Part 6

Under the terms of the Veterans’ Bureau Act, the Director is charged with the responsibility for proper examination, medical care, treatment, hospitalization, dispensary and convalescent care, necessary and reasonable after care, welfare of and nursing service to beneficiaries of the Veterans’ Bureau, and since he is so charged, the manner in which dispensary and reasonable necessary after care can be afforded is a matter of immediate importance. It is therefore proposed to establish in each District Office and sub-district office a dispensary of standard type which will vary only in size according to the amount of work in the city and surrounding territory which it serves. It is proposed to establish a type of dispensary to be used as a standard which will provide facilities for a medical clinic, a tuberculosis clinic, a neuro-psychiatric clinic, a surgical clinic and an eye, ear, nose and throat clinic. In addition, there will be a dental unit, primarily for the purpose of making accurate dental examinations, and secondarily for the purpose of furnishing dental treatment. It is proposed to establish an X-ray laboratory and a small clinical laboratory and pharmacy. These are the facilities of the standard type of dispensary proposed.

In the District Offices, and in a few of the largest Sub-offices, this standard type will be developed to the greatest extent as these offices bear the greatest burden of making examinations and furnishing out-patient treatment. In addition to the clinics above mentioned these Offices will be equipped with complete Physiotherapy Clinics.

The initial expense involved in establishing dispensaries will necessarily be large, but once established, will not only furnish medical service of the highest type to patients of this Bureau, but will, it is believed, result in an actual economy when compared with the present method of providing similar medical service practically on a contract basis. X-ray service alone costs the Government large sums annually which, with the establishment of the dispensary, can be practically eliminated. Laboratory service is also an expensive item of out-patient service when performed by contract, which can also be eliminated. Dental treatment to which patients of the Veterans’ Bureau are entitled under the law, is a matter of grave concern as it is handled at the present time on account of the great expenditure involved. This expense can be very materially reduced if the Bureau establishes its own dental dispensaries where careful examinations can be made and definite determination of the dental disability can be made by trained examiners. Treatment to which the patient is entitled can then be furnished either by the dispensary or performed by contract under close supervision.

Every medical officer in charge of a hospital is faced with the problem of de-hospitalization of patients of this Bureau who have reached the maximum amount of recovery afforded by hospital treatment. I believe there is not a medical officer here who is not facing this problem at the present time and who knows that patients are in hospital not actually requiring further hospital treatment but who do need further medical attention and careful medical observation to enable them to make a complete recovery.

It is believed that the dispensary with its trained professional staff to render medical treatment and to provide medical follow-up and after care during that period when the patient is undergoing the final stage of his physical recovery and is making his social and vocational recovery to a life of usefulness in the community, will meet a long felt need. It is believed that the period of hospitalization can be materially shortened if the patient can be discharged directly to a well organized out-patient dispensary where his treatment will be continued and his social and industrial rehabilitation made under the careful surveillance of trained medical groups. The effects of hospitalization, prolonged after the maximum benefit has been received, are injurious to the average patient and if continued, soon makes of these patients domiciliary charges upon the Government. This is to be deplored and prevented.

As soon as the dispensaries are established, this Bureau is, and will continue to place them more fully at the disposal of the hospitals for the purpose of shortening hospitalization and hastening his physical and social recovery. This is one of the most important functions of dispensary service.

The Director is charged, under the law, with not only providing treatment for compensable claimants of this Bureau, but he is also charged with maintaining the physical condition of claimants who are undergoing vocational rehabilitation during the period of their training. The dispensaries have been located as far as possible to serve the greatest number of trainees and will provide medical service to take care of the so-called intercurrent diseases and accidents from which the trainee may suffer as well as furnish him treatment for diseases or disabilities connected with his service. With the increasing number of claimants availing themselves of vocational rehabilitation, the problem of medical service is one of no small import and it is believed that the dispensary furnishes the best solution of this problem.

There is another class of beneficiary of the Veterans’ Bureau who is entitled, under the recent Veterans’ Bureau Act, to medical treatment—namely, those claimants whose disability is not sufficient to warrant an award of compensation. Heretofore only patients who were compensable were entitled to medical treatment and the claimant must have a disability of ten percent or more to entitle him to compensation. Under Section #13 of the Veterans’ Bureau Act, a patient with any degree of disability is entitled to treatment for a disease or disability, which is connected with or aggravated by service. This adds a class of patients to whom the Veterans’ Bureau must provide treatment now and in the future. The dispensaries, it is believed, will meet this demand.

The establishing of dispensary service by the U. S. Veterans’ Bureau is therefore the logical outcome of past experience in the examination and treatment of its patients. The Director is also enjoined by the Veterans’ Bureau Act to furnish adequate medical care including dispensary service, follow-up and after care to claimants of this Bureau. The matter has been given and is being given careful consideration in this Bureau and it is hoped that in the near future the dispensary service of the U. S. Veterans’ Bureau will extend throughout the United States, for the convenience of all disabled veterans of the World War and for the betterment of the treatment which this Bureau is endeavoring to give.”

COL. FORBES: stated that it was believed that the dispensary was the type that could do everything but put the man to bed; that it was decided that it would require an appropriation of seven million dollars to put over the dispensary program; that the Bureau has a dental bill of 435 thousand dollars; that the dental work is one of the big items, as is the x-ray service under the present contract system; that heretofore the examiner was the workman; that the patient would go for examination, and the examiner would say: “You have two teeth out on this side, and it is no use to put one in on this side unless you have the other two put in also; that the bureau has had bills come in for dental service for one mouth in the amount of $350.00; that that service has been abused; that x-ray bills for one mouth have ranged from $15 up; that $3.50 was decided upon as a general figure.

“We shall now have a half hour’s discussion of the topics presented in today’s program so far.”

DR. LAVINDER: suggested that explanation be made to the officers present concerning out-patient relief, stating that shortly the Veterans’ Bureau will assume entire responsibility in that connection.

COL. FORBES: repeated the statement that the Veterans’ Bureau will assume the entire responsibility.

COL. EVANS: Called attention to the part of General Sawyer’s address which summarized the personnel for a 200–bed hospital, and stated that he believed there was an error in the numbers as he had formerly compiled them;—that 14 people would be sufficient to cover the three phases of work (Occupational Therapy, Social Service, and Vocational and Prevocational Training).

GENERAL SAWYER: stated that the correction would be made.

SURGEON CHRONQUEST: asked if the personnel just mentioned applied to all types of hospitals, general, T.B., and N.P.

COLONEL FORBES: stated that they do.

SURGEON BAHRANBURG: stated that he thought there must be an error in the figures as given; that at St. Louis they have a 650 bed hospital, with an average of 600 patients; and that with the use of aides in greater proportion than here mentioned, they cannot do as much work as is required of them in that line.

COL. FORBES: asked for his recommendations concerning additional aides.

SURGEON BAHRANBURG: suggested 12 as the number of physio-therapy aides; and the same number for occupational aides. He added a few words concerning the clinic at St. Louis, stating that they had 162 cases last month; that they have an x-ray laboratory, etc., and that the cost of operation of the dental clinic was a little over $8000 a month.

SURGEON YOUNG: inquired as to the basis on which were derived the figures for total per diem cost.

COL. FORBES: that the Bureau has a complete analysis of the cost of operation, and that this matter would be discussed later in the conference.

DR. SANFORD: stated that he was interested in the dental clinic in Denver, and remarked that the dental clinic was the hardest to handle. He added that their dental bill for one month was $3760, but that their expenses in that connection were much less now; that they have a personnel of eight full-time doctors—three men in the laboratory; and that the clinic there is a complete one.

COL. FORBES: “There is no question but what the fee basis is costly. Our own clinics are the most economical.”

COL. BRATTON (Army & Navy Gen. Hosp.): asked how long this expense for dental treatment was to continue,—if it were to continue during a man’s life.

COL. FORBES: stated that the law provides that any man who has 8% disability has a dental disability; that the x-ray is largely responsible for this dental treatment; that the matter is one to be adjusted by those present who are responsible for having the x-rays made and for prescribing dental treatment.

SURGEON McKEON: made reference to Colonel Patterson’s paper and the necessity for removing men from hospitals as soon as the need for hospital treatment ceases to exist. He stated that men are retained in hospitals longer than is necessary, due largely to the fact that they want to take up vocational training. He recommended that the Rehabilitation Division make a survey of a patient about three months prior to discharge, so that when the patient is able to be discharged from the hospital, he may enter training at once.

COL. FORBES: Read Section 2 regarding vocational training; but added that in the rearrangement of the Veterans’ Bureau now in process there will be a closer liaison between the Rehabilitation Division and the Medical Division, and the Rehabilitation Division will be represented in the hospitals.

COL. EVANS: stated that a recommendation is to be presented to Col. Forbes, for his approval or disapproval, to the effect that the educational director in a hospital will be the Bureau’s representative there in regard to rehabilitation work and will furnish data regarding the man as to what he has done and what he can do.

GEN. SAWYER: said he understood that this representative was accounted for in the list presented formerly by Col. Evans.

COL. EVANS: answered that that was the provision made.

COL. FORBES: said that he believed that the rehabilitation proposition is much more of a medical problem than an educational one; that there must be a closer medical observation of the men and not quite so much education; that if the physical disability can be removed first, then the man is better equipped for vocational work; that the man should have the maximum of hospital treatment before he is put into vocational work; that the problem is 90% medical and 10% educational.

SURGEON DEDMAN (Greenville): stated that his place had adopted the system of sending a copy of the physical report of the Board of Medical Officers to the social welfare part of the Red Cross, and one copy to the educational department of the Veterans’ Bureau so that the Bureau might be in constant touch with the man’s physical condition. He recommended that there be in the sub-offices experts on T.B., etc., and thereby eliminate the sending of men to hospitals when they have no trace of such disease.

He expressed appreciation of the work of the Red Cross in his community.

COL. FORBES: added his appreciation of the splendid service rendered by the Red Cross, and stated that that organization had recently made available to the Bureau $175,000 for recreational purposes.

SURGEON STITES: stated that the educational director at the Alexandria hospital is kept in constant touch with every patient there, particularly those approaching discharge. He also stated that he was particularly impressed with what was contained in General Wood’s paper with reference to the care and treatment of disabled veterans whose disability is in no way connected with the service; that there are veterans in his community who need treatment, but whose disability is not connected with service.

COL. FORBES: emphasized the fact that the law provides that the disability must be in line of duty or during the period of military service.

COL. FORBES: in answering a conferee, stated that the law providing for admission to Soldiers’ Homes was amended to apply to veterans of the World War; and that all that is required of the man is to make application to any National Soldiers’ Home and present an honorable discharge from the service.

SURGEON MILLER: expressed his interest in Dr. White’s address; that it called to mind a condition which exists at some of the T.B. hospitals. He said that a case of Dementia Praecox is often found with active T.B., and that where such a patient is accustomed to taking convulsions, it is very disturbing to the other patients at the hospital.

COL. FORBES: said that the N.P. cases could be sent to Marion, Indiana.

SURGEON MILLER: said he had a telegram saying that admittance was refused to active T.B.-Dementia Praecox cases.

COL. FORBES: recommended that he take this up with his Surgeon General.

SURGEON WILBOR: spoke concerning the patients at Gulfport, and stated that many of these men lack confidence in themselves as regards training and have to be encouraged. He recommended that the men be given a partial course of training in the hospital, after discharge, in order to give them sufficient confidence.

COL. FORBES: said that he believed that if a man were able to pursue six or seven hours of educational activity, he should not be hospitalized; that heavy machinery, etc. should not be in hospitals.

COL. FORBES called upon Captain Blackwood, U.S.N.

CAPTAIN BLACKWOOD: stated that he did not have anything special to say, as he had intended reserving his remarks until later. He said that he was discouraged at hearing so many exaggerated adjectives used by the conferees; that it should be realized that the patients came from all walks of life; that the physical examination upon entering the service was superficial in many cases, and the men are only now being examined as thoroughly as they should have been before; that they are now receiving better treatment than they would in civil hospitals, as the Government is trying to eliminate the possibility of the patient’s having a disease of which he is not aware, and thereby save future trouble and expense for the Government.

COL. FORBES: “Would you say that in all cases of medical doubt, a man should be x-ray’d?”

CAPTAIN BLACKWOOD: “Yes.”

CAPTAIN BLACKWOOD: stated, in addition, that he considered the matter of dispensaries a very good one.

He also recommended that the amount of paper work for medical office be reduced, as it seemed that the work they are trying to do in medical way will be subservient to the clerical work. He stated that he had reference to both Navy and Veterans’ Bureau papers.

COL. FORBES: asked for his recommendation in this connection.

CAPTAIN BLACKWOOD: replied that he could not make any sweeping statement.

COL. FORBES: called upon Colonel Kennedy, U.S.A.

COL. HANNER: represented Colonel Kennedy.

COL. FORBES: inquired as to the number of patients at Letterman Hospital.

COL. HANNER: answered that they have 84. He inquired concerning a few patients sent to them by the proper authorities, where the disability has no connection with the service.

COL. FORBES: inquired as to what had been done in such cases.

COL. HANNER: replied that the men had been taken in and that some of them had been hospitalized and some not—pending authority from the District Manager to discharge them from the hospital.

COL. FORBES: stated that if there is a question of doubt, the man is to be given the benefit of the doubt and his hospitalization continued; that if it believed that the disability is not due to service, the officer is to be guided strictly by Regulation 27, and he should inform the District Manager; that the Sweet Bill provides very liberally for the care and treatment of ex-service men, and that he would see that everyone present received a copy of the Sweet Bill, a copy of the Vocational acts, and the original War Risk Act and its amendments; that he wanted all to read them very carefully. He added that it is the medical advice and decisions that the Bureau has to depend upon regarding the care and treatment of the men.

DR. SNELL, (N.H.D.V.S.) asked if a man should be hospitalized if he presented himself to Dwight, Illinois, for example, but his disability was not of service origin.

COL. FORBES: said that the man is to be hospitalized, and his case determined later; that is he has a contagious disease the city will take care of him.

COL. FORBES: called upon Surgeon Quick (P.H.S.)

SURGEON QUICK: stated that he was connected with a Marine Hospital, which did not take T.B. or N.P. cases; that the patients were beneficiaries of the Veterans’ Bureau and were mostly of the surgical type; and that he felt there was very little he could add to what had already been brought to the attention of the gentlemen present. He stated that he believed the large percentage of medical men would agree that rehabilitation was more of a medical matter than an educational one.

He also expressed himself as being in favor of the dispensary plan for the Districts; but added that he felt there must be a great deal of cooperation between the District Managers and the Medical Officers in hospitals; also, that medical officers in dispensaries should use a great deal of judgment in referring cases to the attending specialists.

COL. FORBES: said that that was a medical question; that the District Medical Officers should go the limit in providing hospital care if in their judgment it is the proper thing to do.

COL. BRATTON: stating that he had charge of the Army and Navy General Hospital at Hot Springs, spoke concerning the discharging of patients from government hospitals by reason of disorderly conduct. He stated that when such men were discharged they were not granted transportation to their homes, and therefore became nuisances to the community there.

COL. FORBES: stated that there is a General Order providing for the payment of such transportation.

COL. FORBES: inquired of this officer regarding the paper work of his hospital.

COL. BRATTON: answered that he found it very cumbersome; that he has to make triplicates; that two of these copies go to the District Manager who sends one to Washington.

COL. FORBES: said he wished he would suggest to General Ireland a medium for reducing this.

COL. BRATTON: said that he was running two sets of records,—Bureau and Army.

COL. FORBES: replied that he was dealing with two distinct sets of men.

COL. BRATTON: stated that he had just made out his annual report. He said his place had treated 851 Veterans’ Bureau patients the last year, and he told the different diseases involved. Added that in many cases referred to them no trace of disease was found; also, that one man was sent from Oklahoma and the only ailment discovered was one decayed tooth.

COL. FORBES: replied to the effect that that man is entitled to vocational training under Section 2.

SURGEON GARDNER (St. Paul): expressed himself as being in favor of the dispensary project, as it would assist the medical officers greatly. He added that he has two patients suffering from paralysis, and does not know where to place them.

LIEUT. COMMANDER HIGGINS: stated that he is not in a hospital, but one thing that impressed him in his contact with men in hospitals was Dr. White’s “third class”, the border-line mental types. He said this type gave the most trouble in hospitals, but that they do not get the sympathy of many medical officers not accustomed to dealing with that type.

COL. FORBES: asked if he believed there were a lot of men hospitalized, drawing compensation and taking vocational training from the Government, who are not entitled to such.

LIEUT. COMMANDER HIGGINS: replied that it would be a very hazardous thing for him to say because he had not been in contact with them; but that from a civil standpoint that might be true.

COL. FORBES: asked Captain Blackwood if everyone in his hospital had a disability.

CAPT. BLACKWOOD: answered in the negative; and added that at his hospital they got diagnosis varying anywhere from baldness to flat feet; that the man claims the disability, and when the hospital cannot find it, the man is discharged. He cited one instance where a man came to the hospital claiming that he was suffering from “Compensation”.

COL. FORBES: called upon Captain Dunbar, U.S.N.

CAPTAIN DUNBAR: said that he came prepared to offer statistics on the League Island Hospital, and added that he thought that that hospital had been doing as much work for the Veterans’ Bureau as any of the naval hospitals; that out of so many sick days, one third of them had been devoted to the patients of the Veterans’ Bureau. Remarked that during the past year it had not been necessary to discharge a patient for disciplinary action, but that so far this year two had been discharged for peddling drugs. He also brought up the subject of treating patients for disabilities other than those mentioned in the diagnoses upon admission to the hospital, and gave as example a case diagnosed as “chronic gastric catarrh”, but found to be an “ulcer” case. He said that in emergency cases they went ahead and operated.

COL. FORBES: instructed him to go right ahead and operate completely.

SURGEON COBB: stated that he did not think that any of the gentlemen present were aware of any General Order allowing the payment of transportation after disciplinary discharge.

DR. LLOYD: gave information to the effect that that General Order was just being printed.

COL. FORBES: stated that he would see that the proper authorization was given, and that the travel blanks were placed right in the hospitals.

SURGEON COOK (Houston): asked if such transportation would take the man to his home or to place of hospitalization.

COL. FORBES: replied that transportation would be to the legal residence or to place hospitalized.

COL. FORBES: called upon Dr. Guthrie to inform the doctors present concerning the difficulties in the Veterans’ Bureau.