of the Government to the patients of the War Risk Insurance Bureau. I would therefore urge upon you the necessity for an early consideration of these needs by the Con- gress. Respectfully, Carter Glass, Secretary. A BILL To authorize the Secretary of the Treasury to provide medical, surgical, and hospital services and supplies for discharged soldiers, sailors, marines, Army and Navy nurses (male and female), and for other purposes. Be it enacted, etc., That hereafter the Secretary of the Treasury shall provide neces- sary out-patient dispensary care and treatment and necessary medical, surgical, and hospital services and supplies, including prosthetic (artificial limbs) apparatus, for all discharged sick and disabled soldiers, sailors, marines, Army and Navy nurses (male and female), and for patients of the War Risk Insurance Bureau, who may apply for treatment, in the same way as now provided for other beneficiaries of the Public Health Service. N5% ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 3 • Se(^ Y2' That the Secretary of the Treasury is hereby authorized to provide addi- tional hospital and out-patient dispensary facilities for the beneficiaries of the Public Health Service (1) by purchase, gift, or lease of existing plants, (2) bv construction on sites now owned by the Government or on sites acquired by purchase, condem- nation, gift, or otherwise, or (3) by such remodeling or extension of existing plants and their equipment, owned or acquired by the United States, as may be necessary economically to adapt such plants to the uses and purposes herein provided; such hospitals and out-patient dispensary facilities to be located at such places as the Secretary may elect and to include the necessary buildings with their appropriate mechanical equipment and approach work, including roads and trackage facilities leading thereto, for the accommodation of patients, officers, nurses, and attending personnel, and for storage, laundries, vehicles and live stock, and including neces- sary furniture, equipment, and accessories, including the development of coal de- posits now under control of the Treasury Department. The Secretary of the Treasury is hereby authorized to accept gifts or donations for any of the purposes named in this act. Sec. 3. That the Secretary of the Treasury in securing sites herein provided for, may request the Secretary of any other department of the Government to transfer to the Treasury Department, such lands or parts of land under his control, not required for other purposes, as may be found suitable for this use, and other departments are authorized to make such transfers to the Treasury Department as may be deemed to be in the interest of the Government. _ Sec. 4. That in carrying the foregoing authorizations into effect, all new construc- tion work herein authorized shall, as far as feasible, be of fire resisting character, and the Secretary of the Treasury is authorized to enter into contracts for the construction, equipment, and so forth, to purchase materials in the open market, or otherwise, and to employ laborers and mechanics for the construction of such buildings and their equipment as in his iudgment shall best meet the public exigencies. Sec 5. That the Secretary of the Treasury « hereby authorized in hip discretion, to employ for service within or without the District of Columbia, without regard to civil service laws, rules and regulations, and to pay from the sums hereinafter author- ized for construction purposes, at customary rates of compensation, exclusively to aid in the preparation of the plans and specifications for the above named objects and for the supervision of the execution thereof, for traveling expenses, field office equip- ment and supplies, commercial printing in or out of the District of Columbia, incident thereto, at a total limit of cost for such additional technical and clerical services and traveling expenses, and so forth, of not exceeding 3 per cent of the limit of cost for construction. All of the above-mentioned work shall be under the direction and supervision of the Surgeon General of the Public Health Service. Sec 6. That the Secretary of the Treasury be and he is Jiereby authorized in his discretion to enter into contracts for the purpose of carrying out the provisions of this act, within the respective limits of cost hereby fixed, viz, the sum of $15,000,000 for the fiscal year ending June 30, 1920; the sum of $25,000,000 for the fiscal year ending June 30, 1921; the sum of $20,000,000 for the fiscal vear ending-June 30. 1922; the sum of $18,425,000 for the fiscal year ending June 30, 1923, in all $78,425,000 for construc- tion purposes; and for furniture and equipment not otherwise provided for the sum of $1,400,000 for the fiscal year ending June 30, 1920; the sum of $2,200,000 for the fiscal vear ending June 30, 1921; the sum of $2,000,000 for the fiscal year ending June 30, 1922; the sum of SI,400,000 for the fiscal year ending June 30, 1923, in all the sum of $7,000,000 for furniture and equipment. Treasury Department, Bureau of the Public Health Service, Washington, October 17, 1919. Memorandum for the Secretary of the Treasury. Subject: Transmitting a tentative draft of a bill to provide additional hospital and out-patient dispensary facilities for all discharged sick and disabled soldiers, sailors, marines, Army and Navy nurses (male and female), and for other purposes, together with a state- ment of the needs for the enactment of such legislation. On September 17, 1918, the Public Health Service submitted a report snowing the needs for additional hospital and sanatorium 4 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. facilities for the war-risk insurance patients and other beneficiaries of the Public Health Service.. This report was submitted in order to comply with an urgent request of the Director of the Bureau of War Risk Insurance for increasing the hospital facilities of the Public Health Service, and after an extended conference with the War and Navy Departments. There is attached hereto a copy of the House Document No. 1294, which sets this forth in detail. Two bills were introduced to supply hospital beds and the state- ment made that: While the two bills mentioned represent only a part of the total number of beds that will be required, I still am of the opinion that these two bills should be enacted into law before further estimates are transmitted to Congress, as they will furnish an appreciable measure of relief and permit a more accurate survey of the ultimate needs of the service in this direction, due to rapidly changing from war to peace con- ditions, and the probable abandonment of several army projects which might be avail- able for use in the care and treatment of the remaining thousands of patients who are entitled to receive hospital accomodations and treatment. A copy of this memorandum dated November 15, 1918, is attached hereto. Following out this plan of supplying immediate temporary needs of legislation proposed by the memorandum referred to, it was urged upon Congress to pass the two bills. But it was stated many times to many Congressmen that this was only the beginning of what would be the requirements to make adequate provision for the patients of the War Risk Insurance Bureau. These statements were repeated on the floor of the House of Representatives and the Senate by Mem- bers of Congress. The bill provided a lump-sum appropriation for a total of $12,049,000 as originally introduced, and no sites were specifically mentioned in the bill except the one for Dawsons^rings, Ky. As these bills passed the House, the site fixing one hospital for Dawsonsprings, Ky., was stricken out and no sit's were specifically given in the bills as .they were passed and reached the Senate. In the Senate the bills were consolidated and instead of providing a lump sum for the supply of hospital facilities a provision was made fixing certain sites and authorizing the purchase of certain hospitals and the acquisition of certain camp hospitals, appropriating a sum of $7,400,000. In conference the conferees added a provision for acquiring the hospital at Corpus Christi, Tex., not to exceed $150,000 and added a lump sum of $1,500,000 for emergency needs. This act was approved March 3, 1919, (Public Act No. 326, 65th Cong.). The total amount appropriated by the act for constructing and acquiring hospitals was $9,050,000. As stated above, the consolidated bill as it finally became a law authorized the taking over from the Army certain camp bas'1, hos- pitals and the lease of other hospitals. It will also be noted all through the history of this legislation that it was not the intention of the service to specifically locate hospitals until after obtaining the appropriation and until after careful survey, as experience might dictate. It was stated many times to Congress during the enactment of the legislation that the service did not believe that camp basg hospitals were suited to its needs, either in point of construction or geographical location. Experience has proven the correctness of these statements. The Public Health Service has taken over these camp base hospitals as directed by Congress, and after earnest efforts ADDITION \L HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 5 to operate them on a satisfactory and economic bas's has been com- pelled to abandon all but two as'entirely unsuiteel to the neee's of the situation. Sick and disabled s.ddiers, sailors, and marines have mani- fested a strong disinclination to accept treatment at these places, in spite of the effort on the part of the Public Health Service to make them attractive and to administer them as civil institutions. As a result it is probable that a considerable number of men are not now accepting hospital treatment and are suffering injury thereby. Owing to the experience of the Public Health Service in the past six months as a result of Congress fixing the* s:t< s of the service hos- pitals, the draft of the bill which is transmitted herewith has pur- posely omitted mention of definite sites and has provided a lumn-sum appropriation with a broad authorization for the Secretary to fix sites according to the neee's of the discharged soldiers, sailors, and marines. Army and Navy m.rs s (male and female). Public Act No. 326 of the Sixty-fifth Congress above referred to made the patients of the War Risk Insurance Bureau beneficiaries of the Public Health Service and the act making appropriations for sundry civil expenses for the Government for the fiscal year ending June 30, 1920, made additional appropriations to enable the Public Health Service to discharge its functions. This latter act, however, carried the important proviso that none of the appropriations made for the Bureau of War Risk Insurance are to be expended to reimburse any expenses incurred by any government hospital or hospital under contract with the Public Health Service, for examination, care and treatment of the beneficiaries of the Bureau of War Risk Insurance. It would thus seem that it was the evident intention of Congress that the Public Health Service should elischarge the medical and surgical functions of the Bureau of War Risk Insurance, but the law contains certain ambiguities which it is desired to correct in tue bill submitted herewith.' The enactment of tnis is deemed nece sary in order tnat all medical and surgical functions concerning patients of the War Risk Insurance Bureau be brought under one governmental agency. The bill as drafted provides that the Public Health Service under tne direction of the Secretary of the Treasury, shall provide for dis- charged soldiers, sailors, marines, Army and Navy nurses (male and female), all necessary examinations, out-patient dispensary care and treatment and necessary medical, surgical and hospital services and supplies. These provisions will, if enacted into law, authorize the Public Health Service to discharge for the Federal Board of Vo. a- tional Education the same medical and surgical functions as are now discharged for the Bureau of War Risk Insurance. Furthermore, if will specifically authorize these functions which are now being per- formed for the Federal Board under the authority of regulations. The provisions proposed in the tentative draft of the bill will authorize the Public Health Service to provide medical relief for the discharged soldiers anel sailors of the United States, in addition, under reciprocal agreement, for such of the discharged soldiers anel sailors of the powers associated with the United States in the world war, residing in the United States and who make proper application there- for. This is in line with the expressed desires of Congress to bring together all of the civil medical work of the Government thus avoiel- ing duplication and competition among the several departments of the Government. Obviously it would be uneconomical and inefficient 6 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. to create new Government medical services especially within the same department with the Public Health Service. The Public Health Service has an organized service which can be expanded to meet the needs of the War Risk Insurance Bureau and the Federal Board for Vocational Education. As stated above, Congress has expressed itself as intending to utilize the Public Health Service for this medical work and the proposal in the tentative bill is in line with this development. A review of the acts of Congress shows that the Government has obligated itself, through the instrumentality of the Public Health Service, to provide medical, surgical, hospital and sanatorium services and supplies for its beneficiaries, including patients of the Bureau of War Risk Insurance. It should be borne in mind, in this connection, that H. R. 8778, as enacted in the House of Representatives, places draftees in the above-mentioned categories. The demands which will be made upon the Public Health Service for providing clinical and hospital facilities for patients of the Bureau of War Risk Insurance are set forth.in a memorandum which has been submitted to the Secretary of the Treasury by the chief medical adviser of the Bureau of War Risk Insurance, a copy of which is attached hereto. DEMANDS FOR MEDICAL, SURGICAL, AND HOSPITAL SERVICES AND SUPPLIES FOR PATIENTS OF THE BUREAU OF WAR RISK IN- SURANCE. An analysis of these demands shows that there will be a minimum total of 641,000 soldiers, sailors, marines, Army and Navy nurses (male and female) discharged or rejected by camp surgeons with iuch mental or physical defects as will make them potential patients who may require medical attention from the Public Health Service nnder the several laws relative to war-risk insurance patients. HOSPITAL NEEDS. Of the above number it is estimated that beds will have to be pro- vided within the next two years for approximately 30,660 patients composed as follows: Table 1.—Beds required within the next 12 months at present rate of increase. General, medical and surgical Leds....................................... 7f 200 Is euro-psychiatric........................,.............................. \\ j 060 Tuberculosis............................................p................ 12, 400 Total............................................................. 30, 660 In general these patients may be expected to be distributed throughout the country in practically the same proportion as the men who were inducted into the military service by reason of the draft act, designated in this memorandum "the military population." Attached hereto is a table showing this distribution. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 7 Table 2.—Number of mii'ary population and percentage of military population by districts, and number of hospital beds required within two years for general medical and surgical patients, tuberculous patients and neuro-psychiatric patients. Military population.* Hospital beds required within 2 years. Distorts.1 Number. Per cent of total. General. Tuber-culosis. Neuro-psychi-atric. Total. No. 1............................ 252,480 665,160 390,240 244,320 410,400 249,120 487,680 619,200 432,480 244,320 96,480 163,200 120,480 385,920 5.30 13.97 8.20 5.13 8.62 5.23 10.24 13.00 9.08 5.13 2.03 3.43 2.53 8.11 382 1,006 590 369 621 377 737 936 654 369 146 247 182 584 657 1,732 1,017 636 1,069 649 1,270 1,612 1,126 636 252 425 314 1,005 586 1,545 907 567 953 579 1,133 1,438 1,004 567 225 379 280 897 1,625 4,283 2,514 1,572 2,643 1,605 3,140 3,986 2,784 No. 2..................... No. 3..................... No. 4......................... No. 5................... No. 6......................... No. 7................... No. 8......................... No. 9.................. No. 10....................... No. 11.................................. No. 12....................... No. 13.................................. 776 No. 14................................. Total............................. 4,761,480 100.00 7,200 12,400 11,060 30 660 1 For States in each district, see map. * Military population as of Nov. 11,1918, not including those of Alaska, Hawaii, Porto Rico, and those not allocated. The table will also show the percentage of beds required in each district, based on the conclusion that this distribution of beds will be practically in the same proportion as the military population according to districts. The above estimates apply to the next two years. Data for the succeeding years are, of course, largely ap- proximate, but there is ample reason to believe that the demands upon the service in this regard will continuously increase in the next few years until it may be expected that the minimum of general bells, 8,000; tuberculous, 14,000; and neuro-psychiatric, 14,000, or a total of 36,000 beds will be required, distributed approximately in the same proportion as the military population. Table 3.—Number of military population and percentage of military population by districts, and maximum number of hospital beds which will be required at peak of hos- pitalization for general medical and surgical patients, tuberculous patients, and neuro- psychiatric patients. Districts. No. 1..... No. 2..... No. 3..... No. 4..... No. o..... No. 6..... No. 7..... No. 8..... No. 9..... No. 10____ No. 11____ No. 12____ No. 13..... No. 14____ Total Military population. Number. 252,480 665.160 300 240 244,320 410,400 249,120 487, 680 619,200 432,480 244.320 96,480 163,^00 120, 480 385,920 4,761,480 Per cent of total. 5.30 13.97 8.20 5.13 8.62 5.23 10.24 13.00 9.08 5.13 2.03 3.43 2.53 8.11 100.00 Hospital beds required at peak. General. 424 1,118 656 410 690 418 819 1,040 727 410 162 275 202 649 ,000 Tuber- culosis. 742 1,956 1,148 718 1,207 732 1,434 1,820 1,271 719 284 480 354 1,135 14,000 Neuro- psychi- atric. 742 1,956 1,148 718 1,207 732 1,434 1,820 1.271 719 284 480 354 1,135 14,000 Total. 1,908 5,030 2,952 1,846 3,104 1,882 3,687 4,680 3; 269 1,848 730 1,235 910 2,919 36,000 8 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. clinical demands. The above takes into consideration only those patients who re- quire hospitalization. It should be borne in mind that there is a great need for a machinery which will not only furnish expert ex- amination for claimants under the Bureau of War Risk Insurance laws, but which will also provide out-patient relief to patients of the War Risk Insurance Bureau. In this connection it may be pointed out that out-patient offices should properly be way stations to and from the hospital, so that patients could be examined care- fully by specialists and sent to hospital for treatment and upon discharge referred to the out-patient clinics in order that a super- vision may be kept over the patient with a view of preventing a recurrence of the ailment for which he has been treated in the hospital. This would be a matter of great accommodation and benefit to patients and would effect a very considerable economy for the Government. Furthermore, it must be remembered that there will be a demand for the clinics by patients who will not require hospitalization. Out-patient clinics as contemplated in this memorandum will provide what is known as group medical practice for the military population. In such groups there will be a director and associated with him specialists in every line of medical treatment, clinical and laboratory diagnosis. The patient, when he enters such a clinic, will have the advantage of specialists' advice and will automatically Eass under the observation of every specialist whose services may e required in the diagnosis and treatment of his ailment. An illustration of such group practice may be found in the Mayo Clinic at Rochester, Minn. About 200 such clinics may be ultimately required. Their distribution throughout the districts will depend upon the distribution of the Public Health Service hospitals and the military population. In considering the estimate of 200 clinics, it may be found advisable to utilize in part the existing high class civil institutions or to reduce the cost of the establishment and maintenance of new clinics by inducing State or municipal health authorities to enter into partner- ship and bear a just proportion of the expense and utilize the clinics jointly for caring for the military and civil population in the same clinic. By this arrangement it may be possible to maintain clinics at a cost somewhat below the amount estimated for a unit. In this program for meeting clinical demands no estimate has been submitted for the cost of establishing clinics owing to the fact that the Public Health Service has now on hand a large part of the equipment which will be required. The question of the housing of clinics will be one of rental rather than one of purchase. Later the matter of acquiring sites and buildings may be considered. In the consideration of a possible partnership between the Public Health Service and State or municipal authorities for the establish- ment of clinics for the joint use of the military and civil population, it should be stated that no such partnership will be entered into until it is established beyond doubt that the civil authorities have maintained or will maintain such institutions in a high-class manner. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. & FACILITIES AT HAND. An attempt has been made to set forth in the preceding paragraphs an exposition of the demands which it may be reasonably expected arill be made upon the Public Health Service in the near future. To %eet the foregoing demands the Public Health Service has already „he clinical and hospital facilities as shown by the following table: Table 4.—Nximber of beds available in United States Public Health Service Institutions, Oct. 11,1919. District and hospitals. District No. 1. Boston (marine)........ Boston (General No. 10). Portland, Mp............ Vineyard Haven, Mass.. East Norfolk, Mass...... District No. 2. Buffalo, N. Y............ New York (polyclinic)... New York (Sta'plcton)... New York (Ellis Island). New Haven, Conn...... Cape May, N. J.......... Dansville, N. Y......... District No. 3. Pittsburgh. Pa. (marine')___ Pittsburgh, Pa. (Parkview). District No. 4. Baltimore, Md--- Norfolk, Va....... Perryville, Md--- Washington, D. C. District No. 5. Key West, Fla.. Memphis, Tenn. Savannah, Ga... Greenville, S. C District No. 6. Alexandria, La... Mobile, Ala...... New Orleans, La. District No. 7. Cleveland, Ohio. Evansville, Tnd. Louisville, Ky.. District No. 8. Cairo, 111................ Chi ago (marine)........ Chicago (Genera! No. 2). Detroit, Mich........... Waukesha, Wis......... District No. 9. St. Louis (General NTo. 40). St Louis (marine)........ District No. 11: Fort Stanton, N. Mex. Number of beds available. General. 80 700 45 24 Tuber- culosis. 340 284 450 160 220 100 75 500 44 155 38 140 545 82 Neuro- psychia- tric. 500 205 250 500 300 Total. 300 10 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Table 4.—Number of beds available in United States Public Health Service Institutions, Oct. 11,1919—Continued. N unber of beds available. District and hospitals. General. Tuber-culosis. Neuro-psychia-tric. Total. 160 850 1,010 160 160 Palo Alto, Calif i.......................................... 850 850 92 92 District No 14: Corpus Christi, Tex.2........................... 235 235 5,567 2,492 1,555 9 614 1 To be replaced by Byron Hot Springs (200) and Franklin (450). 2 Temporarily closed on account of storm. These facilities are already in use by the beneficiaries of the service. In addition to the hospital and sanatorium facilities of the Public Health Service as shown in Table 4, the following, Table 5, will show the number of hospitals and the number of beds reported available in civil institutions for the care of the beneficiaries of the service as of October, 1919: Table 5.—Beds available in civil institutions for service men, by districts. All classes of beds. Tuberculosis beds. Mental beds. General beds. District. Total number. Number per 100,000 service men. Total number. Number per 100,000 service men. Total number. Number per 100,000 service men. Total number. Number per 100,000 service men. i 12,998 324.2 «3,110 77.6 81,949 48.6 * 7,939 198.0 No. 1................ 1,802 1,349 1,192 1,175 382 676 900 2,833 543 776.3 230.9 371.0 575.8 115.0 335.4 231.5 548.7 151.6 412 629 249 142 64 152 362 382 55 177.5 107.7 77.5 69.6 19.3 75.4 93.1 74.0 15.4 434 78 220 376 187.0 13.4 68.5 184.2 956 642 723 657 318 480 505 2,154 351 411.9 109.9 225.0 322.0 95.7 238.2 129.9 417.2 98.0 No. 2................ No. 3 No.4................ No. 5................ No. 6................ 44 33 297 137 21.8 8.5 57.5 38.3 No. 7................ No. 8................ No. 9............... No. 10............... No. 11............... 205 1,469 35 437 244.1 990.0 31.7 134.8 150 407 25 81 178.6 274.3 22.7 25.0 40 269 47.6 LSI. 3 15 793 10 335 17.9 534.4 9.1 103.3 No. 12............... No. 13............... No. 14............... 21 6.5 1 846 institutions. 8180 institutions. 3 84 institutions. • 582 institutions. A survey made by the district supervisors shows that a certain proportion of the beds in existing civil institutions are available for treatment of war-risk insurance patients. This is also shown in Table 5. At the present writing there are about 4,500 patients in the Public Health Service hospitals and about 3,200 in civil institutions. Of the 4,500 in Public Health Service hospitals about 3,100 are war-risk insurance patients. The 3,200 in civil institutions are war-risk insurance patients. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 11 War-risk insurance patients in service hospitals and civil institu- tions are shown according to general classification of large groups of disease in the following table: J Table 6.—War-risk insurance patients in hospitals. Public Health Service hospitals: Tuberculosis.................. 1,088 Neuro-psychiatric............ 547 General..................... 1,414 Total...................... 3,050 Civil institutions: Tuberculosis.................. 1,191 Neuro-psychiatric............ 1, 665 General..................... 317 Total...................... 3,173 At the present time the Government is throwing an undue load upon the several States and communities in the care of these classes oi patients and in some instances local patients are being denied treatment because of the fact that beds are occupied by war-risk insurance patients. The experience so far obtained in the treatment of war-risk in- surance patients shows that it is highly desirable to provide Public Health Service hospitals as rapidly as possible for the tuberculous and neuro-psychiatric patients, and to not depend to any great extent upon civil or State institutions for the care and treatment of these patients. Difficulty has been experienced in securing satis- factory contracts with hospitals for the care and treatment of war- risk insurance patients. In regard to tuberculous and neuro-psychiatric patients the treat- ment in civil institutions has not always been satisfactory. In a number of instances it has been necessary to discontinue the use of certain sanatoria and to transfer the patients to other institutions. In high-class civil institutions for general hospital patients it is be- lieved that the care and treatment has been and will continue to be satisfactory wherever these institutions have attempted to supply hospital treatment for war-risk insurance patients. TUBERCULOSIS. As has been shown by the preceding table, a total of 12,400 beds will shortly be required to proviele adequate treatment for the tuber- culous patients of the war-risk insurance. At present the Public Health Service is operating four tuberculosis sanatoria with an ap- proximate bed capacity of 2,400. Fully 50 per cent of the tubercu- lous patients under treatment are in civil institutions. The total number of patients now under treatment is 2,233, of which 1,057 are in Public Health Service hospitals and 1,176 in civil institutions. The total increase in the number in hospitals in September was about 25 per cent over the preceding month. In view of the experience of the service in hospitalization of tuberculous patients in civil insti- tutions it is believed that the Public Health Service should within the next two years provide sanatoria in suitable locations with a minimum capacity of 10,000 beds. This would require the buying or building of institutions for this purpose. The matter of the loca- tion of these institutions is one which will require careful study and consideration, since not every climate nor every location in a good climate is well suited for the treatment of tuberculosis. In this con- nection due consideration should be given to the psychology of the 12 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC.. tuberculous patients, it being borne in mind that there is a widespread belief that the dry and arid regions of the West and Southwest are absolutely essential to the cure of this disease. Whether or not this is true will not be discussed here, but this popular belief has a decided influence on the mental attitude of the various tuberculous patients. In view of the foregoing, it is highly desirable not to fix in the act sites for any of the tuberculosis hospitals. NEURO-PSYCHIATRIC CASES. Table No. 1 given above indicates that in the near future provisions will have to be made for the hospitalization of approximately 11,000 of these patients in special institutions. It will also be necessary to provide separate institutions according to the nature of the nervous or mental disorders to be treated. This will necessitate the provid- ing of proper institutions for epileptic, feeble-minded, insane, and psychoneurotic patients. All these institutions should be grouped under the general phrase "Neuro-psychiatric" in order that patients receiving treatment therein may not in after years bear the stigma. of having been committed to an insane asylum. An analysis of the above table shows that the maximum number of beds at present available for this class of patients is 1,500. This number should be increased by approximately 9,500 within the next two years, in order to meet the demands of the situation. There are at present 2,100 neuro-psychiatric patients under treatment of which 75 per cent are in civil institutions. The number under treat- ment increased during September at the rate of 15 per cent. Reference to the chart accompanying the report of the chief medi- cal idviser, shows that the number of insane patients is expected to reach its maximum in 1929, at \*hich time about 4,900 beds will prob- ably be required. The psychoneurotic cases are expected to reach the maximum at about 1928, at which time it is estimated a little more than 2,000 beds will be required. The injuries and disease of the central nervous system are expected to reach a maximum of about 1,100 in 1921, and continue at that rate for about 15 years. The epileptic beds required will almost reach their maximum within the next three or four j7ears, but unfortunately the demand for this type of bed is not expected to diminish for about 25 years. It is not altogether easy to make an estimate in the case of the feeble-minded, but it is believed that during the next ensuing 20 years at least 1,000 beds will be required on the basis that these patients will spend only about one-third of their time in hospitals. As in the case of tuberculosis, the experience with civil hospitals with the nervous and mental patients of the War Risk Insurance Bureau has shown that the Public Health Service should provide Government institutions for the care and treatment of these patients and not to depend to any great extent upon civil institutions for this Eurpose. The service has already in operation five hospitals with ed capacity of 1,555 for this purpose. To make adequate provisions hospitals will have to be acquired or built to provide within the next two years for approximately 9,500 beds. At the present time the State hospitals for the insane are for the most part overcrowded and inadequate to meet the needs of the- ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 13 civilian population, without being forced to care for the large num- ber of cases which have resulted from and have been discovered during the recent war. Up to the present time all States, with the exception of one, have agreed to receive insane patients of the War Risk Insurance Bureau into one or more of their State insane asylums. Almost invariably, however, the}7 have done this entirely as a patriotic act and at con- siderable trouble and sacrifice to the needs of their own population. Only the frankly insane can be treated in such institutions. In view of the extensive program for mental hygiene, which is now being made in many States, it is entirely probable that many civilian cases, which have escaped attention, will require hospitalization at an early date. This will add to the State burden and therefore make it more urgent that the Government should relieve the fctate institu- tions of caring for war-risk insurance patients in so far as practicable. As in the case of the institutions for the treatment of tuberculosis, the location of the institutions for the care of the neuro-psychiatric patients is one requiring expert stuely; it will depend in part upon the location of the existing institutions of the Government, the dis- tribution of the military population or the distribution of the neuro- psychiatric patients. Endeavor should be maele, however, to so locate these institutions that patients will be under treatment at no very great distance from their homes, thus making it possible for their friends and relatives to visit them at reasonable intervals. In this connection cognizance should also be taken of the number and availability of existing local institutions. GENERAL, MEDICAL, AND SURGICAL PATIENTS. Reference to Table 1 given above will show that in the very near future the number of war-risk patients requiring general, medical, and surgical care will be approximately 7,200. At present the Public Health Service has 3,300 available beds for these patients in hospi- tals owned by the service. It must be stated, however, that one of these hospitals is in an old Army camp, which must be abandoned at the earliest practicable date unless the buildings are replaced by modern fire-resisting structures. Furthermore, ex-soldiers and sail- ors do not like these hospitals, suggesting as they do the conditions under which their disabilities arose. The cost of maintenance and operation of hospitals of this character is excessive. It is not ex- pected that the service will be able to abandon this hospital in the next fiscal year, however. Therefore, 3,900 additional beds should be provided within the next two years. In addition to the above the hospitals now operated by the Public Health Service are so dis- tributed as to provide for the districts in a uniform manner. It has been the policy of the Public Health Service and the War Risk Insurance Bureau to provide for the hospitalization of patients as near to their homes as possible and to this end regulations have been adopted for hospitalization of patients according to districts. This makes it impracticable to utilize all of the beds in some districts at one time. As a consequence there are in some districts a number of vacant beds at certain times, while in other districts there is a great shortage of beds. With a view to eliminating the camp hospi- tals at the earliest practicable moment 4,750 beds should be pro- 14 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. vided. Following out the principle of providing hospitals to accom- modate war-risk insurance patients as near their homes as practi- cable at least one hospital should be provided in every State, the size of each depending upon the needs of the military population. In such States where it is impracticable to build Public Health Service hospitals provisions should be made in those States for the securing of the same by rental of wards in well-conducted generaj hospitals of high character where there will be no question as to the character of treatment which will be provided. However, it will be necessary, if such general hospitals are utilized, to provide an ade- quate system of inspection, in order to guarantee that the war-risk insurance patients receive adequate and proper treatment. The above estimate of a total of 30,660 beds which will be needed by the Public Health Service within the next two years is based upon the data submitted in the report of the chief medical adviser of the Bureau of War Risk Insurance to the Secretary of the Treasury. Another estimate of the bed requirements for hospitalization of the beneficiaries of trhe Public Health Service based upon the experience of the rate of hospitalization in Public Health Service hospitals from April 28, 1919, to October 11, 1919, a period of 24 weeks, has been considered. This estimate shows that the number of patients in Public Health Service hospitals increased from l.,650 occupied beds to a total of 4,900, during the 24 weeks. The estimate also sets forth the fact that in addition to the 4,900 beds occupied in the Public Health Service hospitals, there is a total of over 3,100 patients of the War Risk Insurance Bureau in civil hospitals. Experience has shown that the weekly increase of hospitalization in civil institu- tions has taken place in about the same proportion as in the Public Health Service hospitals, a total of 8,000 patients now being hospital- ized, in bath Public Health Service hospitals and civil institutions. If the increase which has occurred in Public Health Service hospitals during the past 24 weeks should continue for the next 12 months (52 weeks), there would be a total of 6,760 additional occupied beds in Public Health Service hospitals. If the increase noted for the Public Health Service during the last 24 weeks holds good for the number hospitalized in civil institutions, the number in civil hospitals at the end of the next 12 months (52 weeks) would also increase by 6,760 occupied beds. This would make a total requirement of 21,620 beds which would have to be supplied by the Public Health Service hospitals or civil institutions as follows: Total now in Public Health Service hospitals.............................. 4, 900 Total now in civil hospitals................................................ 3, 200 Estimated increase in Public Health Service hospitals during the next 12 months................................................................ 6, 760 Estimated increase in civil hospitals during the next 12 months.............. 6, 760 Total number of patients in Public Health Service and civil hospitals during the next 12 months......................................... 21, 620 This number, 21,620, is 9,040 less than the number, 30,660 esti- mated by the chief medical adviser of the Bureau of War Risk Insurance. This difference is accounted for by the fact that the chief medical adviser based his estimate of beds required upon the presumption that the bill, H. R. 8778, as enacted in the House of Representatives will become a law, and add many thousand more potential beneficiaries to come under compensation. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 15 UTILIZATION OF HIGH-CLASS CIVIL INSTITUTIONS. In the plan as presented above for the care of war risk insurance atients, it will be noted that recommendation is made for the ospitalization in public-health institutions of a large majority of all tuberculous and neuro-psychiatric patients. As stated, the care and treatment of these patients in civil institutions is not proving; entirely satisfactory. However, in the case of general, medical and surgical patients, the experience in the utilization of high-class civil institutions has been and may be expected to continue reasonably satisfactory. In the plan it is therefore proposed to utilize to a certain extent the high-class civil institutions for the hospitalization of general, medical, anel surgical patients. It is believed that arrangements can be made with these institutions which would prove satisfactory if Congress will authorize the making of leases with them to extend over a period of 10 years under supervision by the Public Health Service. In such a plan it would be necessary to contract for such services by taking over a whole unit or ward and contract for medical and hospital care of such patients as may be assigned to a unit or ward without regard to whether or not every bed was occupied. This plan would segregate the war-risk patients from the general free wards of such institutions and would place them practically on the same basis as pay patients of the institutions. Furthermore, the institution would be paid a reasonable amount for such services, no part of which would be accepted from the institutions by the Government on a charity or teaching basis. In all such institutions medical officers of the Public Health Service would be assigned to duty to see to it that the war-risk patients receive all proper hospital care. The officer would be in charge of the medical care with instructions to utilize the staff of the hospital on a salary or fee basis when the services of consultants might be needed. The utilization of civil institutions on this basis would be contracted for only in case it was not found practicable to establish a Government hospital. But before making such a contract it would have to be established that there would be a sufficient number of beneficiaries to justify a contract as outlined above. This utilization of civil institutions would, if practiced on a small scale, provide for at least some hospital facilities in every State in the Union. By this method the Public Health Service could pro- vide more easily accessible hospital service for beneficiaries other than tuberculous or neuro-psychiatric. If easily accessible, those needing general hospital care will be more likely to avail them- selves of such service and would not be so likely to delay treat- ment until it is too late. In fact, it is reasonable to expect that many patients would not avail themselves of hospital service if they had to travel long distances to reach the Government hospital. The use of civil institutions should not in any way preclude the building of Public Health Service hospitals in such centers as the expectancy of war-risk insurance patients might justify. Further- more, the use of units in civil institutions would be in the nature of evacuation hospitals where patients would be collected and later transferred to Public Health Service hospitals, especially those cases where the treatment might be expected to be prolonged or where certain highly specialized consultants might be required. I 16 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC, The plan proposed would probably meet with the highest approval and cooperation of the civil institutions and the medical profession of the country because such practice would eliminate the possi- bility of competition between the Public Health Service and civil institutions and the medical profession in a given locality. Such a plan has made it possible for the Public Health Service to reduce its estimate for hospital beds by several millions of dollars, but it can not be adopted as the solution of the entire problem. It should be stated, however, that part of such a saving to the Government would be offset by the possible higher per diem cost of providing for patients in civil institutions. One favorable point for consid- eration is that such a practice would improve the general hospital situation in the country and ra;se the standard for hospitalization. This would undoubtedly be of the highest service to the civil popu- lation in future years. ORTHOPEDIC PATIENTS. In order to supply highly specialized medical, surgical and hospital services, supplies and apparatus for the physical reconstruction of the maimed anel disabled soldiers, sailors and marines who have suffered mutilating injuries in the war with Germany, it will be necessary provide at least one large orthopedic hospital of 500 beds. This hospital should be properly equipped and manned. This will require the installation of highly specialized electrical, hydrotherapeutic, mechanical and other like apparatus. It will also be necessary to locate this hospital in a large medical center where the ssrvices of the best specialists can be had in consultation. In order to provide for expansion, in the case of need, the site should be sufficiently large to permit of extension, as the needs of such S3rvices may require. MEDICAL SUPERVISION. This bill also provides for medical supervision of all discharged soldiers, sailors, marines, Army and Navy nurss (male and female) and authorizes the Public Health Service to furnish medical care and treatment to any discharged soldier, sailor and marine irrespective of date of receipt of the injury or disease. Under the present law discharged soldiers and sailors are not entitled to medical relief unless they are compensable under the war- risk insurance act as at present construed. They are not compen- sable under that act unless they have at least 10 per cent disability. This operates to exclude from hospital care those who have less than 10 per cent disability. There are doubtless thousands of soldiers and sailors who have been discharged, and by reason of their service in the trenches have suffered injuries, which though not causing 10 per cent disability at present, will eventually result in serious disability if not cared for properly now. It is hardly necessary to point out here that the aftereffects of influenza, pneumonia, bron- chitis, tonsilitis, eye and ear diseases, defective teeth and the like will eventually result in disabilities which will bring these men under compensation of the War Risk Insurance Bureau. Further- more, it is a well-known fact that if these men are properly cared for now and receive proper treatment, without regard to the 10 per cent ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 17 disability, it will delay the date when they will come under compen- sation and in many cases prevent disabilities which would bring them under compensation. In addition to this class, there is another large class of the military population who were inducted into the service with certain physical and mental defects, which have been aggravated by the military service which have not as yet cause a 10 per cent disability. This class should also be brought under medical supervision in order to delay or prevent their coming under compensation. There is another group of patients who were discharged with dis- abilities which are liable to be aggravated by sickness contracted after discharge. For example, a man discharged with arrested tuberculosis is liable to have the disease made active by contracting colds, bronchitis, influenza, pneumonia and the like. It can readily be seen that all such men should be carefully treated for any disease from which they may suffer at any time in the near future because such care will delay or prevent them from coming under compensation. There is still further another group composed of those who hold the life insurance policies upon which the Government is obligated to pay the insurance in case of death or certain disabilities. It is ob- viously good business to keep these policyholders under medical supervision in order to prevent disability and to defer death claims. Large life insurance companies have for sometime recognized this fact and are endeavoring to have their policyholders kept under medical supervision and examined by the company's physician at least once a year, without regard to whether or not they are sick. From the above it will be seen that in order to provide for all pos- sible contingencies the only remedy would be to enact a law which would provide governmental medical care for all discharged soldiers and sailors. This is apparent because there is such a large proportion of the discharged men who will require governmental medical care in order to safeguard the interest of the Government. In the tentative draft of the bill there is therefore included a sec- tion that the Public Health Service provide medical care and treat- ment for all discharged soldiers, sailors, marines, Army and Navy nurses (male and female), and patients of the War Risk Insurance Bureau. The provision to bring all of the former military population under medical benefits will operate to save the Government millions of dollars in preventing or deferring the payment of compensation and insurance claims. This, in addition to the enormous economic sav- ing, which will accrue to the country by providing medical super- vision for such a large portion of the population at the greatest pro- ductive age period. It is a well-known fact and one which has been taken cognizance of by all industrial insurance corporations, that it is a wise plan to keep all insured persons under medical supervision. In their experience it has saved them thousands of dollars in the pay- ment of compensation and insurance claims. All progressive large business establishments now provide medical supervision for their employees. Similar provision in this bill is for economic reasons followed out and similarly planned for the discharged soldiers, sailors and marines. H. Doc. 481, 66-2---2 18 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. The estimates of the number of beds in the above plan to properly hospitalize all patients of the War Risk Insurance Bureau is based upon those who are entitled to medical care under the present law, and those who will be entitled if H. R. 8778, which has already passed the House shall become a law in its present form. If the proposal in the tentative draft of the bill is accepted by Congress and becomes a law, it will therefore be necessa ry to increase very largely the estimates of the number of beds which will be required. CONCLUSIONS. A review of the estimates for hospital beds which will be required within the next two years for war-risk insurance patients may be summed up as follows: First. The chief medical adviser, Bureau of War Risk Insurance, estimates that approximately 30,660 hospital beds will be required for war-risk patients by the end of the next two years. This is based on the assump tion that H. R. 8778 will become a law as it passed the House of Representatives extending the benefits of the War Risk Insurance Bureau to draftees discharged by camp surgeons for disabilities and limited service men. Second. An estimate based on the rate of increase during the past 24 weeks shows that if the present rate continued for one year (52 weeks), there would be then 21,620 occupied hospital beds. If the present rate of increase is further increased by adding to the beneficiaries those discharged by camp surgeons and limited service men, the estimate of the chief medical adviser, Bureau of War Risk Insurance, of a requirement of 30,660 hospital beds by the end of two years is approximately correct, especially if there is a moderate increase during the second year which is the time limit on the chief medical adviser's estimate. Third. The grouping of the patients will be about as follows: General, medical and surgical.............................................. 7, 200 Tuberculosis.............................................................. 12,400 Neuro-psychiatric........................................................ 11,060 Total estimated as required within 2 years...........................30, 660 Fourth. The Public Health Service has in Government-owned or leased hospitals beds grouped as follows: General, medical and surgical.............................................3, 300 Tuberculosis.............................................................2,400 Neuro-psychiatric.........................................................1,500 Total now operated by Public Health Service......................... 7, 200 Fifth. The additional number of beds required by the Public Health Service within the next two years, based on the estimate of the chief medical adviser, Bureau of War Risk Insurance, would be approxi- mately as follows: General, medical and surgical............................................ 3, 900 Tuberculosis............................................................10, C00 Neuro-psychiatric........................................................ 9, £00 Total additional beds required by Public Health Service..............23,400 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 19 Sixth. Appropriation required to provide the Public Health Service with the additional beds is estimated by the architect as follows: General, medical and surgical, 3,900 beds at $3,250....................$12, 675, 000 Tuberculosis, 10,000 beds at S3,250.................................... 32, 500, 000 Neuro-psychiatric, 9,500 beds at $3,500................................ 33, 250, 000 Total appropriation required for acquiring buildings for 23,400 beds withm next 2 years.................................... 78, 425, 000 Furniture and equipment, 23,400 beds at $300 per bed................ 7, 020, 000 Total for buildings, furniture, and equipment.................... 85, 445, 000 Very respectfully, Rupert Blue. Table 7.—Number of beds in all civil hospitals per 100,000 population and per 100,000 service men, by districts.1 District. Continental United States. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. Popula- tion.5 106,871,294 6,141,326 15,287,505 9,154,813 5.496,056 lii, 451,174 6,365,566 10,631,386 12,154,362 8,S9S,319 4,4411,395 2,15i,445 3,608,817 3,116,606 8,972,125 Number of service men.3 232, 584, 321, 2.14, 332, 201, 388, 516, Number of beds in civil hos- pitals.4 776,110 63,347 181,402 77,011 37,558 35,611 19,596 80,902 89,024 59,028 30,942 14,287 41,195 2.1,958 25,249 5,291 Number of beds per 100,000. Population. Servicemen 1,031 1,187 841 683 341 308 761 732 663 695 664 1,142 672 281 19,359 27,291 31,055 23,970 18,405 10,716 9,722 20,808 17,242 16,481 15,216 17,012 27,763 18,996 7,786 21,749 1 Tables 7 and 8 are imperfect. They are based upon figures obtained from the directory of hospitals, sanatoria, and allied institutions. The institutions listed are not all hospitals, but comprise homes for the aged, homes for the blind, etc. Due to the lack of information it was difficult to separate the allied insti- tutions from bona fide hospitals. All institutions as listed were therefore considered in compiling the data. Bed capacity was not given for all institutions. « Bureau of the Census estimate July 1, 1919. The estimate for the United States as a whole differs slightly from the total of the estimates by States. * War Department records. * Directory of hospitals, sanatoria, and allied institutions, published by Modern Hospital Publication Co 20 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Table 8.—Number of hospitals, sanatoria, and similar institutions in the United State* with bed capacity, by Districts and by States.1 Districts and States Total number of insti-tutions listed. Number of insti-tutions where capacity is not given. Number of beds in all insti-tutions where capacity is given. Districts and States. Total number of insti-tutions listed. Number of insti-tutions where capacity is not given. Number of bedsin all insti-tutions where capacity is given. District No. 1...... 762 139 63,347 761 155 59,028 73 47 79 1 500 63 14 6 11 96 12 4,382 2,926 4,735 44,434 6,870 129 150 242 240 514 26 20 50 59 96 7 803 10'676 17 042 New Hampshire.. 23 507 District No. 10 North Dakota— South Dakota___ Minnesota........ 30,942 District No. 2...... 1,257 268 181,402 78 54 265 117 20 20 33 23 3,056 3,867 19,110 4 909 Connecticut...... 957 100 200 219 21 28 144,751 12,224 24,427 District No. 11 Wyoming........ Utah............. District No. 3...... 611 109 77,011 310 85 14,287 Pennsylvania___ 588 23 100 9 76,147 864 42 60 154 54 701 13 28 31 13 1,292 2 184 8,333 2,478 District No. 4...... 444 133 37,558 New Mexico...... District No. 12 California........ Maryland........ District of Co- 100 113 162 69 22 41 41 29 7,992 5,937 15,414 8,215 196 41,195 518 115 68 161 20 15 33,161 5 851 lumbia......... 2'183 District No. 13 Washington...... District No. 5...... 495 97 35,611 345 73 20,958 North Carolina... 132 137 53 122 51 17 25 6 31 18 11,667 8,3.'.2 4,199 8,120 3,263 175 116 54 24 36 13 12,285 6 685 South Carolina... Idaho............ l'987 District No. 14 Texas............ Florida....... 1,010 93 25,249 District No. 6...... 260 61 19,596 245 700 65 61 21 11 15 023 Louisiana........ 98 53 109 30 7 24 8,170 5,753 5,673 5,473 4 753 District No. 15 104 19 5,291 Tiitrict No. 7...... 797 167 89,902 23 45 29 7 6 3 8 2 Porto Rico...... Ohio............. 410 145 212 76 31 60 50,595 12,526 17,781 1,423 1,569 1,865 Indiana......... Canal Zone...... All districts___ 9,322 1,829 District No. 8...... 951 138 81,024 781,401 Illinois......... 381 275 287 42 45 51 45,341 21,239 23,444 Wisconsin....... Michigan..... » See footnote No. 1 on Table 7. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 21 Table 9.—Population and service men in continental United States, in absolute numbers and percentages, by districts and States. Number. Per cent. District and State. Popula-tion.' Service men.2 Popula-tion. Service men. Continental United Stat es......... 106,871,294 4,009,079 100.00 6,141,326 232,116 5.75 5.79 787,042 367,439 448,274 3,889,607 64S,904 15, 287, 505 26,552 11,223 14,970 157,101 22,270 .74 .34 .42 3.64 .61 .66 .28 .37 3.92 .56 Vermont.................. New Hampshire........... 584,137 14.30 14.57 Connecticut................................... 1,307,163 10,fc33,795 3 146 547 55,218 410,569 iis asn 1.22 10.14 2.94 1.38 2.95 9,154,813 | 321,282 District 3........................ 8.56 8,936,091 | 313,297 218,722 | 7,985 5,496,056 204.064 8.36 .20 7.81 .20 5.14 5.09 2,255,036 1,465,729 1,395,405 379,886 78,528 55,895 51,700 17.945 2.11 1.37 1.30 .36 1.96 Maryland.............................................. 1.40 1.28 .45 10,451,174 332,312 9.78 8.29 2,337,879 2,497,668 1,07S,664 2,975,394 9" 1,51.9 80,139 74,705 54,284 86,973 36,211 2.19 2.34 1.57 2.78 .90 2.00 1.86 1.36 2.15 .92 U,oUj,oUO 1 201, 004 5.96 5.03 1,912,603 1 71,271 2,026,361 ! 56,740 2,426,602 ! 73,543 1.79 1.90 2.27 1.78 1.41 1.84 10,631,386 388,808 9.95 9.70 5,335,543 2,423,001 2,872,842 205,852 77,983 104,973 4.99 2.27 2.69 5.13 1.95 2.62 T2Tl54,362 516,328 11.37 12.88 6,400,473 | 272,235 3,173,089 i 142,397 5.99 2.97 2.41 6.79 3.55 2, 580, 800 10 L, 696 2.54 8,898,319 358,154 8.33 8.93 1,309,627 1,896,520 2,224,771 3,467,401 49,614 66,645 101,638 140,257 1.23 1.78 2.08 3.24 1.24 1.66 2.53 3.50 4,449,395 203,350 4.16 5.07 817,554 753,897 2,378,128 499,816 27,253 ■<0,130 106,918 39,049 .76 .71 2.22 .47 .68 .7/1 2.67 .97 2,150,445 83,981 2.01 2.10 195,791 463, 431 1,040,842 450,381 12,223 19,421 38,751 13,586 .18 .44 .97 .42 .30 .49 .97 .34 ------ 22 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Table 9.—Population and service men in continental United Slates, in absolute numbers and percentages, by districts and States—Continued. Number. Per cent. District and State. Popula-tion.' Service men.2 Popula-tion. Service men. District 12................................................. 3,608,817 148,382 3.38 3.70 3,209,792 118,745 280,280 131,484 5,488 11,410 3.01 .11 .26 3.29 .12 .29 District 13................................................. 3,116,606 110,330 2.92 2 75 914,493 478,356 1,723,757 34,430 20,467 55,433 .86 .45 1.61 .86 51 1.38 8,972,125 324,281 8.39 8.09 4,687,136 2,465,402 1,819,587 174,061 84,909 65,311 4.38 2.3,1 1.70 4.34 2.12 1 63 Bureau of the Census estimate for July 1,1919. 2 War Department reports. [House Document No. 1294, Sixty-fifth Congress, second session.] Treasury Department, Office of the Secretary, Washington, September 20, 1918. The Speaker, House of Representatives, Washington, D. C. Sir: I have the honor to submit herewith a tentative draft of legislation, with the request that the same be referred to the Committee on Public Buildings and Grounds for immediate consideration: "Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That the Secretary of the Treasury be, and he is hereby, author- ized and directed to provide immediate additional hospital and sanatorium facilities for the care and treatment of discharged, sick, and disabled soldiers and sailors, pa- tients of the War Risk Insurance Bureau, and for others entitled to treatment by the Public Health Service, by lease or purchase of existing plants or the construction of new hospitals and Sanatoria, to include the necessary buildings, with their appor- priate mechanical equipment and approach work, including roads leading thereto, for the accommodation of patients, officers, nurses, attendants, storage, laundries, and live stock, on sites now owned by the Government, or on new sites to be acquired by purchase or otherwise at such places as he may elect, including the remodeling of such of the existing or authorized buildings and their equipment, owned by the United States, as may be necessary to economically adapt such facilities to those herein provided, at the sanatorium at Fort Stanton, N. Mex., and at such of the marine hos- pitals where increased facilities can be placed, at a limit of cost for sites and buildings, and so forth, as aforesaid, complete, of $9,700,000, or as much thereof as may be found necessary; for miscellaneous furniture and equipment for the above, $800,000; in all, $10,500,000, and the above amounts are hereby authorized, and when appropriated to be immediately available and remain available until expended. "The Secretary of the Treasury, in securing additional sites herein provided for, may request the Secretary of War, the Secretary of the Navy, the Secretary of Agriculture, or the Secretary of the Interior to transfer to the Treasury Department such lands or parts of land under their control, not required for other purposes, as may be found suitable for this use, and they are hereby authorized to make such transfer as may be in the interest of the Government. "In carrying the foregoing authorization into effect, the Secretary of the Treasury may enter into contracts for the lease or purchase of existing buildings, grounds, and equipment, or purchase materials and labor in open market, or otherwise, and employ laborers and mechanics for the construction of such buildings and their equipment as in his judgment shall best meet the public exigencies, within the limits of this authori- zation. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 23 "And the Secretary of the Treasury is hereby authorized, in his discretion, to em- ploy, for service within or without the District of Columbia, without regard to civil- service laws, rules, and regulations, and to pay from the sums hereby authorized, at customary rates of compensation, such additional technical and clerical services as may be necessary, exclusively to aid in the preparation of the drawings and speci- fications for the above-mentiorled objects and the supervision of the execution thereof, for traveling expenses, and printing incident thereto, at a total limit of cost for such additional technical and clerical services and traveling expenses, and so forth, of not exceeding $330,000 of the above-mentioned limit of cost. " Attached hereto are photostatic copies of certain reports and recommendations, which are self-explanatory and show the necessity for the above legislation. Respectfully, W. G. McAdoo, Secretary. Treasury Department, Bureau of War Risk Insurance, Washington, June SO, 1918. The Secretary of the Treasury. Subject: Need of enlarged hospital facilities. Sir: 1. I have the honor to invite your attention to the care and treatment of men who have been discharged from the military and naval forces of the United States who are beneficiaries of the Bureau of WTar Risk Insurance, and are in immediate need of sanatorium facilities. 2. Under the provisions of the amended act of October 6, 1917, defining the duties of this bureau it is provided in article 3, section 300, paragraph 3, that the sick or injured beneficiaries "shall be furnished by the United States such reasonable govern- mental medical, surgical, and hospital services and with such supplies, including artificial limbs, trusses, and similar appliances as the director may determine to be useful and reasonably necessary. " 3. Section 303 provided that "as frequently and at such times and places as may be reasonably required, submit himself to examination by a medical officer of the United States or by a duly qualified physician designated or approved by the director. " 4. At present the only "governmental" hospital services available for this work are the hospitals and relief stations of the United States Public Health Service, as the hospitals of the Army and Navy can not be used for the treatment of discharged sol- diers and sailors under the law, because these men have resumed their civilian status, and for the further reason that these hospitals are entirely occupied with the sick and disabled who are now in active military and naval service. The chief medical adviser of this bureau is now making use of every hospital and relief station of the Public Health Service in all parts of the country and as this hos- pitalization of discharged soldiers and sailors is increasing the necessity of making increased provisions in the hospitals of this service will be more acute when the Army is numerically increased. 5. The great problem connected with this work is the caring for discharged soldiers and sailors suffering from tuberculosis, and as 10,000 have already been discharged and are eligible for compensation and sanatorium treatment, the chief medical ad- visor informs me that he has already filled the Government sanatorium at Fort Stanton, N. Mex., to its capacity, and that he is finding difficulty in procuring suitable bed space in local hospitals, where the cost of maintaining them is greater than in the Government institutions. 6. The experience of the allied nations should be our guide in making preparation for the cases which will inevitably become a charge upon this bureau in the near future, as both England and France have returned tens of thousands of cases from the front broken down by this disease. 7. It is therefore the desire of this bureau that this condition be represented to the Surgeon General of the United States Public Health Service directing his attention to the department's needs in this respect, and urging his cooperation in providing sufficient bed space, either by the enlargement of hospitals now existing or the con- struction of new buildings. Respectfully, William C. DeLanoy, Director. 24 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. memorandum. August 10, 1918. The Secretary: Referring to the attached letter from the Director of the Bureau of War Risk Insurance, addressed to the Secretary of the Treasury, I beg to strongly approve the suggestion that the attention of the Surgeon General of the United States Public Health Service be directed to the needs of the medical work of the War Risk Insurance Bureau, as pointed out in the letter of the director, and that he be urged to cooperate in providing the necessary facilities for taking care of this work with the least possible delay. Sincerely, Thos. B. Love, Assistant Secretary. To Surgeon General, United States Public Health Service, by direction of the Secretary. Approved: J. H. Moyle, Assistant Secretary. August 14. September 11, 1918. report of the committee appointed by the chairman of the conference of officers of the army, navy, and public health service to obtain data regarding the number of men discharged from the military forces, and the percentage of those engaged who will become beneficiaries of the war risk insurance* bureau; also to present conclusions, if any could be reached, regarding the accommodations which should be furnished to those patients. This committee has the honor to make the following report: The largest number of discharged soldiers requiring treatment will be cases of tuberculosis. Fourteen thousand men have already been discharged from the Army on account of this disease. During the remainder of the calendar year 1918 and during the year 1919, it is estimated that 20,000 men will be rejected on their primary exam- ination at the camps after induction into the service. The War Risk Insurance Bureau of the Treasury Department would have to care for these patients. From its experience, three-fourths, or about 26,000, will avail themselves of sanatorium treatment. It is estimated that the average length of time the patients will remain in a tubercu- losis sanatorium is six months. Therefore 13,000 beds will be required for these patients. The number of soldiers that will be discharged from the Army hereafter during the war will be small, as it is the policy of the War Department since May 21, 1918, not to discharge tuberculosis soldiers as long as they need sanatorium treatment. Prac- tically the same policy is followed in the Navy Department. The War and Navy Departments have made no provision for the treatment of patients other than those of the active forces, and therefore no beds are available for patients of the War Risk Insurance Bureau. The number of soldiers discharged for diseases other than tuberculosis that will require hospital accommodations will probably be small and can be taken care of in existing hospitals. Earl H. Bruns, Lieutenant Colonel, Medical Corps, United States Army. W. E. Eaton, Lieutenant Commander, Medical Corps, United States Navy. \V. G. Stimpsox, Assistant Surgeon General, United States Public Health Service. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 25 Treasury Department, of the Public Health Service, Office of the Surgeon General, Washington, September 17, 1918. report of the proceedings of a conference held at the office of the surgeon general of the army to consider what provision should be made for the hospital treatment of patients of the bureau of war- risk insurance. Officers of the Army, Navy, Public Health Service, and the chief medical advisor of the Bureau of War Risk Insurance were present at this conference. A committee was appointed by the chairman to obtain data regarding the number of men discharged from the military forces and the number which would in all probability, become bene- ficiaries of the War Risk Insurance Bureau during the remainder of the year 1918 and the year 1919. A copy of the report of this committe is attached. This report shows that 13,000 beds should be provided for patients for the War Risk Insurance Bureau suffering from tuberculosis, and the Army and Navy state that they have made no provision for the treatment of these patients, nor do they contemplate doing so. The number of patients suffering from tuberculosis for whom beds will be necessary is estimated to be 26,000, but only one-half of this number of beds will be needed, as it is improbable that any patient will remain at the sanatorium for more than six months at one time. These beds will not be for temporary purposes, however, but will be needed for years to come, because, with recurring breaT downs of tubercular soldiers they will apply for reentrance and treatment, and will be entitled to receive it under provision of the war-risk insurance act. If new buildings are built for this purpose, at least six months will be required for their construction after authority is granted by Congress, at a cost of approximately $26,000,000. It is recommended that the estimates for 5,000 beds only be approved at this time, at a cost of approximately $10,000,000, and the remaining beds be provided for in a supplementary estimate, to be submitted to Congress at a later date. The draft of a bill attached to these estimates authorizes the Secretary of the Treasury to construct new buildings or rent existing buildings, if such can be found. Rubert Blue, Surgeon General. Treasury Department, Bureau of the Public Health Service, Office of the Surgeon General, Washington, September 17, 1918. The Secretary of the Treasury. Sir: Complying with departmental instructions of August 10, accompanying a letter from the Director of the Bureau of War Risk Insurance, dated July 30, 1918, a copy of which is hereto attached, there is submitted herewith for your consideration and approval estimates for the supply of hospital and sanitoria facilities for the care and treatment of beneficiaries of the War Risk Insurance Bureau and others entitled to receive treatment by the Public Health Service of this department, which it is recom- mended be transmitted to Congress for their earliest possible consideration as an un- usual necessity brought about by war conditions. These estimates are based on careful calculations in collaboration with the medical advisor of the War Risk Insurance Bureau, for the supply of minimum facilities which, it is believed, will serve the country's needs in this direction along the lines set forth in the letter from the director of that bureau, above mentioned. Attention is invited to the last paragraph in the letter above referred to, in which it is stated that 10,000 soldiers and sailors suffering from tuberculosis have already been discharged and are eligible for compensation and sanatorium treatment. It should be stated that this bureau has, in an effort to supply accommodations for the greatest possible number, filled many of its hospitals to overflowing, by placing beds in hallways, on verandas, and even in tents scattered about the reservations, and has already rented private dwellings to be converted into temporary hospitals in order to relieve the demand for hospital treatment arising from this source, from the increased merchant marine service, and the constantly growing work incident to caring for in- jured civil employees of the Government under the compensation act, and while further efforts are being made to locate and make use of privately owned hotels and other property that may be adaptive to this use, this practice is neither satisfactory nor economical. Bureau Memorandum for the Secretary. 26 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. In providing these increased accommodations, it should be stated that our estimates are based on supplying facilities for caring for approximately 5,000 patients, as a mini- mum of the total number of patients entitled to receive treatment from these sources, who will require or demand same. It is not thought desirable, however, to limit the availability of the appropriation to accommodations for any specific number, as it may later on be found necessary to provide for a greater proportion than that above mentioned, if the same can be done within the limits of this appropriation. One of the primary considerations in locating these sanatoria facilities is to have them in suitable climates and within economical travel and purveying areas, and in such sections of the country that beneficiaries need not of necessity be widely sepa- rated from their native surroundings or homes. In meeting these conditions it is thought that approximately 2,000 should be placed in quarters to be erected on marine hospital sites, indicated in the attached list; that a new hospital and sanatorium should be located at Norfolk, Va., with a capacity of approximately 300 patients; one at Seattle, Wash., with a capacity of 150 beds; and that the balance be distributed in new sanatoria, located as may be best suited to the needs of the service to be performed. For your convenience there is submitted herewith a tentative draft for legislation, which it is believed provides for all the necessary things to be done in supplying these additional facilities. The estimated cost of the necessary sites and buildings, including miscellaneous furniture and equipment, is $10,549,000. Respectfully, Rupert Blue, Surgeon General. LIST OF PROPOSED HOSPITAL AND SANATORIA ADDITIONS. Boston, Mass.; Chicago, 111.; Cleveland, Ohio; Detroit, Mich.; Evansville, Ind.; Louisville, Ky.; Norfolk, Va.; New Orleans, La.; San Francisco, Cal.; Seattle, Wash.; St Louis, Mo.; Wilmington, N. C; Fort Stanton, N. Mex.; Berkshire Hills; North Carolina. memorandum for the secretary of the treasury. Treasury Department, United States Public Health Service, Washington, November 15, 1918. There is transmitted herewith a tentative draft of a letter to the Speaker of the House of Representatives, calling attention to legislation pending before Congress, which it is of the utmost importance should be enacted into law if this bureau is to furnish the hospital accommodations demanded of it by the War Risk Insurance Bureau, for the care and treatment of patients delegated to that service by act of Congress. I feel that too strong emphasis can not be given to the immediate enactment of this legislation, and earnestly request that the entire weight of your influence be brought to bear on Congress to that end. While the two bills mentioned represent only a part of the total number of beds that will be required, I still am of the opinion that these two bills should be enacted into law before further estimates are transmitted to Congress, as they will furnish an appreciable measure of relief, and permit a more accurate survey of the ultimate needs of the service in this direction, due to rapidly changing from war to peace con- ditions, and the probable abandonment of several Army projects which might be made available for our use in the care and treatment of the remaining thousands of patients who are entitled to receive hospital accommodations and treatment. Respectfully, Rupert Blue, Surgeon General. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 27 Chart I.—Hospital growth in the United States, 1873-1918. [Embracing all classes of hospitals and sanatoriums but excluding allied institutions, such as homes for tho aged, homes for the deaf and blind, rescue homes, etc.] Number of hospitals................ Number of hospital beds............ Ratio of hospital beds to population Population......................... 1873 149 35,453 1-1,088 38,558,371 1918 7,158 657,965 1-174 114,201,039 Increase. Per cent. 4,700 1,755 525 196 Chart II.—Classification of hospitals and sanatoriums by capacities, 1918. Bed capacity. Number of hos-pitals. Per-centage of total. Bed capacity. Number of hos-pitals. Per-centage of total. Under 25..................... 3,004 1,766 1,153 661 342 41.97 24.67 16.11 9.23 4.78 500 to 999. 101 131 1.41 25 to 49...................... 1.83 50 to 99 Total.......... 100 to 199..................... 7,158 100.00 200 to 499................. Chart III.—Classification of hospitals, sanatoriums, and allied institutions according to character of cases admitted, 1918. HOSPITALS AND SANATORIUMS. Class. Number of insti-tutions. Number of beds. Class. Number of insti-tutions. Number of beds. 4,863 169 48^ 539 63 215 165 69 202 270,209 3,518 38,881 283,761 7,288 8,995 17,660 2,289 6,287 40 91 50 56 77 77 2,483 Alcoholism and drug addic- 3,259 3,987 3,494 3,620 Total................... 2,234 Eye, ear, nose, and throat___ 7,158 657,965 ALLIED INSTITUTIONS. Number of insti-tutions. Capacity. Number of insti-tutions. Capacity. 748 712 184 109,127 74,289 12,640 Homes for the deaf and blind. Total................... 117 15,070 1,761 211,126 Estimated number of hospital beds in allied institutions......................................... 21,113 Total n umber hospital beds in hospitals, sanatoriums, and allied institutions.....................679,078 28 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Chart V.—Ratio of hospital beds to population by States, 1918 (excluding hospitals for the insane and for convalescents) Alabama.................. Arizona....................... 1- Arkansas................... California................... Colorado.................... Connecticut............... Delaware.................. District of Columbia......... Florida..................... Georgia..................... Idaho..................... Illinois.................... Indiana.................... Iowa....................... Kansas..................... Kentucky................. Louisana................... Maine..................... Maryland.................. Massachusetts.............. Michigan..................., Minnesota.................. Mississippi.................., Missouri.................... Montana..................... 1- 758 . l-28ft 1- 77 570 . 1-145 1- New Hampshire................. 1-241 1- 140 1-285 1- 159 New Mexico..................... 1-18^ 1- 238 1-171 1- 278 1-588' 1- 118 1-345 1- 469 673 Ohio........................... 1-278 1- 1-958- 1- 295 Oregon........................... 1-238 1- 227 Pennsylvania.................... 1-244 1- 297 Rhode Island.................... 1-235- 1- 261 South Carolina.................... 1-771 1- 354 South Dakota................... 1-287 1- 506 Tennessee....................... 1-456 1- 416 330 208 Texas........................... 1-46S 1- Utah............................ 1-283: 1- Vermont......................... 1-339 1- 179 277 Virginia.......................... 1-394 1- Washington...................... 1-219- 1- 226 West Virginia..................... 1-441 1-1 222 Wisconsin........................ 1-26$ 1- 305 Wyoming........................ 1-202 1- 131 United States territorial possessions. 1-788- Treasury Department, Washington, October 6, 1919. From: The chief medical adviser, Bureau of War Risk Insurance. To: Assistant Secretary Moyle. Subject: Report on estimate of demands to be made by the Medical Division, Bureau of War Risk Insurance. (Through the Director of the Bureau of War Risk Insurance and Assistant Secretary Shouse.) Sir: In consonance with your verbal direction of recent date, I have made a review of the situation confronting the Treasury Depart- ment in the care, treatment, and rehabilitation of sick and disabled soldiers, sailors, and marines, and have the honor to submit the follow- ing memorandum thereon. In reading this statement it is requested that you bear in mind the fact that the entire problem is one without precedent in history; that much of the data upon which this report is made is ol necessity only approximate, and that in many instances it is impossible to foretell with any degree of accuracy just what demands will be made in future upon the services involved. I am convinced, however, that the problem will grow with time rather than diminish^ and that if mistakes are made they are far more apt to be in the direc- tion of underestimating rather than of overestimating the magnitude of the situation confronting the governmental agencies functioning in the premises. LEGAL. The war-risk insurance act, section 302, paragraph 3, states: In addition to the compensation above provided, the injured person shall be fur- nished by the Jnited States such reasonable governmental medical surgical and hos- pital services with such supplies, including artificial limbs, trusses,'and°simi'lar appli- ances as the director may determine to be useful and reasonablv necessary ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 29 The director, subject to the general direction of the Secretary of the Treasury, is vested with "full power and authority to make rules and regulations" to carry out the purposes of the war-risk insurance act and to designate the methods of making medical examinations. The law further states that for the purposes of the act the officers, enlisted men, and other persons in the military service "shall be held and taken to have been in sound condition when examined, accepted and enrolled for service." This places upon the Government the obligation of care and treatment of men whose injury or disease may have escaped detection by the examin- ing physician. Persons applying for compensation under this act are required by section 303 thereof to submit "to examination by a medical officer of the United States, or by a duly qualified physician designated or approved by the director," and, "every person in receipt of compensation for disability shall submit to any reason- able medical or surgical treatment furnished by the Bureau when- ever requested by the Bureau." Public Act No. 326, Sixty-fifth Congress, approved March 3, 1919 (see copy attached1), authorizes the Secretary of the Treasury "to provide immediate additional hospital and sanatorium facilities for the care and treatment of discharged sick and disabled soldiers, sailors, and marines, Army and Navy nurses (male and female), and patients of the War Risk Insurance Bureau, and the following per- sons only." The act making appropriations for sundry civil expenses of the Government for the fiscal year ending June 30, 1920, and for other purposes, contains the following proviso: Provided, That none of the appropriations made herein for the Bureau of War Risk Insurance shall be expended to reimburse any expenses incurred by any government- owned hospital or hospital under contract with the Public Health Service for exami- nation and care or treatment of beneficiaries of the Bureau of WTar Risk Insurance. From the foregoing it is evident that the Government has obli- gated itself (1) to provide "reasonable governmental medical, surgi- cal, and hospital services and supplies" for the patients of the War Risk Insurance Bureau, (2) that the Secretary of the Treasury is authorized to provide additional hospital and sanatorium facilities for these persons, and by inference (3) that the Public Health Service shall provide examination, care, and treatment of beneficiaries of the Bureau of War Risk Insurance, (4) because the Public Health Service is the "governmental medical, surgical, and hospital" agency of the department in which both the Public Health Service and Bureau of War Risk Insurance now operate. There is still another legal aspect to the question which would seem pertinent to the consideration of the problem. Section 22, paragraph 7, of the war-risk insurance act defines the term men and enlisted men to mean "a person whether male or female, whether enlisted, enrolled, or drafted into active service in the military or naval forces of the United States." It has been held by the Judge Advocate General of the Army that a man who has been accepted by a draft board and dispatched to a camp had been drafted into active service. On the contrary, it has been held by the general counsel of the Bureau of War Risk Insurance that the man did not actually enter active service until he was accepted by the medical officers of the Army. ' Not piinted. 30 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC.. H. R. 8778, now under consideration by the Congress, attempts to solve this question by the following proviso: Sec 31. That if after induction by the local draft board, but before being accepted and enrolled for active service, the person died or became disabled as a result of dis- ease contracted or injury sufferd in the line of duty and not due to his own willful misconduct involving moral turpitude, or as a result of the aggravation, in the line of duty and not because of his own willful misconduct involving moral turpitude, of an existing disease or injury, he or those entitled thereto shall receive the benefits of compensation. In this connection it may be pointed out that medical, surgical, and hospital services are by law furnished ' 'in addition to compen- sation." This proposed act would increase very largely the amount of medical and surgical work which would have to be performed by the Government, since many men were accepted by the draft boards, and were subsequently rejected by the Army on account of physical or mental disabilities. A conservative estimate of the total number in service in the armed forces of the United States during the war with Germany is 5,041,470. This figure includes the Army, Navy, Marine Corps, and the correlated- military forces and those men sent to mobilization camps and rejected by camp surgeons. This is more than twice the number who served in the Northern Army and Navy during the Civil War. While the statistics of the Pension Bureau do not furnish an exact parallel with the situation which now confronts the Government, inasmuch as pensions were allowed for injury, disease, age, and finally for service, they furnish some sort of criterion of the way in which the work of caring for the men who served in the war with Germany may be expected to expand. The following table shows the number of Army and Navy invalid claims allowed per annum from July 1, 1861, to June 30, 1897, a period of 36 years. It will be noted that in the first fiscal year only 413 such claims were allowed, while in the fiscal year 1897, 3,726 claims were allowed. The total number of claims allowed out of an army of 2,400,000 men was in 36 years, 579,115. If the same proportion obtains with the veterans of the war with Germany there will be 1,209,950 active invalid claims in the year 1955. Original pension claims filed and allowed each year from July, 1861, to July 1, 1897. Fiscal year ending June* 30— Invalid (Army And Navy) claims allowed. Fiscal year ending June 30— Invalid (Army And Navy) claims allowed. 1862...................................... 413 4,121 17,041 15,212 22,883 16,589 9,460 7,292 5,721 7,934 6,468 6,551 5,937 5,760 5,360 7,282 7,414 7,242 10,176 1881.......... 1863...................................... 1882...... 22,946 32,014 27,414 27,580 31,937 35,283 35,843 36,830 50,395 41,381 17,876 10,232 6,129 5, 415 3,864 3,726 1864...................................... 1883. . 1884 . 1866...................................... 1885 . 1867...................................... 1886 .. 1868...................................... 1887 . 1869...................................... 1888 . 1870...................................... 1889. . 1871...................................... 1890 . 1872...................................... 1891 .. 1873...................................... 1892 . 1874...................................... 1893 .. 1875...................................... 1894... 1876...................................... 1895 1877...................................... 1896 . 1878...................................... 1897 . 1879.................................... Total 1880...................................... 579,115 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 32 In considering this table it should be borne in mind that it relates to invalid claims and not to medical treatment. It may be assumed that there are a considerable number of men who will not ask for compensation, but who, nevertheless, would be eligible to and require treatment under a broad construction of Public Act 326. The following table shows the distribution of the armed forces of the United States by point of origin. This will give some approxi- mate idea of the potential patients by States: State. New York..... Pennsylvania.. Illinois........ Ohio.......... Texas......... Michigan...... Massachusetts. Missouri....... California...... Indiana........ New Jersey___ Minnesota..... Iowa.......... Wisconsin..... Georgia........ Oklahoma..... Tennessee..... Kentucky..... Alabama...... Virginia....... North Carolina Louisiana...... Kansas........ Arkansas...... West Virginia. Mississippi..... South Carolina Connecticut... Per cent. 9.79 7.93 6.68 5,33 4,29 3.61 3,53 3.42 2.98 2.83 2.80 2.64 2,63 2.61 2,28 2.13 2.02 2.00 1.99 1.94 1.94 1.76 1.69 1.62 1.48 1.44 1.42 1.33 Approxi- mate total (Army, Navy,and Marine Corps). 469,920 380,640 320,640 255,840 205,920 173,280 169,440 164,160 143,040 135,840 134,400 126,720 126,240 125,280 109,440 102,240 96,960 96,000 95,520 93,120 93,120 84,480 81,120 77,760 71,040 69,120 68,160 63,840 State, Nebraska.................. Maryland.................. Washington............... Montana................... Colorado................... Florida.................... Oregon.................... South Dakota............. North Dakota............. Maine..................... Idaho...................... Utah...................... Rhode Island.............. Porto Rico................ District of Columbia....... New Hampshire........... New Mexico............... Wyoming................. Arizona.................... Vermont.................. Delaware.................. Hawaii.................... Nevada.................... Alaska..................... American Expeditionary Force.................... Not allocated.............. Philippines................ Per cent. 1.27 1.25 1.20 .97 .92 Approxi- mate total (Army, N ,-v. and Marine Corps). 60,960 60,000 57,600 4', 5^0 44, l'O 42, 720 38,-,'00 37,920 33,120 31,200 24,480 22,080 21,600 21,120 20,160 18,240 15,840 14,400 13,440 12,000 9,600 7,200 6,720 2,880 1,920 1,920 480 SOURCE OF WAR-RISK CLAIMANTS. Potential claimants to compensation and relief under the war-risk insurance act fall into three major classes: 1. Total United States armed forces raised to November 11, 1918. Total strength of Army, Navy, and Marine Corps compared as to original strength and increments. Number. Per cent of total forces. Per cent of total military forces. Per cent of mili-tary in-crement. Total United States armed forces raised to Nov. 11, 1918...... 4,791,172 100.00 4,185,220 605,952 87.35 12.65 100.00 378,619 7.92 291,880 6.97 127,588 164,292 86,739 Navv 69,029 13,599 4,111 32 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Total strength of Army, Navy, and Marine Corps compared as to original strength and increments—Continued. Number. Per cent of total force. Per cent of total military forces. Per cent of mili-tary in-crement. 4,412,553 92.08 3,893,340 93.03 100.00 203,786 2,810,296 877,458 5.23 67.15 72.18 22.54 390,874 296,978 189,606 10.04 7.63 4.87 United States Guards (commissioned and enlisted)....... 1,800 519,213 .05 462,229 24,702 437,527 54,690 1,799 52,891 2,294 2. Accepted by local boards for groups A and C, but rejected by camp surgeons: 200,300. 3. Drafted and furnished transportation to camps, but not mus- tered into service for reasons other than physical: 50,000 (estimated). Total: 4, 791,170 200,300 50, 000 5, 041, 470 KNOWN DEMOBILIZED DISABLED. 1. Of 4,791,170 men: Discharged, United States Army, 1917................................... 16, 400 Discharged, United States Army, 1918................................... 113, 500 Discharged, United States Army, 1919 (approximately)................... 156,000 Discharged, United States Navy (estimated)............................ 24. 500 Discharged, United States Marine Corps (estimated)...................... 2, 800 Group "C" men, all with physical defects................................ 'Ill, 900 Total........................................................... 425.100 2. Two hundred thousand three hundred accepted by local boards but rejected by camp surgeons, all with physical disability. 3. Sixteen thousand five hundred limited-service men called, but rejected at camps. Total: 425,100 200,300 16, 500 641, 900 Maximum number discharged with some disability......................... 641, 900 1 Qualified for special service or limited service; defects of eye, ear, nose, throat, teeth, or skin of some- what greater degree than were permitted by the standards for unconditional acceptance. Abnormalities of tha extremities; operable hernia; small fcenign tumors; urethral strictures; nocturnal enuresis- stam- mering; temporary anemias or debilities. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 33 A certain percentage of disability, however, is of minor character. DISTRIBUTION OF DISABILITIES (NOT INCLUDING TRAUMATISMS PRODUCED BY EXTERNAL CAUSES). Of 113,512 men discharged from the United States Army during the calendar year 1918 for physical disabilities (unfit for military service), the following distribution of diseases, by class of disease, obtained: Class. Number. Per cent of total. Relative standing. 1. Infectious disease (excluding tuberculosis and venereal diseases)..... 2. Tuberculosis.......................................................... 3. Venereal diseases.................................................... 4. General diseases..................................................... Arthritis.................................................. 4,835 H^-perthyroidism.......................................... 4,040 Others....................................................2,619 5. Diseases of nervous system........................................... Epilepsy...................................................4,009 Neurocirculatory asthenia................................. 1,550 Hysteria................................................... 1,360 Neurast henia.............................................. 1,340 Other forms...............................................3,028 f. Mental alienation.................................................... Mental deficiency.......................................... 8, 251 Dementia precox..........:...............................3,202 Cons'itutional psychopathic states......................... 2,553 Psychoneurosis............................................2, 240 Other forms............................................... 1, 712 7. Eyes and their adnexa, diseases of................................... 8. Ear, diseases of...................................................... 9. Nasal fossae, diseases of............................................... 10. Throat, diseas. s of................................................... 11. Circulatory system, diseases of........................................ Mitral insufficiency........................................4,111 Cardiac disorders, functional............................... 2,829 Mitral stenosis............................................. 1,739 Aortic insufficiency........................................ 873 Myocarditis................................................ 810 Tachycardia.............................................. 757 Other forms............................................... 4,135 12. Respiratory system, diseases of....................................... Asthma...................................................2,418 Bronchitis................................................. 483 Other forms............................................... 1,216 13. Digestive system, diseases of......................................... Hernia.....................................................2,502 Mouth and adnexa........................................ 1,256 Other forms............................................... 1,874 14. Genito-urinary system, diseases of.................................... 15. Skin and cellular tissue, diseases of................................... 16. Bones and organs of locomotion, diseases of........................... Pes planus.................................................5,791 Organ of locomotion.......................................3,353 Ankylosis................................................. 905 Fractures................................................. 1,804 Others.................................................___2,659 17. Congenital malformations and ill-defined diseases.................... Total.......................................................... 934 10, 293 8,860 11,494 11,287 17,958 4,198 4,011 335 108 15, 244 5,632 1,615 1,135 14,512 1,357 0.8 9.0 7.9 10.1 9.5 15.7 3.7 3.5 .3 .1 13.4 1.4 1.0 12.8 10 113,512 100.0 DISTRIBUTION OF DISABILITIES. By the end of demobilization there will have been discharged from the Army, Navy, and Marine Corps a total of approximately 313,200 men with some disability. This number does not include group "C" men (limited service) nor those men who were accepted by local draft boards or camp surgeons and later found unfit for military service. As to the type of disability among these men, there are no better figures than those contained in a report from the statistical section H. Doc. 481, 66-2---3 34 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. of the Surgeon General's Office which shows discharges from the United States Army by specific disease or condition for the year 1918. This list comprises"l 13,512 discharges by specific disease or condition. The proportion of each class of disease to the total diseases has been made, and the result is shown in the preceding table. These pro- portions have subsequently been applied to the total of 313,200 discharges from the United States Army, it being logical to presume that those conditions which obtained during 1918 among 113,500 men would doubtless represent approximately the conditions ob- taining among some 313,200 men discharged with disability for 1917, 1918, 1919. Estimated totals for specific classes of diseases for all men discharged with disability, 1917, 1918.1919. U. S. Army classification. Per cent of class to total group. Number. Total................................................. 5-6. Diseases Of nervous system and mental alienation 9. Diseases of circulatory system.................... 16. Diseases of bones and' organs of locomotion........ 4. General diseases.................................. 2. Tuberculosis..................................... 3. Venereal disease.................................. 13. Diseases of digestive system...................... 7. Diseases of eyes and their adnexa................. 12. Diseases of respiratory system.................... 8. Congenital malformation and ill-defined diseases.. 17. Diseases of ear.................................... 14. Diseases of genito-urinary system................. 15. Diseases of skin and cellular tissue................ 1. Infectious disease................................. 9. Diseases of nasal fossae........................... 10. Diseases Of throat................................. 100.0 25.2 13.4 12.8 10.1 9.0 7.9 5.0 3.7 36 2.2 35 1.4 1.0 .8 .3 .1 313,200 78,930 41,970 40,090 31,630 28,190 24,750 15, 660 11,590 11,280 6,890 10,960 4,380 3,130 2,500 940 310 Distribution of disabilities among 52,640 draftees, accepted by local draft boards but not accepted by camp surgeons. Class: 1. Infectious disease................................................. 72 2. Tuberculosis (total)............................................... 4, 762 3. Venereal disease................................................. 2,095 4. General disease. .....................,........................... 1, 268 5. Nervous system, disease of........................................ 1, 876 6. Mental disease................................................... 3,494 7. Disease of eye................................................... 7,794 8. Disease of ear..................................................... 2,331 9. Disease of nose.................................................. 85 10. Disease of throat.................................................. 47 11. Circulatory system, disease of..................................... 7, 245 12. Respiratory system, disease of..................................... 721 13. Digestive system, disease of...................................... 7, 711 14. Genito-urinary system, disease of................................. 514 15. Disease of skin................................................... 571 16. Bones and organs of locomotion, disease of.......................... 8, 836 17. Malformations and ill-defined diseases............................. 3, 218 Total.......................................................... 52, 918 Based upon the figures of the first million men inducted, 5.32 per cent of those arriving at camp were rejected upon physical grounds. Therefore, from June, 1917, to February, 1918, 28,300 men were rejected at camps. From February, 1918, to November, 1918, there ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 3 5 were 172,000 additional rejections, making a total of approximately 200,300 men who were rejected by camp surgeons after being accepted by draft boards. In the previous table there is shown the relative incidence of each group of diseases to total noted for 52,640 of such rejections. Apply- ing those figures to the total number thus rejected, namely 200,300, the following table is obtained: Distribution of disabilities among 200,300 draftees accepted by local draft boards, but not accepted by camp surgeons. Class: 1. Infectious diseases................................................ 274 2. Tuberculosis (total)............................................... 18,120 3. Venereal disease................................................... 7, 970 4. General disease.................................................... 4, 733 5. Nervous system, disease of........................................ 7,158 6. Mental disease..................................................... 13, 297 7. Disease of eye..................................................... 29, 646 8. Disease of ear..................................................... 8, 862 9. Disease of nasal fossa.............................................. 321 10. Disease of throat.................................................. 180 11. Circulatory system, disease of....................................... 27, 550 12. Respiratory system, disease of........,............................ 2, 740 13. Digestive system, disease of........................................29, 310 14. Genito-urinary, disease of (nonvenereal)............................ 2, 953 15. Disease of skin................................................... 2,169 16. Bones and organs of locomotion, disease of........................... 33, 789 17. Malformations and ill-defined disease...............................12, 228 Classifications by disease or conditions of men accepted for domestic service only is not available, in consequence of which it is impossible to determine the severity of their conditions. This group com- prises 111,900 men who were accepted and 16,500 men who went to mobilization camps but were not accepted, making a total of 128,400. Thus there is a large group of potential claimants about whom little medical data is as yet available. That these men might repre- sent a problem of considerable magnitude can not be denied, how- ever where their condition was aggravated by service, during 1918, to an extent necessitating discharge, they have been included in the list of discharges for disability for 1918. Another point to be borne in mind is the fact that of the first 1,000,000 men accepted for general military service at mobilization camps, 294,875, or about 30 per cent, were accepted with physical defects. This percentage was probably maintained, certainly not diminished, for the total number of inducted men. How great such a factor may be can not as yet be estimated. Therefore, of the approximate 641,900 known potential immediate claimants, classified disease conditions are known for only 513,500. It must be borne in mind that not all of these cases will be com- pensable, because (a) some conditions were not aggravated by service; (b) some conditions are of such a minor character as not to warrant compensation or relief; (c) in a few cases, major or minor, there will be no claim for compensation or relief. What percentage of the total cases of disability this will be is not estimatable at present because of the meagerness of data. It is safe to presume that the majority of the cases of mental alienation and nervous diseases, tuberculosis, diseases of special senses, dis- eases and conditions of the bones and organs of locomotion, will at 36 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. some time present claims for both compensation and hospital relief. It is also safe to presume that there will be a considerable number of claimants among the other specific groups of diseases and condi- tions who will make claims for compensation, where prolonged hospitalization will not be as a rule necessary. Attention is invited to the fact that no consideration has been given to disability due to traumatisms produced by external causes, per se. Data are not at present available for this group. It has seemed advisable, in view of the nonavailability of such data, to disregard it temporarily, since many injuries and conditions re- sulting from such have been included in the seventeen groups re- corded. Such is particularly true as to general and ill-defined dis- eases, and diseases of the bones and organs of locomotion. It is believed that the remaining number (those not included) is relatively small, and will not when known seriously interfere with the general conclusions of this survey. As soon as these data are available, they will be correlated with the data here given, and will form the basis for a supplementary report EYE, EAR, NOSE AND THROAT. From the table of total disabilities by cause it is seen that diseases of the eye and adnexa amount to 41,236; diseases of the ear, 79,882; diseases of the nasal fossae, 1,261; diseases of the throat, 490. Of the diseases of the eyes and adnexa refractive errors (astigma- tism, hyperopia, myopia, defective vision) form the largest item, probably fifty per cent. Such cases require little hospitalization, but will require optical apparatus and repeated examinations. Of the remaining, trachoma will prove the most persistent, and will require hospitalization. Of the diseases of the ear, deafness and otitis media will be the greatest factors. Of the diseases of the nasal fossae, sinusitus has the greatest incidence. Hospitalization of these groups of diseases and conditions will not be extensive. Repeated examination with the corresponding cor- rection of defects will however probably obtain over a long period of time. Some idea is thus given on the amount of eye, ear, nose and throat work that must be taken care of by the Public Health Service. It is next in order to consider over what period of time this work will last and when its maximum will be reached. The extent and volume of treatment to be given will depend upon the policy that will be estab- lished as to what extent the Government will care for these affections, and who are the privileged beneficiaries. If it is decided to look after the needs of service men for life, then there will be a medical demand for approximately the next 60 years. If provisions are made for replenishing adjuncts, as artificial eyes, glasses and dentures, the demand will be constant for that period. If the prevalence of glasses in the general population is an index of the disabilities of eyes, it shows that they are increasing, and it is a clinical fact that the great majority of persons have refractive errors which cause defects of vision and eye strain. As soon as the policy is established that oculist's examinations and glasses gratuitously ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 37 are to be given, it is believed that beneficiaries will immediately avail themselves of the opportunity of ascertaining the condition of their eyes, and the greater part will be furnished prescriptions for lenses, which will have to be changed as time goes on. During the next few years service disabilities of the eyes will receive immediate examination and treatment, and be cured or arrested, but the fact must not be lost sight of that such conditions of the eye as iritis, trachoma, and conjuctivitis, are apt to recur hence a certain number of cases will always be under treatment. To sum up the possibili- ties of future eye work it may be stated that there will be a constant necessity for facilities for caring for all sorts of eye disturbances; the greatest demand for which will be the immediate post-war demobili- zation period. The maximum of the work will occur on the state- ment of a policy of gratuitous eye treatment and glasses. The de- mand for eye attention will be constant thereafter up to the time when the average service man reaches 55. EAR WORK. As with the eye, the ear disabilities will increase with age. The history of the United States Pension Office shows a vast increase in ear troubles as pensioners grow older. There may be a reason for this as stated by Medical Referee J. F. Kennan, who says that most ear conditions required treatment at the start, which the claimant was in most cases unable to pay for, or neglected to observe. Slight degrees of deafness at the start, in 1865-1870, which were not com- pensable, developed later to an incapacitating degree. It might be said of the future of ear work as of eye, that the necessity will be great at all times, with the maximum demand for ear treatment and examination at the initial period and to continue for five years, and when the claimant reaches middle age there will be another rise in the demand. NOSE AND THROAT. With the policy of free treatment for disabilities of nose and throat, it is not considered that the claimant will reject the offer of gratui- tous treatment. The disabilities of the nose and throat should be in a great measure relieved by operations during the next five years, providing that all the service men follow their directions as to opera- tion and treatment, and that there is an adequate number of phy- sicians to take care of this work. The fact that surgical and medical cases per se proper to other sections will diminish as to time goes on by process of elimination, but the disabilities of the special senses will increase and constitute the large proportion in course of time, is borne out by the history of the United States Bureau of Pensions. CARE OF NEURO-PSYCHIATRIC CASES. Among the diseases and disabilities arising under the stress of mil- itary training and modern conditions of warfare are special diseases affecting the mind and nervous system. The treatment and care of these disorders require special knowledge of the problem involved. To master the principles of these problems, close application to the 38 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. study of mental and nervous diseases is imperative. The very nature of these disorders therefore makes it necessary that special treatment and hospitals be provided for their cure. e THE MAGNITUDE OF THE PROBLEM. - ft Authentic but unofficial information has been obtained.as to the number of men discharged by the United States Army for mental and nervous disabilities as of August 12, 1919. A census has also been made of the number of such disorders under treatment in the United States Army general hospitals on the above-mentioned date. Some idea of the magnitude and scope of the demands which the Bureau of War Risk Insurance will make on the Public Health Serv- ice in the matter of care and treatment of nervous and mental diseases may be obtained by reference to Table No. 1. Table No. 1—Neuro-psychiatric disorders coming under the observation of the Medical Corps of the United States Army during the war with Germany. Injuries and diseases, general nervous system. Fndo-crino-path-ics. Fpi-lepsy. Psycho-neuro-ses. In-sane. Inebri-ates (drugs, et al.) Feeble-minded. Consti-tutional psycho-inferiors. Total. Discharged as of Aug. 12, 1919................... 7,213 4,823 6,940 45 13,626 318 11,241 1,303 1,858 22,355 183 6,462 147 74,590 1,998 Under treatment at United States Army general hospitals, Aug. 12,1919................ Total.............. 7,213 4,823 6,985 13,944 12,544 1,858 22,538 6,609 76,588 It will be observed from the foregoing table that 76,588 men have been or are about to be relieved from duty with the Army because of nervous and mental disorders. NCIDENCE OF NERVOUS AND MENTAL DISEASE IN THE ENTIRE MILITARY PERSONNEL. In order to determine the number of cases of such diseases that are likely to be discharged from the Army, Navy, and Marine Corps, it is necessary to determine the incidence of such diseases among the entire mobilized military personnel. It is believed that a definite rate of frequency of these disorders may be determined from the large number of men involved. Taking the total Army personnel as strength and the number of mental and nervous diseases occuring among them as the factor, the rate of such diseases among the mil- itary population is 191.4 per 100,000 or almost two in every 11,000. This rate appears to be exceedingly high but it must be remem- bered that it represents the accrued cases from birth to 25 years of age, this being the average age of the man comprising the military population. On the basis of five per 1,000 the rate of feeble- mindedness in the general population, 20,000 mentally defective per- sons should have come under the observation of the military author- ities. From the ages of 10 to 25 years, a decade and a half, one case of nervous and mental disease should have occurred each year in each 1,000 of the general population. On this basis, the total ex- ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 39 dected accrumerit of nervous and mental diseases amongthe military forces should have been 80,000 cases. However, on the basis of 191.4 mental and nervous cases occurring in each 100,000 mobilized troops there should have come under observation 91,872 such cases. It is known, however, that a number of persons suffering from mental and nervous diseases were not enrolled or accepted for ser- vice. Of the total nervous and mental diseases coming under the observation of the Surgeon General of the United States Army, 39,285 served three months or more. The number of cases falling within certain broadly classified groups is shown in the following table: Table No. 2.—Neuro-psychiatric diseases serving three months or more with United States Army. Injuries and diseases to the central nervous svstem......................... 4, 050 Epilepsy...................................".............................. 3, 915 Psychoneureses.......................................................... 7, 830 Insane............................................:....................... 7,155 Feeble-minded...............'............................................ 12, 645 Constitutional psychopathic state.......................................... 3, 690 Total..............................................................39, 285 These 39,285 persons represent the actual known number of cases that will probably be eventually compensated for mental and nervous disabilities under the war-risk insurance act and who will also become beneficiaries of the Public Health Service. But recently proposed additional legislation indicates that all men when once accepted by local boards as sound, but eventually rejected by camp surgeons as unsound, will come under the war-risk insurance act, and will therefore be compensable and qualified for hospital relief. In view of which, hospitalization figures have been based upon the total cases of mental and nervous diseases observed, namely, 76,588. INJURIES AND DISEASES TO THE CENTRAL NERVOUS SYSTEM. After reviewing the type and character of 7,213 nervous diseases that will become beneficiaries of the War Risk Insurance Bureau it is found that 45 per cent are mild cases and will not require hospital residence; of the remaining 55 per cent, three-fifths will require hos- pital residence during the year ending August 1, 1920, the average residence of each case being six months. The Public Health Service should therefore provide 1,190 beds for the care of such cases during the year ending August 1, 1920. EPILEPTICS. Of the 6,940 epileptics beneficiaries of the War Risk Insurance Bureau, 10 per cent will become permanent residents of hospitals during the year following their discharge. In addition thereto 10 per cent of the 6,940 cases will be in the hospital on any one day of the year, therefore of the total epileptics entitled to treatment 1,388 beds should be provided during the year ending August 1, 1920, for the care of this class of patients. 40 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. FEEBLE-MINDED. There is another and large group of cases who will eventually become dependent and require institutional care. This group com- prises the feeble-minded, of whom 12,530 are potential beneficiaries of the service. Approximately 10 per cent of these will require institu- tional supervision during the year ending August 1, 1920. During the next ensuing 20 years at least 40 per cent of these cases will require institutional care and supervision. Therefore approximately 1,900 beds will eventually be required for the care of this class of beneficiaries. PSYCHONEURESES. Of the 13,944 psychoneureses cases requiring care, 50 per cent will recover during the year ending August 1, 1920. Of these recoveries 10 per cent will recur each year. Only 20 per cent of the total requir- ing treatment will accept it during the first year following demobili- zation. The total number of beds required for the care and treatment of this disease during the year ending August 1, 1920, is estimated to be not less than 2,250, the average residence of the 4,500 cases treated during that year being six months. INSANE. Of the 12,544 insane cases entitled to treatment, 40 per cent will be cared for by relatives, friends, and agencies other than the Government; 60 per cent will require hospital care during the year ending August 1, 1920. Of the number requiring hospital care, 40 per cent of the total will be daily occupying beds, making a total of 3,010 beds to be provided for the insane during the year ending August 1, 1920. CONSTITUTIONAL PSYCHOPATHICS STATE. There now remains to be considered a group of cases that have been designated constitutional psychopathic state. The Public Health Service will eventually be required to care for at least 50 per cent of these persons because of the occurrence of periodic attacks of mental derangement. It is estimated that 20 per cent of the 6,609 such cases will require treatment during the year ending August 1, 1920. These cases will remain in the hospital an average of nine months, thus making a total of 4,332 beds required for the care of the insane. During the year ending August 1, 1920, the United States Public Health Service will be asked to furnish the following number of beds for the care and treatment of mental and nervous diseases: Diseases and injuries to central nervous system............................. 1,190 Epileptics................................................................ 1,388 Feeble-minded.......................................................... 1( 900 Psychoneureses.......................................................... 2, 250 Insane.................................................................. i\ 332 Total.............................................................. 11, 060 Of the 4,800,000 men and women comprising the military popula- tion of the United States during the war with Germany a certain number of new mental and nervous diseases will occur each year. The service must therefore provide for this group of cases that will occur from year to year. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 41 Some idea of the number of new insane cases' occuring from year to year may be gathered from the following table: New admissions to hospitals for insane for certain age groups. Age groups. Rate per 100,000 of general popula-tion of same age newly admitted to New York State hospitals. 20 to 24 years............. 62.8 70.6 80.1 90.8 92.1 106.4 161.2 25 to 29 years............ 30 to 34 years.......... 35 to 44 vears.......... 45 to 54 years.............. 55 to 64 years.......... 65 and over............ It is usual to estimate that one new case of nervous or mental disease, which includes the insane, will occur in each 1,000 of the general population. A glance at the foregoing table is convincing •of the conservatism of this estimate. The number of cases of nervous and mental diseases that the Public Health Service will probably have as its beneficiaries from year to year from the military population as the. result of the war with Germany is shown in the attached graph. The number of beds required for each type of neuro-psychiatric disorder is also shown in the same graph. AFTER-CARE. There remains to be considered the needs, of the patients dis- charged or paroled from the special hospitals required for the care and treatment of these disorders. The Government must continue to assume the responsibility for the welfare and rehabilitation of these cases in their homes and in the community. Paid workers must therefore be employed to determine the environment to which cases are going after leaving the hospital. Work must be found for them and advice and counsel provided. Mental clinics should therefore be established for this purpose. 'These mental clinics would serve the discharged man as well as the community in general. The establishment of such clinics would serve a true purpose in mental hygiene. It is believed that these mental clinics should serve as out-patient departments of the several State hospitals throughout the country, the State assuming the responsibility of establishing a clinic, the Government referring its cases for special examination and a reasonable fee being paid for services rendered. These clinics could therefore be utilized by the general population. TUBERCULOSIS. One of the fundamental subjects that must be determined is what constitutes tuberculosis in a degree sufficient to be compensable. Some standard must be determined as to what the word "tubercu- losis" should be applied. As far as the Bureau of War Risk Insurance is concerned, a man who shows present active tuberculosis, after having served, is recog- 42 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC nized as having been reactivated by service, although The Adjutant General's Office may be silent on his lung record while in the service. This is based upon the known reluctance to mark a man's discharge papers as being consumptive when discharged; and also to the proven fact that the disease is seldom contracted after maturity. The epidemic of influenza occurring synchronously with the draft exposed many men to infection during the period of trial before they were finally accepted by the service as soldiers or sailors. These men, who were finally not connected with the Army, have formed a large part of the border-line cases that have reached this bureau of claims. The large incidence of tuberculosis among Negro stevedores account for 14 per cent of the entire number of tuberculosis patients return- ing from abroad and probably a large proportion of the 500 deaths reported of tuberculosis on the other side. From available data, the total number of active cases of tuber- culosis (all forms) which will result after demobilization has been completed, including those cases which were sent to mobilization camps and there rejected by camp surgeons, will be approximately 46,000. Of this number approximately 18,000 men were rejections at mobilization camps. Thus there will have been observed 28,000' cases in the several services. That this figure is approximately correct is shown by the following; data: Known active cases of tuberculosis. Discharged on S. C. D., 1917.............................................. 3, 82S Discharged on S. C. D., 1918............................................... 9,434 In Army and general hospitals, August, 1919................................ 4, 200' Invalided home, United States Navy....................................... 1, 779* In naval and general hospitals........................................____ 812 Marine Corps (estimated)................................................. 590 Total present cases.............................................____ 20, 638 From this total there must be subtracted the deaths which have occurred to date. No accurate data of such is available. Never- theless, among young male adults as a whole, the annual death rate from tuberculosis is approximately 2.5 per 10,000 living persons. With a total maximum armed force of 4,800,000, it is probable that there would occur from September, 1917, to September, 1919, some 2,200 deaths. Thus the total known cases is cut down to 18,438. This does not include, however, those cases discharged from the Army and Navy during 1919 on which no data is available. This figure might well bring the total known cases up to the estimated 28,000 previously noted. It is therefore reasonable to state that the total number of tuberculosis cases will approximate 46,000. In addition to these cases there will be those cases which will develop within the next two years, and each year thereafter. The importance of the latter factor can only be determined by the future policy of the Bureau of War Risk Insurance. If the bureau is to recognize all claims of tuberculous men, regardless of when incurred,. the problem will be tremendous. A perspective of the magnitude of such a problem can be obtained by applying the accepted state- ment that 7 per cent of all deaths are from tuberculosis. This would! mean an accumulated total of more than 300,000 cases. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 43 It is at least probable that the bureau will care for all tuberculous claimants who present claims within the next two years. Among 4,800,000 soldiers, sailors, and marines there developed in one year approximately 10,300 cases of tuberculosis. This would mean that 2.5 per 1,000 developed each year. Estimating that there will be at 26 years of age 6,400 deaths each year, it would mean that about 4,000 additional cases of tuberculosis will develop each year among ex-service men. This figure is maintained for several years with but slight variation. On the basis that only those cases which developed in the service, namely, 28,000, will be compensable, it is arbitrarily estimated that not more than 20,000 will accept hospital relief. Experience indi- cates that the tuberculosis sanatorium patient spends approximately 135 days in the hospital each year. If this situation prevailed among war-risk patients, there would be necessary each day, not taking accounts of deaths, about 7,400 beds. The following statement can be made relative to necessary beds: Number of cases. Probable daily beds. For known cases to date............. For cases rejec ted by camp surgeons. 28,000 18,000 7,400' 5,000 The accompanying chart shows the estimated expectation for cases of tuberculosis with the corresponding hospital beds required for each year, beginning with the year 1920. Death rates for the various ages from tuberculosis are those cal- culated for males of the registration area by the Prudential Life Insurance Co. Incidence rates have been arbitrarily assumed, based on the experience in the Army for the year 1918, with a gradual reduction of such a rate after a 10-year period. The great problem will be not only proper hospitalization of dis- abled men, but proper supervision of those able to be about and the protection of their families. To follow each one into his home would no doubt be inquisitorial and irritating, but to supply them with proper instruction in methods of living should be our duty and privilege. As to the average period a patient of the age period between 21 and 30 will be expected to remain in a hospital, it is very variable. A fair estimate would be eight months from hospitalization. The well- known tendency to migrate, and restlessness, together with the lack of authority to retain, even after they are careless, and become a menace to the community, will account for this. Another factor that will lengthen the stay is that the age of com- mencement will be much younger than is the case in the usual civil hospital. The Negro element will, of course, provide the largest pioportion of acute and rapid cases, only exceeded by the small number of Indians. GENERAL SURGERY. It has proven most difficult to form any reliable estimate as to the amount of surgical work which will be necessary among future war- risk insurance claimants. 44 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. To date there have been reported 291,000 casualties in the United States Army, 200,000 of which are wounds. What percentage of these will be completely healed by time of discharge can not be stated. Furthermore, of 113,500 discharges during 1918, 16,412, or nearly 15 per cent, were surgical diseases or conditions, which would mean that of all discharges for disability by disease some 45,000 would be of a surgical nature. This does not include those 200,000 men rejected at mobilization camps. While most of the surgical diseases and condi- tions will probably be compensable, present hospitalization indicates, Earticularly in the case of wounds, that relatively few will need ospitalization. The wounds reported have been mostly wounds of the leg, thigh, hand, forearm, shoulder, and chest, the percentage being from high to low in the order named. The machine-gun bullet wounds reported have been mostly of the lower extremities. Wounds of the chest, shoulder, back, and abdomen seem to have been mostly shrapnel wounds. Wounds involving joints have resulted in ankylosis, of which prognosis is generally not good. Wounds of the hands, re- sulting in minor amputations, have often been disabling because of the fact that the stumps were tender, as many of these operations were done hurriedly. The surgical cases which can not be classified as wounds are as follows: Abdominal: Abscess. Adhesions. Appendicitis. Bone injuries. Burns. Bursitis. Carbuncle. Cellulitis. Deformities. Dislocations. Rib resections. Fistulee. Crushes. Fractures. Hernia, post operative and chronic, many of "which existed prior to induction into the service, or aggravated by service. Necrosis. Tuberculosis of joints, most of which ex- isted prior to induction into military service, or aggravated by service. Sprain. Strains. Stricture. Synovitis. Tumor, benign and malignant. Ulcer. Phlebitis. Many of the draftees who suffered from curvature of the spine or ankylosis of joints, broke down under military exercises, and were finally disabled, and when discharged were in much worse physical condition than they were before entering the service. This was true of nearly all tuberculous conditions. It may be stated that the strenuous life of military service did not improve the physical condition of any men who had other than functional disorders. A class of claimants has come up for which, no doubt, legislation pending at the present time will afford some relief, who at present are left very poorly provided for, i. e., those select men who were not accepted for military training and finally discharged. Some of these select men were refused for voluntary enlistment, but afterwards taken in the draft, sent to camps, and were allowed to remain there for several months. Therefore the surgical work of the United States Public Health Service hospitals is doubly difficult because it involves reconstruction of men who had been thoroughly broken down physically before they ■came under the care of the service. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 45 It may be stated in this connection that many service men clamored for their discharges after the signing of the armistice, and were dis- charged in a disabled condition because thev had developed what might be termed "hospital phobia" and a general dislike for military service. As to the statement of physical condition given on discharge papers, it is the fact that this is of very little value except where a specific statement of wounds received has been entered on the paner. In nearly all instances it has been necessary to request an abstract of the medical record of the claimant where his application for com- pensation had shown physical condition good on separation from the service. In most instances, the claimant's hospital record has been proof that he was disabled at the time of his discharge. This is true of a large percentage of the cases where abdominal opera- tions have been performed, as the claimant may suffer from post- operative hernia or post-operative adhesions. It is obvious that reconstruction work of this class of claimants is very difficult, and requires the services of the most skilled surgeons. This especially applies to orthopedic cases, as many s°rvice men, in their desire to return to civilian status, cut short the period of re- construction treatment, and took their discharge from the service at the earliest possible moment. Many of this class of claimants will submit themselves to hospital- ization at a later date, because at present they are loathe to leave remunerative employment to take treatment, the good results of which can not in all cas s be guaranteed. There should be established in at least every State for the treat- ment of this class of claimants a clinic of the United States Public Health Service following the general plan of the Clinic for Functional Reeducation of New York City. In most cas s of wounds, it will be necessary to reexamine these claimants from time to time, to note improvement or deterioration in their physical condition. This is especially true of high explosive shrapnel wounds, in which fragments of metal are still embedded in the tissues. The sharp edges and irregular contour of these fragments do not lend themselves to permanent incapsulation, as would be the case of a rifle bullet embedded in the tissues. Therefore these wounds will break down from time to time, and the claimant will need rehospitalization. It is, therefore, strongly urged that at least one surgical bed be provided for each thousand service men. PROSTHETICS. The following is a report of the work of the prosthetic section, to date: Total number of major amputations reported by the Army................ Total number of amputations that have come under the attention of the pros thetic section, to date................................................ Number of beneficiaries with amputated legs, under observation..........., Number of legs ordered and delivered................................... Number of legs ordered but not yet delivered............................. Amputations of legs for which no order has been issued................... Number of beneficiaries under observation with amputated arms........... Arms ordered and delivered............................................ Arms ordered but not yet delivered...................................... Arms not ordered....................................................... 3,800 2,157 1,229 428 461 340 923 381 503 44 46 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC, A number of beneficiaries were fitted with permanent artificial legs before pressure atrophy was complete, for the reason that the temporary artificial legs furnished were no longer serviceable through breakage or not fitting properly. This will necessitate refitting these beneficiaries in the future with another permanent artificial leg, or rebuilding the socket of the leg already furnished, to fit the amputation stump accurately. The board of orthopedic surgeons, convened by the Director of the Bureau of War Risk Insurance for the purpose of detei mining the best specifications for artificial legs, recommended that each beneficiary be furnished with two legs, in order that he would have a good leg in reserve, in case of breakage. It is believed that all of these beneficiaries should be refitted within six to eight months, and that alterations in the socket of the original permanent leg, that may be necessary, should be made, in order that it will fit accurately and serve as a reserve leg for the beneficiary. It was also recommended by the board of orthopedic surgeons that beneficiaries be furnished a light arm with a Dorrance hook attach- ment, in addition to the arms with mechanical hands, which the beneficiaries are selecting. This Dorrance hook can not be attached to the arms with the mechanical hands. Since this hook is exceed- ingly useful and can be furnished with a light arm, at a cost approxi- mately one-fourth that of the permanent arms with mechanical hands, it is believed that each beneficiary should be fitted with this device for practical use. GENERAL MEDICAL CASES. Of the original 513,000 cases there have been, in accordance with the foregoing data, accounted for the following number of cases: Tuberculosis............................................................. 46, 310 Surgical cases (estimated)................................................ 75, 000 Eye, ear, nose, and throat................................................. 62, 869 Mental and nervous....................................................... 76, 588 Miscellaneous............................................................ 22, 847 Total.............................................................283, 612 There thus remain 229,388 cases which will be classed as general medical cases. More than 50 per cent of this number are diseases or conditions among men rejected at demobilization camps, chief of which are diseases of the circulatory and digestive systems. The extent to which these cases will be a problem will depend largely upon the future policy of the bureau. However, even if many of these cases prove compensable, the ex- tent of hospital relief will be slight, and the length of stay of such patients in hospitals would be relatively short. Therefore of the 229,388 cases there remain approximately only 115,000 cases which can be called general medical cases which are dis- charged as such from the service. The only acceptable method to use to determine the amount of hospitalization these cases would need for the next few years is to apply the present figures of general medical cases in hospitals to the number of either mental and nervous cases or tuberculosis cases, and ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 47 apply that proportion to the estimated number of beds for the future, determined by one of the other two classes of disease. Thus: Number of general medical and surgical cases hospitalized....................2, 010 Number of neuro-psychiatric cases hospitalized............................... 2, 002 That is, at present the number of general medical and surgical cases in hospital is the same as the number of neuro-psychiatric cases. If this ratio is maintained, then the estimated future necessary beds for neuro-psychiatric beefs will approximate the number of beds necessary for general medical and surgical cas s, or 7,135. It is estimated that beds necessary for surgical cas^s will be about 1 per 1,000 enl'sted men (not including Regular Army), or approximately 4,000 beds. Then the number of beds estimated as necessary for medical cas s will be 3,200. Because of the nvagerness of data from which to work, it is im- possible to chart the probable number of expected cases with nece ssary hospital beds for this class of diseas-s and conditions from year to year. It is logical however, to assume that the maximum bed capacity will be during the first two years (1920-1921) and that thereafter there will be a decided decline in both cases and corresponding hospital beds until the late middle age, when there will be an increase due to the greater incidence of so-called organic diseases (diseases of circulatory system, cancers, etc.) It is safe to presume that such an increase will in no way approximate the number of cases noted during 1920- 1921. VENEREAL DISEASES. Attention is invited to thp phrase: ''Because of his own willful misconduct, involving moral turpitude," included in section 31, H. R. 8778, quoted early in this report. Upon the interpretation of the meaning of this phrase will depend largely the question of furnishing treatment and hospitalization for the tens of thousands of cas- s of venereal diseases occurring among the military and naval forces of the United States. The importance of the proper interpretation of this question can best be judged by the consideration of the magnitude of the incidence of this class of dis^as^s. The incidence of venereal dis^ascs in the Army has been estimated by the Surgeon General's Office to be 8 per cent of the military strength. This is borne out by the following data: The accumulated number of cas^s of venereal diseases among troops in the United States only, as reported in the weekly telegraphic re- ports to the Surgeon General of the Army from September 1, 1917, to September 19, 1919, was 240,535. To this total must be added the number of cas s occurring among men in the American Expeditionary Forces. No accurate data on this number is available, but a conserva- tive estimate would be 75,000. In addition, there were several thou- sand cas s among men accepted by local draft boards but rejected at mobilization camps by camp surgeons. Furthermore, there will be those cas'S of Venereal ehVas^-s which originated among men in the United States Navy and in the United States Marine Corps, though the incidence among these two corps is apparently less than in the Army. It can therefore be conservatively estimated that among the total military and naval forces of the United States, there have occurred nearly 400,000 cases of venereal diseases. While it is true that prob- 4 8 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. ably 60 to 75 per cent of theso cases existed prior to induction into service/nevertheless these men were accepted by draft boards as in sound condition, and thus many of them are potential claimants under the war-risk insurance act. Of the total number of cases reported the following approximate classification of specific diseases can be made: C"................................................:".:::::::»SSS SheaV.:::::::::::::::::::::::::::::::::::::::::::::............ra^^t Although the reports of the demobilization boards indicate that not more than 50,000 cases of venereal diseases, per se, are noted among discharged men, it is probably true that many cases were missed by the examining officers, or that many cases which are at the present time inactive will be reactivated. Thus it is seen that the problem of venereal disease may be enor- mous, dependent upon the construction which the legal authorities will place upon the phrase "Not due to his own willful misconduct involving moral turpitude." It would seem that the burden of proof of "willful misconduct involving moral turpitude" must of necessity rest upon the Government. To stigmatize a man suffering from a venereal disease by saying that the disease was contracted because of his "moral turpitude"1 when that man had obeyed the prophylactic regulations of the Army or Navy, or if that man had contracted the disease prior to his enlistment in the service, would be a task which no court or man would care to undertake or dis- charge with justice. Moreover, it is believed that in the long run it will be economy to promptly treat all cases of venereal diseases occurring among ex- service men. The bulk of these men are insured. Any reasonable measure that may be undertaken for the prolongation of their lives will result in a longer premium-paying period, and will therefore lessen considerably the loss which will accrue upon maturity of the policies. Furthermore, a considerable number of these men suffer from obscure symptoms which it will be difficult to connect defi- nitely with venereal diseases and they will be able to draw compen- sation thereon. The prompt scientific treatment of these men now is a measure of prevention which will reduce to a considerable extent future cases of locomotor ataxia, insanity, blindness, rheumatism, and a host of ailments which it will be difficult to prove were not the result of military service. Cure of these men in the early stage of these diseases is therefore necessary from the standpoint of economy,, justice, and public health. GENERAL CONCLUSIONS. The foregoing data has indicated that hospitalization must, in all probability, be planned in accordance with the following statement: Number of beds, neuro-psychiatric......................................... 11,060 Number of beds, tuberculosis............................................. 12,400 Number of beds, surgery......................................-.......... 4,000 Number of beds, general medical......................................... 3, 20O Total number of beds............................................. 30, 66a ' Moral turpitude is defined as an act of baseness, vileness.or depravity in the private or social duties which a man owes to his fellow man or to society in general, contrary to the accepted and customary rules of right and duty between man and man; anything which is contrary to justice, honesty, modesty, or good morals may be classed as moral turpitude. ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 49 The data given in the succeeding pages is made up from all re- ported date to date on hospital facilities, both of United States Public Health Service Hospitals and private hospitals. In the con- clusion estimates are made as to the number of additional beds necessary to be provided, in the light of figures here presented. Periodic reports are made to the United States Public Health Service on the number of beds available in private hospitals through- out the country, by district and by specific condition accepted, for War Risk Insurance patients. The data tabulated below give the consolidations of all such re- ports received to date (Sept. 15, 1919). Synopsis of private hospitals, by districts. General. Bed capacity. Tuber-culosis. Bed capacity. Neuro-psychi-atric. Bed capacity. Total. District. Hos-pitals. Beds available. District No. 1........ District No. 2........ District No. 3........ District No. 4........ District No. 5........ 60 33 24 52 29 23 57 166 32 None. 6 78 1 19 None. 1 951 453 723 677 318 483 505 2,202 342 25 29 11 13 5 12 12 21 5 402 623 690 150 64 152 302 377 55 16 6 6 14 434 70 220 376 101 68 41 79 34 41 72 203 41 1,787 1,146 1,632 1,203 382 District No. 6........ District No. 8........ District No. 9........ District No. 10....... 6 3 16 4 44 23 300 137 679 890 2,879 534 District No. 11....... District No. 12....... District No. 13....... District No. 14....... 15 793 10 2G0 8 28 1 6 150 407 25 48 1 8 1 3 40 269 21 15 114 3 28 205 1,409 35 329 District No. 16...... 50 1 50 Total.......... 581 7,782 176 3,505 84 1,934 841 13,220 1 No definite statement of number of patients. The weekly census report of the Public Health Service Hospitals for the week ending September 13, 1919, show that of 4,384 patients under treatment approximately 80 per cent or 3,442 are war-risk insurance patients. Available beds for this week number 4,623. Presuming that 80 per cent of these will be taken by war-risk insurance patients, it would mean that 3,700 of these beds are available for such. There are in addition planned 2,790 additional beds, which would make 2,231 more beds available to war-risk insurance patients. Thus, the total number of beds of the United States Public Health Service available to war-risk insurance patients are as follows: Occupied.................................................................... 3,442 Available at present...................................................... 3, 700 To be available soon........................................................ 2,231 Total.........................................-.......................... 9,373 H. Doc. 481, 66-2—4 50 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Totals, by districts, for hospitals, United States Public Health Service,1 differentiation as far as possible by diseases accepted. General. Bed capacity. Tuber-culosis. Bed capacity. Neuro-psychia-tric. Bed capacity. Total. District. Hos-pitals. Bed capacity. 4 4 1 4 4 3 3 4 1 525 893 48 454 790 1,366 150 675 556 1 2 1 240 400 672 5 6 2 4 5 3 3 5 2 765 District No. 2........ 1,293 District No. 3........ 720 454 1 988 1,778 District No. 6........ 1,366 District No. 7........ 150 District No. 8........ 1 188 863 District No. 9........ 1 73 629 District No. 10....... District No. 11....... 1 1 173 800 1 2 1 1 173 District No. 12....... 1 1 1 120 74 188 920 District No. 13....... 74 District No. 14....... 188 District No. 15....... District No. 16....... Total........... 31 5,839 4 2,034 5 1,500 40 9,373 1 All figures for bed capacity have been calculated on the basis that 80 per cent of the total number of beds in hospitals listed will be available to war-risk insurance patients. Synopsis of hospitals by districts, United States Public Health Service hospitals, State and private hospitals—reported available beds for war-risk insurance patients. General. Tuberculosis. Neuro-psychiatric. Total. District. Hos-pitals. Beds. Hos-pitals. Beds. Hos. pitals. Beds. Hos-pitals. Beds. District No. 1........ District No. 2........ District No. 3........ District No. 4........ District No. 5........ 64 37 25 56 33 26 60 170 33 P) 6 79 2 20 P) 1 1,476 1,346 771 1,131 1,108 1,849 655 2,877 898 (l) 15 913 84 448 P) 50 25 29 11 13 6 12 12 21 6 P) 9 29 1 6 P) 402 623 690 150 1,052 152 362 377 128 P) 323 1,207 25 48 (l) 17 8 7 14 674 470 892 376 106 74 43 83 39 44 75 208 43 (l) 16 116 3 47 P) 1 2,552 2,439 2,353 1,657 2,160 District No. 6........ District No. 7........ District No. 8........ District No. 9........ District No. 10....... District No. 11....... District No. 12....... District No. 13....... 6 3 17 4 P) 1 8 44 23 488 137 P) 40 269 2,045 1,040 3,742 1,163 P) 378 2,389 109 District No. 14....... District No. 15....... District No. 16....... 21 P) 28 P) 524 P) Total.......... 612 13,621 180 5,539 106 3,441 898 22,601 ' None reported. Thus, it is noted that in all there have been reported 898 hospitals with a bed capacity of 22^01 available to patients under the war- risk insurance act. Thus, 22,601 beds are divided, as far as possible into: General cases...............---........;................................ 13 621 Tuberculosis................................................................ 5J 539 Nervous and mental cases................................................. 3' 441 Total.............................................................. 22,601 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 51 The following table shows, by large groups of diseases, the number of patients at present hospitalized; the estimated average number to be hospitalized at any one time through the year of 1921; the number of beds reported as available for war-risk insurance patients, and the total number of beds in the United States; figures are given in per per 1, 000 rates, and in absolute numbers: Table.—Rates per thousand. Actual num-ber in hospi-tal per 1,000 enlisted strength Sept. 20, 1919. Estimated nn m her daily hospi-tal patients 1920-21, per 1,000 enlisted strength. Available beds in U. S. Army, in-cluding U. S. Public Health Serv-ice hospitals per 1,000 enlisted strength. Total hospi-tal beds, U. S. Army per 1,000 total population. Mental and nervous diseases.................. Tuberculosis................... 0.500 .521 .502 2.76 3.17 1.80 0.8*5 1.40 3.40 2.38 .37 General....................... 2.55 Total................................... 1.53 7.65 5.52 5.30 ABSOLUTE NUMBERS. 2,002 2,010 2,132 11,060 12,COD 7,100 3,441 5,539 13,621 244,012 37,691 261,345 Total............................ 6,144 30,660 22,601 543,048 RESUME. (a) From the foregoing data it is seen that a little more than 20 per cent of the expected number of patients are at present hospital- ized at any one time. 1.53 per 1,000 enlisted men are now hospital- ized, and 7.65 per 1,000 are expected. (b) The total reported number of beds available per 1,000 enlisted men closely agrees with the total number of beds in the United States per 1,000 total population. As is to be expected, this number is not sufficient. (c) The number of beds available for general cases is more than it is expected will be required, while the number of beds available for mental and nervous diseases and tuberculosis are insufficient. CONCLUSION. 1. The total number of beds made available by the United States Public Health Service and private hospitaM for war-risk insurance patients at the present time, namely, 22,601, is insufficient, and such a total must be increased by approximately 8,000 to make up the desired total of 30,660. 2. The number of beds available at present for general medical and surgical cases, namely, 13,621, is too great by approximately 6,400. Only 1,360 more beds than are at present furnished by Public Health Service hospitals (making a total of 7,200) are necessary. 52 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 3. The number of beds at present available for neuro-psychiatric cases, namely, 3,441, is insufficient, and such a total must be increased by approximately 7,600 to make up the desired total of 11,060. 4. The number of beds at present available for tuberculosis cases, nameh^, 5,539, is insufficient, and such a total must be increased by approximately 7,060 to make up the desired total of 12,000. W. C. Rucker, Chief Medical Advisor. Respectfully forwarded, approved Oct. 6, 1919: R. G. Cholmeley-Jones, Director Bureau of War Risk Insurance. Respectfully forwarded, approved: JOUETT SlIOUSE, Assist int Secretiry. ADDENDUM. Tn the following tables are contained data on total hospital beds throughout the United States (as reported by the American Medical Association) in their relation to the total population of the United States, and to the number of service men. The number of hospital beds is first given in total, to be followed by classifications of such beds in accordance with the type of diseases or conditions for which they are intended. Number of beds. Population. Rate per thousand. Number of service men. Rate per thousand. TOTALS. District: 1...................................... 46,488 107,525 41,545 33,704 27,258 14,869 56,555 78,269 40,002 26,029 11,821 28,019 15,864 24,622 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,692,529 8,171,119 7.966 7.580 4.860 6.370 . 2. 753 1.859 5.542 6.778 4.600 6.377 6.123 8.769 5.886 3.003 232,166 584,137 321,282 204,064 332,312 201,554 388,808 516,328 358,154 203,350 83,981 148,382 110,330 324,281 2...................................... 3...................................... 4..................................... 5...................................... 6...................................... 7................................... 145.346 151.842 111.606 128.063 140.670 188. 848 143.728 75.836 8...................................... 9...................................... 10..................................... 11................................ 12..................................... 13................................ 14..................................... Total................................ 552,570 102,399,218 5.393 4,009,129 137.590 SURGICAL. District: 1...................................... 259 895 350 203 403 204 575 222 337 201 5 26 125 441 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,692,529 8,171,119 .044 .063 .041 .039 .041 .026 .056 .019 .039 .049 .003 .008 .046 .054 232,166 584,137 321,282 204,064 332,312 201,554 388,808, 516,328 358,154 203,350 83,981 148,382 110,330 324,281 1.116 1.530 1.088 .995 1.213 1.012 1.478 .431 .940 .989 .059 .175 1.132 1.358 2................................. 3................................ 4.............................. 5............................... 6............................... 7................................. 8............................... 9.................................... 10............................... 11................................. 12..................................... 13................................. 14................................... Total................................ 4,246 102,399,218 .041 4,009,129 1.057 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. 53 Number of beds. Population. Rate per thousand. Number of service men. Rate per thousand. TUBERCULOSIS SANATORIA. District: 1..................................... 3,554 11,058 4,477 1,128 1,186 395 2,475 4,770 1,155 1,894 2,710 1,570 656 663 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,092,529 8,171,119 .608 .780 .519 .215 .120 .049 .241 .413 .133 .464 1.404 .491 .243 .081 232,166 584,137 321,282 204,064 332,312 201,554 388,808 516,328 358,154 203,350 83,981 148,382 110,330 324,281 15.318 2..................................... 18.909 3..................................... 13.923 4..................................... 5.517 5..................................... 3.570 6..................................... 1.959 7..................................... 6.360 8..................................... 9.254 9..................................... 3.224 10.................................... 9.318 11..................................... 32.249 12..................................... 10.582 13..................................... 5.943 14..................................... 2.042 Total................................ 37,691 102,399,218 .368 4,009,129 9.385 EYE, EAR, NOSE, AND THROAT. District: 1..................................... 319 727 59 419 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,692,529 8,171,119 .055 .051 .007 .080 232,166 584,137 321,282 204,064 332,312 201,554 388,808 516,328 358,154 203,350 83,981 148,382 110,330 324,281 1.375 2..................................... 1.243 3..................................... .183 4..................................... 2.053 5 ................. 6..................................... 152 144 432 722 25 11 40 712 15 .019 .014 .037 .083 .006 .005 .013 .264 .002 .754 7 ................................. .370 8..................................... .838 9 ................................ 2.014 10................................... .123 11 .................................. 1.309 12 ....................... .270 13 .................................. 6.451 14..................................... .046 3,777 102,399,218 .037 4,009,129 .940 GENERAL. District: 20,208 46,070 17,812 16,210 11,950 6,703 28,485 33,361 21,034 13,852 6,892 16,971 9,725 12,072 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,692,529 8,171,119 3.456 3.248 2.066 3.096 1.207 .838 2.777 2.885 2.419 3.394 3.570 5.312 3.608 1.473 232,166 584,137 321,282 204,064 332,312 201,554 388,808 516,328 358,154 203,350 83,981 148,382 110,330 324,281 87.096 78.786 55.395 79.429 35.969 33.247 73.206 64.720 58.685 68.152 82.015 114.185 88.108 37.182 261,345 102,399,218 2.551 4,009,129 65.075 GYNECOLOGICAL. District: 151 481 225 372 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,692,529 8,171,119 .026 .034 .026 .071 232,166 584,137 321,282 204,064 332,312 201,554 388,808 516,328 358,154 203,350 83,981 148,382 110,330 324,281 .651 .822 .699 1.823 40 152 .004 .013 .113 .295 72 .026 .485 eo .001 .024 1,499 102,399,218 .015 4,009,129 ,373 54 ADDITIONAL HOSPITAL FACILITIES FOR DISCHARGED SOLDIERS, ETC. Number of beds. Population. Rate per thousand. Number of service men. Rate per thousand. INSANE. District: 1..................................... 21,997 48,294 18,622 15,372 13,719 7,415 24,836 39,332 16,754 10,057 2,203 9,340 4,646 11,425 5,835,678 14,191,991 8,595,590 5,241,108 9,937,310 8,029,361 10,251,954 11,558,494 8,678,672 4,085,944 1,931,164 3,198,304 2,692r529 8,171,119 3.761 3.405 2.160 2.936 1.386 .927 2.241 3.402 1.927 2.464 1.141 2.923 1.724 1.394 232,166 484,137 321,282 204,064 332,312 201,554 388,808 516,328 358,154 203,350 83,981 148,382 110,330 324,281 94.807 2..................................... 82.583 3..................................... 57.914 4.............................. 75.323 5.................,.................... 41.292 6............................ 36.778 7....................... 63.828 8............................. 76.304 9................................... 46.744 10.............................. 49.480 11........................... 26.216 12.................................... 62.952 13................................ 42.093 14.................................... 35.189 Total............................ 244,012 102,399,218 2.382 4,009,129 60.758- MAP Or THE UNITED STATES SHOWING LOCATIONS OF DISTRICTS FOE ^UPkRVIMON OF WAR RISK WORR _________________________________________________,___________ .____-__ _____________________________________________________________________?.n.5.zr. —'----------------------------------------------------------------------------------~~ — ' -------------------.....—.....- - "~ ■ ' juMfm 153165°—H. Doc. 481,66-2. (Face page 54.) No. 1. 153165°—H. Doc. 481,66-2. (Face page 54.) No. 2. ��999999999993 50,000 QJ YEARS 1930 1934 1920 1924 (926 1932 1936 f940 1944 1948 1952 1956 i960 1964 1968 COMPILED BY STATISTICAL SECTIO/M MEDICAL- DIVISIOAt