Part 20

The T.B. man needs special treatment, nursing care and dietetic care. One of the chief things to give to a T.B. infirmary is good dietetic care;—place the food before your patient in an appetizing manner; too much will disgust him.

Then have your ambulant section and sub-divide it into the section in which there is clinical activity of the disease, and into the section in which the clinical condition of the disease is quiescent. By doing this you can give your people graduated exercises, whatever diets they may need, periods of rest, and occupational therapy; and you can do it in an organized, scientific way, and get away from the everlasting complaint, “You let the fellow in the next bed do it; why won’t you let me do it?”

You have got to study the psychology of your patient. It may be a little out of the line of segregation of cases. We have heard the talk here of cases, of hospital management, and all that; but be sure in dealing with the ex-service man, or any other case, that you do not treat him merely as a case; that you do not segregate the medical officer in charge. I find there in the South that one of my life-savers is the fact that my office door is open to any patient. When I first got to be understood there was a line-up. I gave an hour every day. Now, since the patients know that everyone can come to me, I have possibly three or four in a day. And I don’t do it either by reversing the decisions of my ward surgeon and my executive officer; I back them up.

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DR. KLAUTZ (N.H.D.V.S., Johnson City, Tenn.):

The subject of occupation in connection with T.B., is not only an extremely important one but an extremely difficult one to administer, particularly in the large government institution, and especially in connection with the psychology of the ex-service man, which has been referred to a number of times. He is apt to misunderstand and to be resentful toward any application of work; and yet at the same time, if we are going to measure the results of the sanitarium treatment of T.B. by the functional restoration to activity and usefulness, we still find that it results in a great many failures. That has been one of the complaints on the part of T.B. workers not only in government but in civil institutions as well.

We still find relapses occurring after the patient has been discharged from the sanitarium or T.B. hospital. Men go into training, and in a short time undergo another course of treatment, and so on. The reason for that is that they have not been given the necessary physical rehabilitation while still in the sanitarium, while under institutional protection and medical supervision.

The question of occupation is so broad that it is impossible to take it up extensively here today. We can point out one or two of the basic principles in connection with its application in the treatment of T.B. One very important feature brought out this morning is the psychotherapeutic object,—the point of view of relaxation or recreation, that is, giving the man something to occupy his mind and improve his morale, helping him to forget his home anxieties and anxiety about compensation.

The second point, or 2 A, deals with muscular reconstruction,—conversion of recently acquired adipose tissue into working force by rebuilding flabby muscular tissue which has resulted from the long period of rest.

2 A is the acquiring of a tolerance for T.B, toxins. This is important. We do know that in the recently toxic stage, exercise or work does produce a reaction which is shown by a rise in pulse rate. We know that if exercise is begun in small doses and gradually increased, the time will come when the patient can be made to take a fairly large amount of exercise continuing over a fairly long period of time, without manifesting the symptoms of reaction. Formerly we gave Tuberculin in gradual doses until we reached the point where the man could take an injection which surely would have killed him at the beginning of the course. The main point is if a man leaves the sanitarium before he reaches this toxin tolerance, he is more likely to break down. This is the reason for the man’s frequently returning to the sanitarium for treatment.

The third point deals with applying occupation as a means of training or retraining the man for some new occupation or modification of his former occupation; and here is where a great deal of judgment and study of the individual case becomes necessary. It is very difficult to find out just what is the best kind of work for the man from a physical and mental point of view; but the important thing is to have the man try it out and test it, and begin this physical reconstruction and rehabilitation if we are to get permanent results from sanitarium treatment. I don’t believe we have solved the problem completely, and I believe other agencies will have to be called in.

In this connection the question of dispensary work and social and nursing follow-up work is going to be extremely important. The man who leaves an institution ought to be followed up very carefully, and effort should be made to bring him back to some medical unit for re-examination at least every two months in order to see if there is any relapse of the former activity.

SENIOR SURGEON R. H. STANLEY, USPHS (R): It is always interesting of course, to be told what we ought to do and how to do it, but it seems to me it would be a great deal more interesting to take the little time we have this afternoon and discuss some of our real problems, and I mean by that problems that we as commanding officers of the hospitals have to contend with every day. I know and you know there are thousands of little things come up upon which we would like to have advice. There are many problems I might be able to solve readily; there are others you would be able to solve. I believe it would be worth more to tell how to get rid of some of these problems.

I believe that the success of running a hospital rests entirely upon the confidence that your patients have in you. If you are sincere they know it, and when they know that they will do anything for you. If you are not sincere they are going to know it mighty quick and you are going to have trouble. If you tell the men you are with them, that you are going to be 50–50 with them, if you call them in and talk to them as you would to a son, and if you let them see you are not doing it because of a matter of necessity, you can get by without writing petitions into Washington.

I found the other day a petition had gone to Washington from my hospital. It was necessary to discharge two men for drinking. It was their first offense. They came to me and said, “You have not treated us fair because it is our first offense.” Just before I left my station I received a letter which was addressed to these men by Colonel Forbes. In that letter he said “I have received your petition signed by 27 patients and asking that the hospital be investigated on account of a few patients being discharged for drinking. I wish to state for your benefit that I have given the matter consideration and I am standing right behind the medical officer in charge.” Leaving out the names, I had copies made of those letters and placed one of them on the bulletin board of the hospital.

When I went out to Whipple Barracks there had been some little disturbance there among the men. They were dissatisfied in various ways and it seemed like a big problem how to handle these men. When I once had their confidence I handled them.

I have found this in my experience, that I have never been able to have a satisfied personnel unless I give them the best I can. So long as you feed them well you will not have much trouble, because that will keep up the morale better than any other one thing I know. If you will feed them, be honest with them, be fair, you will have very little trouble in running the hospital.

SURGEON J. F. WALLACE, USPHS (R): The subject of entertainment probably would cover the subject of recreation at hospitals. It is rather hard for me to describe what recreation should be given at a tuberculous hospital because it depends on the location of the hospital. At the hospital at Fort Stanton where I am located we do not have any entertainment. If any social workers come down there I will be glad to entertain them, because we have only three visitors a year down there. That is one of the things in which I would compare our institution with some of these other institutions.

For many years I have been connected with a large sanitorium where we had strict discipline and little entertainment. The patients were satisfied. Our average stay of patients is six months. In looking over your sanitoriums you don’t find many patients staying six months.

When I was in the Army I was in one of the largest t.b. sanitoriums of the country. They sent back hundreds of men to this hospital and people came out and entertained them. They were entertained every night by the Red Cross with moving pictures, they were entertained in the afternoons by a local organization; they were entertained to death. These men afterwards got out and were not satisfied unless they were placed in an institution which was a social center. After I went out I was Chief of the Eleventh t. b. district of Denver. I noticed that the men who were treated at Fort Lyon were a better class to handle because they were not so much entertained. Once in a while I would talk to some of these men and ask them if they wanted to get well, as I could tell them a place to go and frequently I used to send them to Fort Stanton where they could not be entertained and they could get well.

If you have ever lived in an isolated place, you can appreciate it. My wife and I had pioneered this sanitorium together for quite a while. Once in a while we used to go to Denver and we could enjoy any show they had in Denver, even the 10–cent and 20–cent ones. I have heard men criticize entertainments at Fitzsimmons; they would swear and walk out while Madame Schumann-Heinck was singing, because they were dissatisfied; they were saturated with entertainment. I am against entertainment for tuberculous patients only in a very mild degree. We have one picture show a week and they enjoy that picture show. We have only Sunday School Sunday morning. The minister will bring in a few amateur singers and the boys think they are wonderful; they are wonderful; and they will all sing.

I have some fifty War Risk patients at my Sanitorium. I have known them for three years. I know them all by name. They were kicked out from Sanitorium to Sanitorium. They came down to Stanton. I went there on the first of July and no man has asked for his transfer or discharge. I suppose there is less turn-over of t.b. patients at any place than at Fort Stanton, where there is no entertainment. These men can go anywhere. We have a 30,000 or 40,000 acre farm. We try to get these men interested in the different things in the Sanitorium. On Christmas we let the men arrange the Christmas trees. They amuse themselves down there. The men trap quite a number of wild animals, bob cats, etc. and they are interested in the place we have, which is close to nature. You would be surprised how little amusement you need for entertainment if you get away from it. You have got to control these men and direct them every minute in the day. You have got to give them a task. Have their hours for rest; their hours for exercise. It is up to you who are running Sanitoriums to entertain your men. You might lecture to them; that is entertainment; but don’t have them twice a week or three times a week. Once in a great while the men are interested in the study of their disease. Don’t speak to them in scientific terms, let them understand the disease. They say in the curing of tuberculosis it depends more upon what a man has from his neck up than what he has from the neck down. Impress upon them that they have got to live a careful life. Keep people out who want to entertain them. Your men will be just as well and better satisfied with little entertainment if you keep them busy all day long.

DR. SMITH, U.S.P.H.S.: I wanted to discuss this afternoon a matter which is of great concern to all branches of the service, and that is Order 59 as applied to transfers from hospital to hospital. Order 59 is going to be watched rather carefully by the Veterans’ Bureau. Order 59 lists hospitals and gives a certain number of hospitals to each district. A district manager in New York may take a tuberculous patient and send him to a local hospital or he may send him away to a certain designated hospital to which he has blanket authority to send him, Oteen or Fitzsimmons; but according to Order 59, once they send a man to a local hospital, the district manager may not remove the man from that hospital and send the man to Fitzsimmons Hospital in Denver. In other words, it is worth watching to see whether Order 59 will not rather tempt the district managers to make a snap diagnosis on the ground and send away to the hospital to which he has blanket authorization to make transfers, on the one hand, a man whose disease is so far advanced, that it might be unwise to send him; or, on the other hand, men with questionable diagnosis. It will be worth watching. I am sure the Veterans’ Bureau will desire information on the subject as to whether you who are out in the tuberculous hospitals will receive classes of patients who are unsuitable in the usual sense of the word for transfer.

Here is another thing we shall all need to watch and concerning which the Veterans’ Bureau will I know desire information. Will the practice of sending patients to the local general hospitals result in a piling up of patients who need to be transferred and whose transfers will be delayed. We all know that a transfer is indicated not only for the purpose of providing a climatic change and we all know that in certain sections of the country there are provided beds for tuberculous patients and it is necessary to keep these beds filled.

According to the present practice and strict interpretation of order 59, if the medical officer in charge of the Naval Hospital in New York has a tuberculous patient and wants to effect his discharge to Fitzsimmons, he first asks the district manager for permission to transfer the patient. The district manager in turn asks the Director of the Veterans’ Bureau; the Director of the Veterans’ Bureau advises the district manager, who in turn advises the officer in charge of the Navy Hospital. Now it will be necessary to watch and see whether this effects an undesirable delay in making the transfers. The Veterans’ Bureau will desire to be informed if such is the case.

There is another thing. A patient under treatment at Fort Bayard, New Mexico, and fit for discharge cannot, according to a strict interpretation of Order 59 be discharged without invoking the same authorities who sent him there. In other words, he must take it up with the district manager, who then advises the man in charge of the hospital.

Order 59 is magnificent in this, if it works out: that no man will be transferred from one hospital to another except upon the recommendation of the medical officer in charge, and you who have had experience in this matter will know what that means. It means that it is not the man with the longest and strongest pull who will be transferred but the man whose transfer is recommended by the officer in charge of the hospital. We are prepared to assist in every possible way in carrying out that order but it is necessary for us to watch the effect from the field and get advices from all hospitals concerned, as to whether this order will not need modification.

SURGEON F. H. MCKEON, USPHS: Some have stated that they were in ignorance of the existence of G. O. 27. At Hospital # 64, upon the receipt of that order we immediately had about one hundred copies made and the entire hospital personnel was supplied therewith. After that every man upon admission was furnished with a copy, together with a copy of the rules of the hospital, for which he signed a receipt. I offer that as a suggestion.

On Tuesday the statement was made here that a man who is able to take five or six hours prevocational training at a hospital has no place in a hospital and should be in training. I think that statement should be qualified somewhat. It may easily happen that a man who can safely take five or six hours prevocational training in a hospital would soon break down under vocational training, for the reason that while he is in hospital his entire life is supervised; he must take a rest hour; he must turn in at a given time at night; he is assured of three or possibly more proper meals a day. Those conditions do not obtain when that man becomes a trainee and I sincerely hope that the follow-up nursing system which the Veterans’ Bureau is putting into effect now will result in a more careful supervision of the trainee’s life, so that when it is found he is living not wisely but too well he may be given proper advice and be returned to the hospital before the breakdown occurs.

This afternoon the subject of hospitalizing the tuberculous veteran in n. p. hospitals was discussed. I rather think it a somewhat sweeping assertion to say that every tuberculous individual with mental symptoms should be hospitalized in a t. b. sanitorium. We will all grant that men with signs and symptoms of an active tuberculosis disease should be hospitalized in an institution for the treatment of tuberculous. But to my mind that does not hold where the disability is clearly a mental disorder; that man is ambulant. The other man gives no trouble whatever because he is bed-ridden. I have no doubt that every t. b. hospital commander here today has had such cases. Your ambulant case, with few if any indications of active tuberculosis but who notwithstanding is tubercular, when he develops mental symptoms is not only a source of annoyance in the tuberculosis hospital but is destructive of morale. His place is clearly in a hospital for the treatment of mental cases.

DR. M. C. GUTHRIE, U. S. VETERANS’ BUREAU: This matter affects us administratively from a different angle. Many of the general hospitals have wards for the cure of tuberculosis. We presume that the turn-over must be fairly rapid. When men have accumulated in sufficient number and their disposition is determined as to whether they should go to a tuberculous institution, and they refuse to go, shall we turn them out or shall we let them stay?

SURGEON L. M. WILBUR, USPHS: If the transfer is suggested in the interest of the physical welfare of the patient and he refuses to accept that transfer, he is interfering with treatment. The regulations provide for that.

SENIOR SURGEON T. R. PAYNE, USPHS: I don’t agree with some of the t. b. men. I think a man can make a fight if he is dissatisfied and does not want to go and I think you will do harm in transferring him. If a man is home-sick and will not improve, I think he will do very much better to stay just where he is and you ought not force that man to go somewhere where he will not be satisfied. A sanatorium is a school to teach men how to live. In a general hospital you will have trouble in enforcing a rest hour because there are a great many other men in the institution who are not compelled to do so. The pass privilege is another thing. Some patients have but one pass a week and other patients get passes frequently. It serves to dissatisfy the t. b. men as they felt they were not on an equal footing. That is the only objection I can see.

SENIOR SURGEON J. E. DEDMAN, USPHS (R): There are several things that occur to me. In the first place there is the question of food. Of course that is the vital thing in every hospital. In our hospital, as I said before, we have a large number of negroes and what you give to the white boys in the north is not satisfactory to the colored patient. I think it is an important thing to try to give the men what they want in the way of food.

When I went to Greenville it was the custom to give the men breakfast at about seven o’clock; luncheon at 10:30; noon meal at 12 o’clock; at noon the men were not hungry and were generally dissatisfied with the food; at 3 o’clock, after the rest hour, they would have another nourishment; supper was served at five o’clock and as a rule they did not care much for that. Then we would send over to the wards large quantities of milk and eggs and bread and butter. They did not need any base balls. They played ball with apples.

It occurred to me that that was a bad system. We omitted the morning nourishment and the afternoon nourishment and I substituted an evening cafeteria luncheon thinking that it was a long gap from the supper at five o’clock to breakfast at 7. We thereby saved a great deal of money and since we did that we find the patients think the food is fine. We also find that they sleep better by taking this light luncheon just before they retire. I mention that for what it is worth.

The rest hour is important in tuberculosis. That is why hospitalization is so essential, because men will not take proper rest. We have a morning rest from 9 to 10, afternoon rest from 1 to 3 and evening rest from 6 to 6:45. The last period is not universal, and we wonder how you can get an accurate record of a man’s condition when you do not get his evening temperature. We find that it has been a great help to us. When I instituted this rest period from 6 to 6:45 I told the men it was for their good and although they objected at first, it appealed to their reason, after they were told why it was done, and we have had no trouble.

Another thing we have inaugurated along this line. I talked with Dr. Smith last spring. He agreed to send to our hospital a school for chiefs. I think this was a most helpful thing, because we had chiefs of medical staffs come to us and take a course that would tend to make for uniformity in administrative medical work in our tuberculous hospitals. I have talked since that time with several of the men who came down to take that course and I believe every one of them expressed the opinion that it was very helpful to him to have an opportunity to exchange ideas and to have the same methods for carrying of medical staff work which required tact and executive ability.

There is one thing I could not pass by because it is of such great importance to the Federal Employees Compensation Commission. We have sometimes employees engaged along various lines, and shortly after I arrived at the station I found one or two who said they had tuberculosis. I think it is most essential to see that not only one man but a board of medical officers examine every employee when he comes into a tuberculous hospital to make sure that he does not show activity in tuberculosis so that later he will not have a claim against the Federal Employees Compensation Commission by saying that he was working in a tuberculosis hospital and contracted tuberculosis while in the hospital.

There are many things I would like to speak of. I was very much impressed with what the doctor said about entertainment. I believe it helps the morale and is the most wonderful thing in the world. We can spend sleepless nights building up morale in a hospital and one man can disturb the entire morale.

In closing I want to say, after all is said and done, the big thing with us is the backing we get from the heads of our department and from the Surgeon General. I have known times I felt like throwing up the sponge. All of us have gone through these moments. The main and only thing that keeps us up is the encouragement we get from the heads of the department and I want to take this opportunity to express my appreciation.