Part 17

Superintendent of Nurses 1 Neuropsychiatric Chief Nurse 1 Chief Nurses 14 Follow-up Nurses 246 TOTAL NUMBER NURSES ON DUTY ——— November 30,—1921— 262

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No. Cases treated at Dispensaries & Relief 610 Stat’ns No. Visited at Homes 6907 No. Needing Medical Care 12938 No. Medical E’s made out 15279 No. Medical O’s made out 339 No. Needing Social Adjustment 1316 —————— TOTAL MEDICAL ACTIVITIES 37,389

No. Neuropsychiatric Cases under supervision 7,329

Total No. Interviews—(Home, Placement) 45,487 (School, Office)

No. Appointments approved during November, 1921 27

No. Reported for duty (Oaths rec’d Central Office 20 to date)

No. Resignations submitted 5

No. Declinations Appointment 1

TOTAL NO. CLAIMANTS UNDER SUPERVISION NOVEMBER 30, 1921— 63,397

(MRS.) K. C. HOUGH, SUPERINTENDENT OF NURSES.

EXHIBIT E

RECONSTRUCTION TRAINING

SUMMARY BY DISTRICTS

January 1, 1922.

─────────────────────────────────────────────────────────────────────── Assigned Enrolled Percentage Dist. Number of Number War Risk to in of Avail. Institutions of Staff Patients Classes Classes Patients Enrolled ─────────────────────────────────────────────────────────────────────── 1 7 30 1443 652 429 66

2 11 50 2282 926 782 84

3 7 16 819 344 257 75

4 9 61 2538 1228 846 68

5 8 66 3846 2053 1394 68

6 4 18 1185 563 452 80

7 19 49 2309 916 753 82

8 15 52 1631 914 711 78

9 5 12 303 260 239 92

10 11 33 1432 707 521 74

11 2 19 1577 617 341 35

12 15 55 2646 1117 725 65

13 3 9 649 172 138 81

14 1 13 942 442 300 70 ─────────────────────────────────────────────────────────────────────── Grand 117 483 23602 10911 7888 72 Total:

ADMIRAL STITT: reminded the men that at the meeting yesterday afternoon a motion was made to discuss the paper on the “The Social Service Worker” this morning, and there were about 25 minutes for the discussion of each of the four subjects—the social service worker, disciplinary regulations, relation of district managers, and physiotherapy and occupational therapy in hospitals.

CAPT. BLACKWOOD: said it was his opinion that the social service worker has done more to aid the Commanding Officer and to follow up the work on the ex-service man, as well as the service man, than anything else he knew of that has been introduced into the hospitals. The social service work in the Navy is all done by the Red Cross, one of the most wonderful organizations in the United States for doing good.

SURGEON CHRONQUEST emphasized the point that diversion and recreation should be distinguished from the social service, with which it is so often linked.

SURGEON LASCHE: stated that at first he was sceptical about the introduction of people under extraneous control into the hospital, but that he incorporated the Red Cross into the official organization of the hospital and made the director a member of the staff. He believed in keeping a fairly close supervision over the activities until he knew the individual, and made a rule that the social worker should send a carbon of every letter written about the patients to the officer in charge. It was found that at the beginning there was no possible reason for about 30% of the letters written, but only one-half of one percent of the letters produced harmful results. He said he was inclined to think that owing to the fact that the Red Cross has the benefit of a nation-wide organization that for the present it is very much better to utilize their services than to establish government employees to do the same work.

COL. BRATTON: said that experience had shown him that the Red Cross is a great aid in carrying on relation to the outside world. He told of the situation in Atlanta. When the hospital was established he found it would be necessary to satisfy the people of Atlanta that the wounded boys were being properly taken care of, and was fortunate to secure the services of a first-class man from the Red Cross. The result was that the people became very interested in the work and sent committees with food, also provided pictures two or three times a week and all kinds of entertainment.

SURGEON PAYNE stated that one of the greatest difficulties he had experienced had been in sidetracking the people who, though kindly disposed, brought food and all kinds of entertainment which were injurious to the patients. He said he did not believe in any kind of athletics in a hospital, unless under the Physiotherapy Department, neither did he believe in dances in a hospital. He said people would bring in all kinds of food and the patients would eat it before going to mess, and then of course would complain of the hospital food furnished. The greatest benefit from the Red Cross had been the coordination of those activities.

COL. BRATTON asked that some of the men who served in General Hospital #6 speak on this subject.

SURGEON WILLHITE: stated he had served under Colonel Bratton, and agreed heartily with all he had said. He stated also that in his work in the hospital in Philadelphia the Red Cross had done the finest kind of social service work, coordinating all the agencies that Dr. Payne spoke of as so detrimental to him, and he believed had been a very great benefit rather than a hindrance.

Dr. Dedman took up the work of the Red Cross in taking care of relatives of patients who come to the hospital. Often these people spend all their money for railroad fare, and have none left when they reach the hospital, and the hospital has to take care of them. He said he had arranged that four or five rooms be fixed up for such people as this and believed some definite authority should be had from the Veterans’ Bureau to house these people and furnish their meals. He stated that some boys will ask for things and others will not. He referred to an instance in which a patient had told a lady that he needed a shirt, and two days later when she brought him one she gave it to him before the whole ward and the boy was ridiculed for a long time afterward. He had had trouble in getting the work done through the social welfare workers in the hospital, as the public wants the individual glory of handing something to the boys themselves. The Red Cross has also been a great aid in investigating home conditions of the patients, especially of tubercular patients who want to go home to die. Also, in the case of a man who asks for a long furlough because his mother or sister is dying, the Red Cross will investigate and get an immediate report, and many times it will be found that the mother or sister is not sick at all.

SURGEON PAYNE: stated that he did not want to be misunderstood, that he did not mean to take credit away from the Red Cross.

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

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

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

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

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

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

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

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

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

ADMIRAL STITT asked that Dr. Lloyd answer that question.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_MOTION_

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

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

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

_RESOLUTION_

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

This resolution was adopted.

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

_RESOLUTION_

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

The meeting adjourned at 12:25 P. M.

_Sixth Session_ Thursday, January 19, 1922.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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