Part 4

At the present time, the Public Health Service has in this work about 1,700 medical officers, not including attending specialists. Of these, about 950 are officers of the Reserve Corps. A Dental Corps has been created and numbers, at the present time, about 180 dental officers. A corps of female nurses has been assembled and numbers, at the present time, about 1,800. A Reconstruction Service has been formed and numbers, at the present time, about 580 reconstruction aides. A Dietetic Service has been organized and numbers about 165 trained dietitians. These figures will give some idea of the large personnel necessary in the performance of this work.

It is difficult to draw distinctions between the various classes of personnel, but it may perhaps be said in general terms, at the present time, that the most difficult qualified personnel to secure is the medical officer. The Public Health Service was peculiarly fortunate in assembling a large Reserve Corps. At the close of the war, many medical men who had been in the military forces were demobilized. Finding themselves somewhat adrift, and having broken completely old associations, they were inclined, if opportunity offered, to continue in the Government service. A special appeal was made to these men by the Public Health Service and inducements were offered to them to accept service in the care of disabled discharged veterans. As a result, the Public Health Service was able to assemble a much larger number of reserve officers than could have been done under any other circumstances.

It has been a matter of great difficulty to maintain among these officers the necessary morale, by reason of the difficult circumstances and conditions under which they are employed. Having only a limited and somewhat uncertain tenure of office, with many uncertainties as to their future, it is worthy of note that they, nevertheless, have, given to the Government a service which could not easily have been secured from any other source. They have shown a fine spirit in the performance of this duty, and, as much as any set of men assembled under such conditions and circumstances, have delivered a service the quality of which is comparatively high. The retention of their services seems to me a matter of importance.

From the inception of this work up to date (Jan. 16, 1922), there have been cared for in hospital by this Service about 245,000 veterans, who have been furnished a total of about 12,831,000 hospital relief days. Also, about 1,945,000 outpatient treatments have been given and a total of over 1,427,000 medical examinations have been made. Many special services of various kinds have been rendered. For example; about 175,000 patients have been given dental treatment. Several thousand patients are being given occupational therapy and several thousand patients given physiotherapy every week. Prosthetic appliances of various kinds have been furnished to thousands of patients.

The important matter of medical social service in its hospitals has not been neglected by the Public Health Service. In cooperation with the American Red Cross, there has been organized an efficient medical social service, which has administered to the needs of the discharged disabled soldiers and sailors. These activities of the American Red Cross have been supplanted by many other agencies, including the American Legion, Knights of Columbus, Jewish Welfare Society, and others. All of these agencies have rendered valuable assistance in the prosecution of this important phase of the work.

The Public Health Service accepted a share in the responsibility for the care of discharged and disabled ex-service men, with a full comprehension of the privilege which had been conferred. It has taken a pride in attempting to give to disabled ex-service men the very best service possible. While its ideals have not always been realized, it has, nevertheless, I believe, always treated the ex-service man with consideration and given him good professional service. It is my endeavor that the character of this service shall continue to improve, and I believe that it does improve constantly. No effort will be spared to render the very best service possible under the circumstances and conditions imposed.

Just what the future will hold for the Public Health Service in this work, it is now impossible to say. It appears, however, that the Public Health Service for sometime to come will be one of the designated agencies for furnishing hospital care and treatment to beneficiaries of the U. S. Veterans’ Bureau. This responsibility of supplying hospital facilities, with all that is implied, will be as adequately met as possible. The Public Health Service at the present time is operating a number of hospitals which, from many standpoints, are not suitable to the purpose to which they have been put. To attempt to operate hospitals in unsuitable buildings, unsuitably located, subjects the Public Health Service to unmerited criticism, but, since these facilities are needed for a time, it will be necessary to continue such places in operation. It is not possible, under such circumstances, to render the highest type of service, but every effort will be made to render the best service possible.

With the construction which is now going on, under appropriations which have been made available by Congress, it is anticipated that, in the more or less near future, it may be possible for the Public Health Service to close some of its unsuitable plants and open others of a far more satisfactory character. This will relieve the present situation a great deal and will do much to obviate the criticism which has been made against the National Government because it has not supplied suitable hospital facilities for the care of men who have given so much to their country.

In conclusion, it seems appropriate to say that the Public Health Service, in all of this work, has realized fully the necessity for the most complete and cordial cooperation with other governmental agencies engaged in it. It has been a firm policy of the Public Health Service to stimulate an attitude of cooperation on the part of all of its employees. It is a matter of peculiar satisfaction at this time to say that the Public Health Service feels that, in the present Director of the Veterans’ Bureau, it is receiving from him a most cordial support in this policy of cooperation and the relationships which exist between these two Bureaus daily grow better, as they must if the work is to be properly accomplished.

It is also to be noted in this connection that the recent creation of the Federal Board of Hospitalization has added to the administrative machinery a piece of co-operating mechanism, which will, undoubtedly, do much to stabilize and coordinate, as well as standardize, many necessary things, which, up to this time, have been carried on more or less independently. A governing body of this character, which can lay down broad policies, influencing all of the official agencies engaged in this work, must of necessity be in a position to subserve a very useful purpose. The sympathetic consideration and support of this body should have a fine moral effect.”

GENERAL SAWYER: “Representing General Wood we have Colonel Mattison.”

COLONEL MATTISON read the following article prepared by General Wood: relative to the N.H.D.V.S. and its Relation to the World War Veteran:

“Of all the various agencies utilized by the Federal Government in caring for disabled men of the World War, the National Home for D.V.S. is probably the oldest in this line of work, dating back over fifty years in its care for disabled soldiers. Immediately after the close of the Civil War, the necessity for some organization of the government to care for the many thousand disabled soldiers of that war became apparent, and in 1866, by act of Congress, the National Home for Disabled Volunteer Soldiers came into existence with a Board of Managers selected by Congress to carry out the purposes of this Act. Prior to this, several of the States, civic and benevolent organizations had taken up the work locally in many parts of the country, but the creation of a National Board superseded the local work and for quite a number of years prior to the time that State homes were established by various States the burden of caring for disabled veterans of the Civil War fell on the National Military Home.

The first Home established was located at Dayton, Ohio and was known as the Central Branch, but as the necessities of the question developed, other branch Homes were established by Congress until at present there are ten different institutions under the control of the Board of Managers, scattered from Maine to California. But as the Civil War was practically a war between sections of the country, all the Homes, with the exception of the one at Johnson City, Tennessee, are located either in the North or on the extreme Northern border of the South. For example the Home at Hampton, Virginia.

Membership in the Home was originally confined to disabled soldiers of the Civil War, but gradually as the need developed, this privilege was extended to soldiers of the Mexican War of 1846, the Indian campaigns, the Spanish American War, and the Philippine service, so that by the year 1917 when the World War occurred, practically all disabled soldiers who had served in any of the wars of the Republic, were eligible to membership in the Home. The high tide of membership in the Home was in 1906 when over twenty one thousand disabled soldiers were members of the various Branches. After the peak of the load had been reached there was quite a decided downward curve in membership owing to the advancing years and heavy death rate among the soldiers of the Civil War, so that by 1917 the membership had decreased to about thirteen thousand men, and there were in the various branch Homes many thousand vacant beds, both in barracks and in hospitals.

In this connection, attention is called to the fact that the Home functioned in a two fold capacity. It furnished hospital service to the man who actually needed such attention and it also furnished domiciliary service to men who were disabled and prevented from taking care of themselves in the active competition of life but who were not actually patients. This latter service is called our domiciliary service and is a service that probably will increase very materially in its scope with the passage of time, as men who have served in the World War, owing to disability will find themselves unable to meet the active competition of the world outside and will therefore need this domiciliary service in a very acute way.

By the Act of October 6, 1917, eligibility in the Soldiers’ Home was given to men who had served in the World War, on exactly the same terms and conditions as it had been given to the veterans of the other wars, and therefore today the disabled soldiers of the World War stand in exactly the same position in their rights to care and treatment in the National Home as does the soldiers of the Civil, or Spanish American Wars. But few men of the World War had taken advantage of this privilege prior to the year 1920 when the Sundry Civil Bill for the F. Y. 1921 gave authority to the Director of the Bureau of War Risk Insurance, now the Director of the U. S. Veterans’ Bureau, to make allotments to the Board of Managers of the National Military Home for alterations and improvements of existing facilities to meet the demand of hospitalization from the Bureau of War Risk Insurance. Such changes were thought necessary as a large amount of space available was barrack space which while satisfactory for domiciliary service, was not satisfactory for hospital service.

Acting in accordance with the desires of Congress, as shown in this bill, the Board of Managers at once entered upon an energetic campaign of construction to prepare their plants for this work. Conferences were held with the Director of the Bureau of War Risk Insurance, and the statement made by him that the greatest need of the Bureau of War Risk Insurance at that time was for tuberculosis and neuro-psychiatric beds. To meet this need, and to grant to the fullest the wish of segregation on the part of the World War men, two branch Homes were set aside and their domiciliary and hospital population moved to other branch Homes, and acting under the advice of the most competent experts, the Board could find, the branch at Johnson City, Tennessee was changed into a tuberculosis sanatorium, and the branch at Marion, Indiana was changed into a neuro-psychiatric sanatorium.

In addition to the complete change of two branch Homes, numerous and extensive improvements and alterations were made at a majority of the other Homes so that the fullest cooperation might be given to the Bureau of War Risk Insurance in its great work, and today outside of the Home at Hampton, Virginia, and the one at Danville, Illinois, which have been practically set aside for the older class of veterans, adequate facilities have been prepared for the hospitalisation of such soldiers of the World War as may be assigned to them for hospitalization.

But in this connection especial attention must be called to one very peculiar and unique feature of the service furnished by the National Military Home, and that is the fact that under the law, the Home must care for the victims of peace as well as the victims of war and furthermore, that the gates of any branch Home are open to any disabled soldier of the World War and that for admission, it is not necessary that the disabled soldier be sent there by the U. S. Veterans’ Bureau or any other organization. If he presents himself with his honorable discharge and the medical examination shows disability, under the law the Home must take care of him as long as such disability exists, this whether the disability be one of war or one of peace. To give a concrete example, if a World War soldier presents himself at any branch Home with a leg or arm amputated, under the law, the Home must take care of him whether he lost the limb in the Argonne or in a saw mill, and this feature is one that I think should be carefully considered because it leads up to the question spoken of above, of domiciliary care. Now a man with a leg gone is naturally crippled in the battle of life and cannot compete on equal terms in almost all professions or trades, but still when the operation is completed and the wound healed, he does not require hospital treatment but comes under the domiciliary class, and I cannot help but feel that there are probably many hundred of cases along this line of disability which if transferred from the active hospitals of other branches of the service to the National Military Home for domiciliary care, will lighten the load very materially of hospitals where active curative work is being done, and increase the number of beds available for active hospital work, and at the same time give the domiciliary case the best of care and attention.

This brief summary of the relation of the National Military Home to disabled soldiers of the World War, leads one to the inevitable conclusion that the work of the Home in caring for these disabled soldiers is one that will increase from year to year and if the results of the Civil War can be relied upon, the peak in caring for these men will not be reached for twenty years, possibly thirty would be a more correct estimate of the time. In other words while it is probable that the hospital peak will be reached by 1923 or 1924, and then fall off, the domiciliary load is one that will grow from year to year and become more and more important as time goes by.

In conclusion, speaking for the National Military Home, I wish to state that the relations existing between the former head of the Bureau of War Risk Insurance, Col. R. G. Cholmeley-Jones, and the present Director of the U. S. Veterans’ Bureau, Col. C. R, Forbes, have in every way been most pleasant and cooperative and every request made by the Home for allotments and assistance in this work has been most generously and promptly met.”

GENERAL SAWYER: “I have pleasure in introducing Dr. A. White, Secretary of the Board of Hospitalization, who will address you on the subject of “the Neuro-Psychiatric Case and How to Meet its Requirements”.”

DR. WHITE:

“The neuropsychiatry problem which the World War created and presented to the medical personnel of the various branches of the Government for solution, may be advantageously considered in three parts.

The first part of the problem consisted of dealing with the conditions which developed in our armies during the war, more particularly those conditions which developed as a result of the stresses of actual service, particularly, of actual fighting. This large, and as you well know, very heterogenous group, in some mysterious way came to be labelled with the diagnosis of “shell shock”, a term which neuro-psychiatrically was most unfortunate, and which continues its vexatious existence.

This group of cases, while a very heterogenous one, consisted largely and perhaps most characteristically, of a multiplicity of types of conversion hysteria, cut aside from any attempt to diagnose in detail the various forms that “shell shock” took, it is sufficient to say that this group as a whole was a group of acute psychoses developed under the severest of stresses of service conditions and that when these stresses were relieved, and particularly after the signing of the Armistice, these patients got well and to all intents and purposes this group as a whole ceased to exist and so is not today one of our problems.

The second group is the group of what I shall call the ordinary State hospital type of psychosis. This includes the type of individual that we ordinarily find in State hospitals, that has always been recognized, that is usually called “insane”, and that for the most part was discovered by the army rather than created by war conditions, although it must be recognized that a certain number in this group might, under the ordinary circumstances of life, have remained stable, at least much longer than they did. However, there is nothing unusual or extraordinary or unfamiliar in this group to the average physician of State hospital experience.

With regard to the treatment of this group, however, it should be said that the great stimulus which came to psychiatry because of the war came because the country discovered, and was astounded by the discovery, that it had distributed throughout the length and breadth of its population a vastly greater proportion of defective and mentally ill individuals than it had the remotest dream of. Because of this stimulus which psychiatry received, the matter of treatment has received very much more intensive thought with the net result that there are today more well recognized agencies for dealing with this class of patients than ever before. Very briefly these agencies may be considered under the following heads, some of which of course are not only well known and well recognized, but have been used for many years, whereas others that are perhaps equally well recognized have only received wide application recently.

The _first_ of these agencies, perhaps, is the application of the general principles of medicine and surgery to the treatment of the sick individual. In other words, the patient’s general health becomes a problem for inquiry and appropriate consideration, irrespective of his mental state, on the general theory that physical health is at least the best condition precedent for undertaking a restoration to mental equilibrium.

The _second_ of these agencies is the complement of the first, and is best designated under the general term of psycho-therapy and consists in the recognition of the mental disease as such irrespective of whether there can be found any physical foundation for it or not, and on the basis of such recognition endeavors to deal with it as a thing in itself. In passing I may say that theoretically the best results would come if these two agencies could work hand in hand each with sufficient understanding of the other.

The _third_ agency, which has been very much broadened in its activities in recent years, I may designate as the social agency. It recognizes implicitly at least, if not consciously, that mental disease at any rate the kind of mental disease included in the second group, the so-called “insane” is a disorder of the individual as a member of the social group and that it manifests itself largely by disturbances of his relation to his fellows, and therefore it becomes a legitimate therapeutic endeavor to attempt a readjustment of these relationships. To this end the social agency has been developed in many directions. In the first place, we have amusements. The simpler amusements may be called, speaking from the point of view of the patient, the passive variety,—the type of amusement that is brought to the patient, such as theatrical performances, moving pictures, and the like, whereas the second type of amusement, which is more advanced and more valuable, is the type in which the patient himself takes part, such for example as theatrical performances in which he is a performer, musical programs, in which he plays or sings. Then there is the group which is not after all very widely separated from the amusement group and yet is somewhat different, and that is the group which we might term athletic activities and which demand upon the part of the patient some initiative. These range all the way from the simplest activities, which are imitative in nature, such as calisthenics under the instruction of the athletic director, to mass games, where a large group of patients are all engaged together in a common purpose, such as push ball, to games of contest requiring not only initiative but a relatively high degree of efficiency, such as the tug-of-war and the various types of races and stunts, boxing and wrestling, and which are from time to time advantageously staged on a field day and receive the added stimulus of an audience. In addition to such activities as the above there are also many minor ones of a similar nature, the principle of which, however, is the same,—the social give-and-take of patient between ward and ward, the instruction in such things as folk-dances, and the like.