Part 19

In other words, during the first thirty days I get three reports as to his condition. If after thirty days he is still doing well, I grant an extension of thirty days. During the second thirty days he reports in twice. If he is still doing well at the end of sixty days, the parole is extended to ninety. I believe in the majority of our cases that if a man makes good for ninety days, it is reasonable to suppose that he is going to make sufficient adjustment to stay outside of the institution. If, as I said, his report at the end of ninety days is a good one, he is then discharged from the Institution, with the privilege, of course, of returning. Now of all the men I have sent out under that scheme this year, I have had less than eight per cent of returns, and I consider that in the first year a fairly good average.

I want to commend that scheme to every man who has charge of an n.p. hospital and after this conference adjourns, I would like to correspond with you on that subject. I would like to compare notes because I believe it is worthy of attention.

There is one other thing brought up in a previous meeting and that was the question of our constitutional psychopath, and drug addict and the building of special hospitals for these men. I personally am not in favor of such a scheme and I will tell you why. I have a considerable number of these men. I believe that every complete n.p. hospital should have a department with definite numbers assigned from the staff who are particularly clever in handling this line of case. I think that they should be handled in your regular n.p. hospital as a separate unit.

Now there is just one thing in connection with that statement I wish to emphasize. There are a certain number of these men who do eventually make an adjustment. For the sake of that percentage alone we should not place the stigma upon them of being sent to practically a penal institution, and that is what it means if you set aside a place and brand it as a place for those of criminal tendencies and drug addicts. We tried that in New York and you all know from the papers what it resulted in.

There has been another plea. Dr. Treadway spoke of the shortage of personnel. It is acute everywhere in every department. Then on top of that comes the plea from the general hospital men, from the t.b. hospital men, for neuro-psychiatrists to be assigned to his staff. That is a physical impossibility. There are not enough n.p. men to go around and I have a solution of that which I have put up to numerous men and that is just this. Along with what General Sawyer said today about every one’s being a well-rounded out man, every man who has charge of a hospital, every man who is on the staff of a hospital taking care of ex-service men ought to go down and buy a copy of White’s Outlines and study it for the next six months. If you will do that you don’t need specialists on your staff. You can make a near enough diagnosis so you will be reasonably certain in 95% of your cases as to whether they ought to be sent to an n.p. hospital or not.

DR. FULLER: I an particularly interested in the question of personnel. The shortage of neuro-psychiatric trained personnel and physicians is a real and very acute problem. We have any number of vacancies for such men in the Public Health Service at the present time. I dare say the same conditions exist in the Army and Navy. I believe that the only way of solving the problem that Dr. McLake spoke of is for the Commending Officers of those hospitals who have one psychiatrist on their staff,—and practically all the large hospitals have one on their staff,—to insist that these psychiatrists interest other members of the staff. The fact that Dr. Treadway brought out, that most young men are not interested in psychiatry is due to the fact they do not know anything about it. I was one of the men who visited the schools last year. I was suddenly confronted by statements made by the deans or their assistants: “Oh, neuro-psychiatry, I don’t expect you will get much enthusiasm from any of the schools on that subject, because that is a post-graduate subject and we don’t make any attempt to teach it during the under-graduate years.” Any number of young men who will state a preference for general medicine can be interested in this subject about which they know nothing. The solution, therefore, depends upon the commanding officers of these hospitals and upon the psychiatrists on their staffs; depends upon their willingness to detail one or more young men to the psychiatrists, who are interested in the subject. I don’t believe that the problem is going to be solved in any other way because there are not enough men outside who are willing to come into the Government service, who are interested.

DR. MILLER: We have a specialist at Oteen who lectures to our entire medical staff Tuesday and Friday of each week. They are very much interested in it and we think it is a very great benefit to the institution and the patients.

COL. EVANS: What are you going to do with the group the doctor describes that ought to be in a colony? What are you going to do with the mentally deficient who will never be able to carry on? There is no appropriation available for that group. If the Soldiers’ Homes are not properly supplied with means or some other special effort made, every community will have these individuals as a reproach upon them, and it occurs to me there is no group of men that would be as able as this group to have the propaganda go forward that there is a problem to be solved in these cases.

DR. WHITE: I had this in mind about some of these difficult problems, some of these border-line cases I didn’t have a chance to speak of the other morning. I suggested there in just a word that in connection with these disciplinary measured such as have recently been promulgated in this order we got this morning, No. 27–A, probably we shall have to come to some form of disciplinary treatment with a considerable group of these border-line cases, and the plea I wanted to make was that discipline should not be used as discipline per se, but that we should seek for all of the possibilities that are incorporated in disciplinary measures which can be brought to bear upon the patient for his welfare; In other words, if we can make out of discipline a therapeutic tool.

Now we are dealing for the most part, in these border-line cases and in the delinquent group, with types of individuals that are more or less defective. Almost all of them are defective in some sort of way, not necessarily intellectually defective but frequently on the affective side; but there undoubtedly has to be some kind of disciplinary pressure brought to bear.

I have in mind a fellow who is a high-grade defective, who has passed through a praecox attack, who has come back to comparative normality. He is a reasonably useful citizen around the institution but he can’t get on outside the institution and he has periods of not getting on well in the institution, because every once in a while he will go out and get drunk. Now what are you going to do with that sort of fellow? Such an individual does not always stand discipline very well. A doctor came to me and talked to me about him the other day and wanted to know what should we do with this fellow. I said, “Shut him up; take his privileges away from him and watch him very carefully, because I don’t believe he will stand shutting up very well. When you have made the maximum impression upon him from that discipline, let him cut.” You have constantly to shift between severity and almost lack of discipline with these people to keep them at their level, and you have to realize all the time it is a matter of very fine adjustment and that after all you can very easily do them a great deal of harm. Therefore I am always more or less disturbed by the constant effort that is being made in bodies like this to standardize all kinds of rules and regulations, because I realize that in this class of cases particularly there are individual problems and they must be left for the individual judgment of the physician who has charge of them.

I have, for example, a clerk in the office, a man who is probably sixty odd years of age. When he is sober he is as efficient a clerk as we have in our office, but he persistently gets drunk and stays drunk for days at a time. Now the easiest thing on earth is to discharge that man. What is going to become of him? He can’t take care of himself. He has a family dependent upon him. That would mean to pauperize him and make him a public charge. I developed some time ago a method of dealing with him. I penalized him every time he got drunk by taking away a certain amount of his pay. It was hard punishment. He does not get much pay. The result was I pushed him to the limit, because it cost him too much to drink. The result was he had longer periods of sobriety than he ever had before, but he did break down once in a while, and when he did we had to forgive him.

Now we have to deal with that sort of problem among our employees and patients, and we are put to it constantly to devise out of our ingenuity how best to meet it; and one of the agencies at our command is the disciplinary measure, which, if wisely enforced, can be used to push the patient to the highest possibility of his adjustment.

Then, in that connection, as to our friends, the morons and epileptics. I am fond of saying that practically everybody, no matter how defective he may be, has a certain capacity for usefulness. There is almost nobody who is, under proper arrangements, a total loss socially. A Moron, of six or seven years of age, may be ten per cent efficient. He may be ten per cent efficient under one set at social conditions, maybe fifteen per cent efficient under another set. He may be total loss under other sets of conditions.

Now a lot of these people, like the young fellow I spoke of a while ago, are very useful citizens in the hospital community. They would be a total liability outside that community. We have always had these people in the community and we always shall have them probably. It is perhaps a worth-while endeavor to try to get the community, through these various social agencies, to appreciate them for certain values. One of the medical officers of the Army was discussing with me, a while ago, this problem in the South, in the cotton mill districts, where there is a large number of mentally deficient people. They do not do much of anything, except perhaps, drink whiskey, breed and make trouble. They go into the mills and either get injured or discharged. A lot of that material is really capable of utilization. The mental defectives, as a whole, are fairly good natured and tractable. There were lots of mental defectives in the Army, enlisted men, who carried on and made good soldiers. Some young fellows went into the Army from the School of Feeble Minded, in Massachusetts, and had excellent records. The Superintendent there kept track of his feeble-minded boys in the Army, and they made excellent records because they belong to that type of individual which has a very strong leaning upon persons in authority and will follow his officer like a Newfoundland dog his master, will obey orders to the letter and they make most valuable persons. So this officer suggested to me that these feeble-minded groups running around might be assembled into industrial units. They could be worked in factories. In order to avoid the possibility of exploiting that type of labor they could be employed under proper social conditions and placed under the eye of a neuro-psychiatrist; and where there was an immense shortage of labor, perhaps factory owners would be pleased to get these men.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Have first your infirmary or hospital.