Part 7

DR. GUTHRIE: said he had been inclined to listen because he felt that the reactions from the field had been more than the Bureau’s. He informed the doctors that Col. Patterson had deemed it necessary to place a Bureau representative in each hospital—the larger ones—in order to take care of the very things that the doctors had been bringing up in the conference. He added that many such matters would be discussed later in the conference in addresses.

SURGEON KOLB (Waukesha): suggested that a hospital to take care of less than 100 patients be established, preferably on an island, for the care of drug addicts and pronounced psychopaths.

COL. FORBES: suggested that Surgeon Kolb present that as a resolution a little later when such were in order.

COL. DE WITT, (U.S.A.): expressed a need for a Bureau representative at his hospital at Ft. Sam Houston, where there were 246 patients, beneficiaries of the Veterans’ Bureau.

COL. FORBES: assured him that a representative would be placed there.

SURGEON RIDLON (New Haven): remarked that the Sweet Bill made provision concerning Pulmonary T.B., but that he felt that T.B. of the bone should be considered in the same class. He also suggested that the period of two years be extended to three, stating that in many cases a boy is not examined for two years; he comes to the medical officer shortly after the two years have expired; the medical officer is pretty certain he has had T.B. within the two years after discharge, but by reason of the two year limit, the claim cannot be settled in favor of the boy.

COL. FORBES: replied that that was a matter for the medical men to decide, but that he could see no reason why the boy’s claim should not be adjudicated.

GENERAL SAWYER: “Many times I have complaints coming through my office. I wonder if you gentlemen would really like to know what my office represents. I am the liaison officer between yesterday and tomorrow. Any difficulties of any kind that ever come through my office are those that do not get through anybody or everybody else. So a number of these complaints about the extensive and exhaustive records and the paper work that is being carried on in the various departments come to me. I think the matter is of such importance that I should like, Sir, to make this motion:

‘That a committee of five, representing each of the departments, be selected to take under advisement the matter _MOTION_ of the paper work of the various departments and to make such suggestions and recommendations as they may deem advisable; this, regarding hospitals’.”

Motion was seconded by Surgeon General Cumming.

Motion carried.

SURGEON KOLB: offered a resolution:

‘That there be established a special hospital of 100 beds for treatment of beneficiaries of the Veterans’ Bureau who are pronounced psychopaths or drug addicts.’

Then followed a general discussion by Dr. Klautz, Dr. Cobb, and others regarding drug addicts who have T.B., regarding the manner of retaining such patients in hospital contemplated.

DR. GUTHRIE: stated that the Bureau is investigating such a matter and invited suggestions from the doctors.

The above resolution was offered as a Motion, and was seconded by Dr. Wilbor.

Motion carried.

DR. FOSTER: suggested the cutting of the man’s compensation as a means or help toward keeping him in the hospital,

COL. FORBES: replied that when a man has become hospitalized, and his disability has been connected with service, he is entitled to $80 a month.

It was here remarked by a conferee that General Order No. 27 would take care of such patients; that if he left the hospital his compensation would be cut and he would not be readmitted within so many months.

SURGEON CHRONQUEST: offered the resolution that action be taken by the Hospitalization Committee toward the establishment of a Federal commitment law in psychopathic cases.

COL. FORBES: replied that there had been decisions made against such a suggestion, by reason of the fact that it interfered with the prerogative of the States.

SURGEON CHRONQUEST: mentioned the possibility of a suit being filed against the commanding officer of a hospital for the illegal detention of a patient.

DR. WHITE: explained that a man in the service—Army, Navy, etc.—could be sent by the Secretary of War, of the Navy, to St. Elizabeths as well as anywhere else; but that the courts in the District state that as soon as the man changed to civilian status his commitment ends, and he is illegally detained.

COL. FORBES: suggested that the question be referred to the Legal Division of the Veterans’ Bureau.

COL. FORBES: “The conclusion of this session precludes me from any further activity here. There is a little lack of enthusiasm here. I want you to remember that we have asked you gentlemen here by and under proper authority, and that it cost a good deal of money to bring you here, which money is coming out of my appropriation. Now you have got to come through with everything that is in your systems; you have got to give us resolutions, advice, etc., and as long as I am coming to these meetings I want to see lots of interest and enthusiasm shown, especially by you gentlemen who are commanding large institutions. Surely you have known lots of improvements you could suggest. I want you to make such suggestions.

During tomorrow’s session when we are having motions and resolutions, have something to offer. We are here to serve the Government and the ex-service men. I want you to help me, because in helping me in my work you are doing what the law has provided for the ex-service men.

I have been in your hospitals, most of them and I am wonderfully well satisfied with the work you are doing. I am wonderfully happy because of the spirit shown and the accomplishment you have made. You have worked against odds many times, and I know there has been lack of appreciation. What moneys you need for medical service it is my duty to see you are allotted. I want you to know that we are not opposing any of the medical activities, because as I said, I believe and I am satisfied that our greatest problem in this work is one of a medical nature. Of course the Veterans’ Bureau must properly operate through its doctors, and those of you who are handling this big medical problem must help me, and I must do what you decide is best to be done in the interests of the men.”

MEETING ADJOURNED—4:30 P.M., Jan. 17, 1922.

_Third Session_ Wednesday, January 18, 1922.

At 10:00 A.M. the meeting was called to order by General Sawyer.

The roll was called by Dr. W. A. White.

GENERAL SAWYER: Called attention to the fact that is had been discovered during yesterday’s afternoon session that a number of resolutions would probably be presented during the Conference, some of which would require very close attention, and that the Federal Board of Hospitalization is of the opinion that it is quite necessary to appoint a Committee on resolutions, whereupon the following Committee was appointed.

Committee on Resolutions.

Major General Merritte W. Ireland, U. S. A., Rear Admiral Edward E. Stitt, U. S. N., Surgeon General H. S. Cumming, U.S.P.H.S.

In accordance with a resolution passed during yesterday’s session, the following Committee was also appointed:

Committee on Forms:

Captain Norman J. Blackwood, U.S.N., Surgeon M. C. Guthrie, U. S. Veterans’ Bureau, Asst. Surg. Gen. J. W. Kerr, U.S.P.H.S., Colonel James A. Mattison, N.H.D.V.S., Major L. L. Hopwood, U.S.A.

General Sawyer urged that the Committee on Forms meet at the earliest possible moment in order that plans may be devised to take up immediately the work involved in this connection and that suggestions be obtained from the Committee, which will necessarily be brought to the attention of the heads of the Departments represented in the Federal Board of Hospitalization. He stated that every endeavor will be made to simplify matters in order that clerical work may be reduced to the lowest point consistent with the requirements of law. He pointed out in this connection that the requirements of this nature had recently been modified by over fifty per cent and that the Internal Revenue Service is now taking up this same subject.

General Sawyer introduced Major General Merritte W. Ireland, who presided over the morning session.

GENERAL IRELAND: requested those present to make extensive notes as to the points brought out by the various speakers relative to such matters it was desired to discuss later, stating that the papers would first be read and would then be open for discussion.

COL. P. S. HALLORAN: read a paper on the subject of “U.S. Veterans’ Bureau Inspections, U. S. Veterans’ Hospitals”, as follows:

“The inspections of the U. S. Veterans’ Bureau hospitals were formerly made by the General Inspection Service of the U. S. Public Health Service.

In October 1921, the Director authorized in General Order #39, the organization of an Inspection Service of the Medical Division of the Bureau under the provisions of sections 2 and 9 of the Act of Congress approved August 9th, 1921, commonly known as The Sweet Bill.

In carrying out Section 6 of the Sweet Bill which authorized the decentralization of the Veterans’ Bureau, the Inspection Section was organized to consist of the Chief and several assistants located in the Central Office, and an Inspection Section in each District Office.

The Section in the Central Office functions under Assistant Director of the Medical Division, and the Inspectors of the District Offices function under the immediate supervision of the District Medical Officer.

The Chief of the Inspection Section directs and co-ordinates the duties of all personnel assigned to Inspection Section including those temporarily assigned to it for special duty, for example, various specialists at the Central Office are available to investigate matters pertaining to their specialty, and for this purpose, are temporarily assigned to the Inspection Section and work under the direction of the Chief of the Section to whom their report is submitted.

Ordinarily the District Inspectors make all inspections and investigations within their respective districts when directed by the District Manager or the Director of the U.S. Veterans’ Bureau. Only special cases are investigated by the Central Office.

In general, the duties of the Inspection Section are to make such inspections and investigations as may be necessary in order to standardize the character of examinations, medical care, treatment, hospitalization, dispensary, and convalescent care, nursing, vocational training, and such other services as may be necessary for the welfare of beneficiaries of the U. S. Veterans’ Bureau.

Upon the organization of the Inspection Service in each District, instructions were given from the Central Office, that the work of the Inspection Service would first be to make complete inspections of all Contract Hospitals caring for ex-service men. The inspection of Governmental Hospitals to be delayed until the Contract Hospitals had all been inspected. This course was taken due to the fact, that is was generally known Governmental Institutions were well organized, and had recently been inspected by Officers of their respective services.

The inspections of Governmental Institutions made by the Inspection Section of the Bureau are limited to matters which directly concern the welfare of the beneficiaries of the Bureau. Investigations of the official conduct of acts or officers of Governmental Services ordinarily are conducted through the regular agencies of those services which are organized to guide and control their own personnel, and to whom such matters are referred through proper channels to the Director of the Bureau for transmission to the services concerned, for their investigation and administrative action.

See General Order No. 28—U. S. Veterans’ Bureau.

It is the policy of the Director to cause an investigation to be made of all complaints received which concern the welfare of the ex-service man, although it is realized that often complaints are grossly exaggerated.

During the comparatively short period which the Inspection Section has been functioning, the following are a few of the principal complaints received and investigated:

(1) Loss of property such as valuables and clothing of patients. Investigation has shown, that patients were not informed of the hospital regulations regarding the disposition to be made of these articles upon admission; adequate lockers not available, or total disregard by patients of existing hospital regulations.

(2) Preparation and shipment of remains of deceased;—casket too small, shabby lining; no flag furnished; shipping-box broken, due to lack of reinforcements; shroud of cheap material.

Investigation usually shows gross exaggeration. In some instances specifications for the casket, shroud and shipping-box have been such that cheap material is provided. Due to this fact the contract price has been too low. The Director is willing to provide sufficient amount and desires that presentable casket and substantial shipping-box be furnished.

Investigation has also shown that record is not always kept that the remains have been inspected by a medical officer, before shipment.

(3) Poor food, especially weak coffee, and food cold when served. Investigation usually shows fares as a rule, are good, the complainant usually being tired of institutional menus.

(4) Cooks and other food handlers not examined for venereal diseases and carriers.

(5) Mixing colored and white patients in wards and dining rooms.

(6) Rough handling of patients by attendants. Reports are usually greatly exaggerated, or without foundation.

(7) Arrogance and overbearing on the part of Medical Officers towards the beneficiaries. Such charges have not been substantiated.

(8) Sputum of T. B. patients not examined routinely at stated intervals. Temperature of T. B. patients not taken.

(9) Rest periods not enforced.

(10) Insufficient bed clothing. Investigation has shown a few instances where blankets through long service are much worn and have lost their warming properties.

(11) Insufficient heating. In a few instances, it has been shown that T. B. patients have no warm place to dress and undress in, when taking open air treatment.

(12) Fire drills not held, and regulations not posted.

(13) Delay in making physical examination after admission of the patient to hospital.

(14) Beneficiaries claiming they were not informed of the provisions of General Order #27, U. S. Veterans’ Bureau, 1921, upon admission to a hospital.

(15) Bed linen not changed sufficiently often.

In general, the above list of complaints are rarely received from Governmental Institutions. When Inspectors have found unfavorable conditions effecting the welfare of the beneficiaries of the Bureau in Governmental Institutions, prompt remedial measures are usually instituted to correct the conditions by the Commanding Officer of the Hospital.”

File No. 89960

UNITED STATES VETERANS’ BUREAU. September 9, 1921.

_GENERAL ORDER NO. 28_

Subject: STANDARD OF REQUIREMENTS FOR HOSPITALS.

The following General Order is hereby promulgated, effective this date, for the guidance of all officers and employees of the United States Veterans’ Bureau:

Minimum requirements have been adopted for all institutions furnishing medical care and treatment for patients of the United States Veterans’ Bureau, including hospitals under contract, as follows:

_REQUIREMENTS FOR ALL HOSPITALS_

1. The hospital should maintain a service whereby at least one resident physician is on duty at all times.

2. There should be an organized medical staff composed of men competent in their respective fields of medicine and actively meeting their responsibilities for the direction of the professional policies, for the medical work of the institution and also for the professional care of the patients in the hospital.

3. Provision for examination and treatment by dentists and specialists in eye, ear, nose and throat and genitourinary work.

4. Resident trained nurses—not less than 1 for each 10 or any part of 10 bed patients.

5. There should be facilities and personnel for the proper administration of dietetics.

6. There should be periodic staff meetings to discuss—

1. Errors of diagnosis.

2. Unsatisfactory results of operative or medical treatment.

3. Autopsy results.

7. Adequate supply of non-professional personnel for all needs of hospital.

8. Satisfactory fire protection for all classes of patients and perfect fire protection for bed-ridden patients.

9. Satisfactory sanitary conditions as regards heat, light, sewage and garbage disposal, toilets, baths, water supply, laundering, cooking, dishwashing, refrigerating, handling and serving of food, care of clothing and valuables, cleanliness of buildings, etc.

10. One hundred square foot of floor space for each bed and distance between beds of 3 feet.

11. All rooms and porches to be screened against flies and mosquitoes during the season.

12. Satisfactory record should be made of personal histories, physical examinations, all professional treatments, all clinical, serological, bacteriological or other Laboratory work done for patients, also all x-ray, fluoroscopic and other special examinations made, progress notes, working and final diagnoses, and these records should be kept in a form permitting ready reference.

13. There should be surgical operative facilities provided with sufficient equipment and competent organized personnel to meet properly all ordinary surgical emergencies and to perform all ordinary surgical operations in a manner and with results which meet general professional approval.

14. There should be clinical laboratory facilities or definite arrangements for these facilities to properly carry out clinical, bacteriological, serological, x-ray and fluoroscopic examinations.

15. Physiotherapy: provision for special treatment, such as hydrotherapy and electrotherapy.

16. The systematic use of occupations for their therapeutic effects, under the direction of workers specially trained for this duty.

17. Special attention to recreation and diversion with reference to their therapeutic value.

18. Patients to be taught the elementary principles necessary to secure co-operation in treatment.

19. No charges to be made for patients absent from hospital for more than 24 hours.

20. No extra charges to be made the patient for thermometer, sputum cups, reclining chairs, blankets, medicines or special diet, nor for any other article of a similar nature furnished without charge to a patient in Government sanatoriums.

_ADDITIONAL REQUIREMENTS FOR TUBERCULOSIS HOSPITALS_

1. Resident physicians skilled in tuberculosis—if not living actually on the premises, to be available in five minutes or less. (Not less than 1 for 50 patients.)

2. Outdoor sleeping facilities, or in lieu thereof, provisions for unlimited ventilation of rooms.

3. Suitable rules prescribed for conduct and published rules providing for a satisfactory regimen of treatment in tuberculosis hospitals.

4. Satisfactory treatment conditions, including measures for enforcing suitable discipline and to prevent absence without leave and to prevent excessive exercise, whether from amusement or otherwise.

_ADDITIONAL REQUIREMENTS FOR NEURO-PSYCHIATRIC HOSPITALS_

1. Direction of the administration of the hospital and leadership in its medical work by physicians trained in the diagnosis and treatment of mental diseases.

2. An adequate medical staff organized so that duties are divided in accordance with the training of its different members and with the requirements of the clinical work.

3. Regular and frequent conferences of the medical staff at which the diagnosis, treatment and prognosis of each new case admitted are considered and at which cases about to be discharged are presented, training in psychiatry for new members of the staff being considered as a special object.

4. The reception of all new cases in a special department or in special wards where they may receive careful individual study and where those with recoverable psychoses may receive continuous individual treatment.

5. Classification of all patients with reference to their special needs and their clinical condition, such classification being flexible enough to permit frequent changes.

6. A system of clinical records which permits study and review of the history of cases even after they have been discharged.

7. When possible, the maintenance of a school of nurses under the direction of a supervisor of nurses, who should have, not only the training in general nursing, but special training in nursing patients with mental diseases.

8. The employment of female nurses in all reception and infirmary wards.

9. Liberal use of parole for quiet, chronic patients who can live in farmhouses.

10. Special provision for the tuberculous.

If, after written notice has been given, any institution furnishing medical care and treatment to patients of the United States Veterans’ Bureau fails or refuses to make reasonable effort to meet the foregoing requirements, such institution will be deemed to be rendering unsatisfactory service, and if under contract with the United States Veterans’ Bureau, such contract may be cancelled, and the Director will refuse to make contracts when the care and treatment offered do not substantially meet the requirements specified herein.

SENIOR SURGEON B. J. LLOYD, (U.S.P.H.S.,(R)): presented the second paper, entitled “Admissions to, Transfers and Discharges from Hospitals of Beneficiaries of the U. S. Veterans’ Bureau,” which is given below:

“I do not often speak in public. Occasionally I attempt to speak extemporaneously, but today I shall claim your indulgence and confine my remarks strictly to what is written in this manuscript, for the reason that if taken in a disconnected sense some of the things I shall say might sound sensational, whereas if taken in a connected sense and in the way I shall say them, I think you will agree with me that there is absolutely nothing sensational in my remarks.

Attendance at this conference is indeed both a privilege and an opportunity. To be asked to address this gathering is a distinction worthy of the best that can be said on the topic assigned.

I take it that you are already familiar with the rights and benefits to which the disabled ex-service man is entitled; that you are familiar with the usual routine of paper work and other procedures in admitting, transferring and discharging, and I shall therefore omit some of the more or less definitely settled, fixed policies in this discussion.