Part 10

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

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

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

Dr. Dedman added that difficulty had been experienced in getting men to leave the hospital. He mentioned the case of a boy who had been admitted to the hospital with active tuberculosis, who was eventually rated as an arrested case and told that he had received the maximum benefit, that this boy did not want to leave the hospital and made a protest to his Congressman.

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

DR. EVANS: informed the Conference that there was on the Director’s desk a ruling stating that personnel from the Veterans’ Bureau will be under the commanding officers on hospitals.

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

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

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

He also stated that he appreciated the importance of the Inspector’s Department, which is of wonderful benefit to the commanding officers.

With reference to G.O. 26, he thought that the length of time prescribed is too long, as with the generality of patients who have received the maximum amount of treatment, it does not make a great deal of difference as to how much notice they have as to when they are going to be discharged, as the necessary arrangements can be made in a very short time without any inconvenience; that there is, however, a certain class of cases which very often takes advantage of the four days’ notice; that it has been his experience that when four days’ notice is given it apparently has no effect on the first day, on the second day the patient will begin to develop symptoms, on the third day the symptoms are very much increased and on the 4th day you get a letter from the patient’s Congressman.

DR. LASCHE: was of the opinion that all the authority needed is given by G.O. 27 of the Veterans’ Bureau, which gives the medical officer in charge considerable authority to enforce discipline; that the average patient, however, chafes under the word “discipline”; that the gentlemen from the Army and Navy have referred to the advantages of discipline. He stated that he was on a discharge board for soldiers after they came home from Europe and frequently heard them say: “Well, by Jove, we are away from this —— discipline now;” that with all due respect to discipline that is necessary in Army and Navy organizations, he does not believe that the same degree of discipline is necessary after these men become beneficiaries of the Veterans’ Bureau; that in a year’s time he has only had to apply the provisions of G.O. 27 on one patient who was A.W.O.L. three times for the period of twenty-four hours or more within thirty days; that he finally discharged this man, who, however, subsequently applied for readmission and was successful in obtaining it within two weeks and all the patients at the institution know that this man got back after he was discharged.

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

DR. T. R. PAYNE: thought that the hospital brand had been placed on a great many men in cases where it should not have been; that once you get a man in a hospital he is going to repeat as long as he can. He referred to a class of so-called gas bronchitis patients and stated that it is well known that during the war all a man had to do was to say he had been gassed and receive a wound stripe, and this same man is now coming in to our hospitals; that the office of The Adjutant General of the Army has no record of such men being gassed; that he has no chest pathology. He thought that these men should never have gotten into the hospitals and should have been handled outside more by psychology than by doctors and hoped that the dispensaries are going to keep these men out of hospitals; that there is no doubt in his mind that a great many neurasthenics should never have gotten into general hospitals; that the great trouble is the compensation given those men places a premium upon their hospitalization; that men are in hospital who have been discharged as having received their maximum hospitalization; that these men have been taken out of vocational training; that they would rather go back into hospital and get $80 a month and three meals a day and be entertained several times a week; that more care must be taken by doctors regarding the men they send in to hospitals.

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

DR. LLOYD: offered the following resolution, which, however, was not adopted:

“That it is the sense of this body that the Federal Board of Hospitalization recommend to the Director of the Veterans’ Bureau and to the Surgeon General of the Public Health Service the designation of an officer of each service to receive special suggestions and recommendations from the field, criticisms also of instructions contained in field orders, circular letters and similar communications; these designated officers to constitute a board for the consideration of these recommendations, with the view of recommending to the Director the adoption of such as are believed to be of value.”

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

“That these officers be detailed to the Veterans’ Bureau for a limited period, say six months; that they be field officers.”

DR. JOHNSON: moved that the resolution of Dr. Lloyd be laid on the table indefinitely, which resolution was adopted.

DR. LLOYD: suggested that it would be well to have one man of each service who could be advised as to what is the matter with certain general orders and know that such matters will not be pigeon-holed but will receive action.

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

GEN. IRELAND: stated that contemplated changes affecting the hospitalization of patients of the Veterans’ Bureau in the Army are always referred to his office for review before they are issued.

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

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

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

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

The following motion was adopted:

“That the Federal Board ask the Veterans’ Bureau to reconsider the question of bed space.”

A motion was offered, which failed of adoption, to the effect that the Director of the Veterans’ Bureau set aside a certain amount for the reimbursement of unavoidable losses of property of ex-service men in hospitals.

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

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

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

DR. HETERICK: stated that his institution is equipped with steel lockers and a small deposit required, which is returned when the patient is discharged; that the patient is told that due preparation has been made for taking care of his clothing and it is in his custody; that the installation of these lockers has reduced the theft of personal property to a minimum; that some times, however, lockers will be broken into.

The meeting adjourned at 12:30 p.m.

_Fourth Session_ Wednesday, January 18, 1922.

Present: Members of the Federal Board of Hospitalization; also, about one hundred conferees.

GEN. CUMMING, presiding, called the meeting to order.

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

“It is requested that, at the first available opportunity, the following officers confer with Dr. Maddox, “C” Building, Room 1–319, concerning urgent construction work going on at their stations:

Dr. W. H. Allen, of Boise, Idaho. Dr. W. C. Billings, of Ellis Island, N.Y. Dr. R. L. Allen, of Arrowhead Springs, Cal. Dr. A. P. Chronquest, of West Roxbury, Mass. Dr. E. R. Marshall, of Detroit, Mich.”

GEN. CUMMING: “This afternoon we are going to consider administrative policies. The first paper will be “Professional Service,” by Dr. Lavinder,”

ASST. SURGEON GENERAL C. H. LAVINDER:

“The subject that has been assigned to me is very broad in its scope, and the time is so limited, that if I may be permitted I wish to tender a written paper.” Dr. Lavinder read the article on “Professional Service”,

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

Leaving this aside and omitting much, there are some things which may be stated in a general way concerning professional service, understanding that it is presumed such service is administered in hospitals properly constructed, properly located and equipped, and operated for the particular purposes which we have in mind.

1. There are certain broad policies in this matter which are worthy of some comment.

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

It has been a general policy of the Public Health Service, of course, to seek in every way to establish in all of its hospitals standards of professional service in full accord with the best modern practice. At the same time we have sought to avoid the fostering of radical methods which might verge on the field of fads. We have preferred to adopt a somewhat conservative attitude in this regard and have been unwilling to make use of methods until they had been fairly well tried out and established as useful.

It has also been a policy, as far as possible, to establish a uniformity in professional service, at the same time doing nothing which might interfere with individual initiative. General Uniformity in professional service is desirable not only for administrative reasons, but for professional ones as well.

It goes without saying that we have felt the absolute necessity of establishing a professional service which would be reasonable in cost. The expenditure of money in professional service is, of course, wise. At the same time it has seemed to us that any professional service which could not be justified on the basis of economy was probably more than necessary.

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

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

2. With regard to the application of professional service to the actual treatment of sick in our hospitals, we have had in mind, in a general way, some rather definite things. In the organisation of our hospitals, whatever the type, we have arranged all of the professional services to meet the demands of the institution. We have attempted to adjust these professional services, so for as possible, to the need of the particular hospital and the particular class of patient treated therein and then properly to coordinate all of these various services under competent chiefs, supplemented by attending specialists. An organization so established should, we feel, meet any reasonable demands which might be made upon the institution without an undue expenditure in the matter of professional personnel.

We have established many highly specialized services, including dentistry. We have not overlooked such things as occupational therapy and physio-therapy and, of course, have taken care to supply the necessary modern laboratories, X-ray equipment and other matters which are essential in the best modern professional service.

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

We have believed in doing much of this work that it was a matter of economy as well as expediency to furnish as complete medical examination as possible. These cases are compensable cases and the matter of records as to their physical condition is of especial importance. The veterans’ Bureau has felt the need of careful and complete examinations as well as records which are dependable. Pains have been taken, therefore, so far as possible, to take such examinations and keep such records of all cases.

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