Part 9

General Order No. 26–A requires that before a patient is discharged from hospital it should be determined whether or not he is in further need of out-patient care; whether or not he is feasible and eligible for vocational training and if he wanted training, that this should be arranged before he is discharged, and that the necessary adjustments or re-adjustments of all matters pertaining to a claimant’s compensation be entirely completed by the time of his discharge from hospital; and further it must be distinctly understood in carrying out all of this that no unnecessary delay in discharge of patients would be allowed. A pretty complex and contradictory situation you might say. However, between the time of the issuance of General Order No. 26 and of General Order No. 26–A—to be exact, on October 14, 1921, a general order was addressed by the Medical Division of the U. S. Veterans’ Bureau to the several Government services—the Surgeons General of the Army, Navy, U. S. Public Health Service, the Superintendent of the National Homes for Disabled Volunteer Soldiers, the Superintendent of St. Elizabeth’s Hospital, and to the fourteen District Managers. The essential parts of this letter are as follows:

October 14, 1921.

PSR/jcs L 10–DMO

District Manager, District No. 1, U. S. Veterans’ Bureau, 101 Milk Street, Boston, Mass.

Dear Sir:

Referring to General Order No. 26 and to Paragraph No. 2, which reads as follows:

“All patients now in hospitals in your District, who do not require further hospital treatment, will be given four days notice to make their personal arrangements and will then promptly be discharged from hospital. Each patient discharged under existing Regulations will be furnished transportation to his bona fide legal residence in the United States or to the place from which he was hospitalized. Notification of such discharge will be sent immediately by the Officer in Charge of the Institution caring for beneficiaries of the U. S. Veterans’ Bureau to the District Manager of the District in which the institution is located.”

In complying with these instructions and before authorizing discharge of patient of the U. S. Veterans’ Bureau from hospital, district Managers will determine:

1st. Whether the patient is in need of out-patient, dental, physiotherapy, or other treatment, or convalescent care. If so, District Managers will make the necessary arrangements to continue the treatment indicated after discharge of the patient from the hospital.

2nd. Whether the patient desires vocational training: If so, his eligibility and feasibility will be determined and arrangements made for placing him in training promptly upon his discharge from the hospital.

3rd. Necessary adjustment or readjustment of all matters pertaining to his compensation will also be completed promptly upon his discharge from the hospital.

In order to accomplish the above patients of the U. S. Veterans’ Bureau will not be discharged from hospitals until District Managers have been notified and the necessary arrangements made by them for the determining of the above factors upon which the District Managers will approve discharge and notify the hospital accordingly.

Instructions contained in this communication do not apply to the Provisions of General Order No. 27, regarding the discharge of patients for disciplinary reasons.

Very truly yours,

ROBERT U. PATTERSON, Assistant Director, U. S. Veterans’ Bureau.

This supplementary letter—perhaps it did not reach you all—was not as susceptible of misinterpretation as General Order No. 26–A. The needs of the patients about to be discharged with reference to after-care out-patient treatment, etc., are not matters which should take long to determine; feasibility for training is also a matter capable of prompt determination; eligibility or the right of a patient for training is a matter that can be handled either before or after a patient’s discharge has been effected, and the necessary adjustments or re-adjustments of matters relating to compensation, while necessary of establishment before discharge from hospital do not require that such patients must remain in hospital until actually in receipt of compensation. It simply means that the important steps leading up to this action should be properly gotten under way, and having done this, the completion of the compensation status can be as readily carried out after discharge as before. Notwithstanding the supplementary instructions following General Order No. 26 still further conflict regarding the application of the two orders in question in the District offices and in the hospitals was apparent from reports received in the Central Office, and it was decided to insert a further explanatory notice in the U. S. Veterans’ Bureau Field Letter No. 20, of December 24, 1921. This notice was as follows:

Judging from letters that have reached the Bureau, there has been some confusion with regard to the exact intent expressed in General Orders Nos. 26 and 26–A.

Rightly interpreted, these orders are in no wise contradictory.

The intent of General Order No. 26–A is fivefold, namely:

(1) To determine the eligibility of claimants for vocational training.

(2) To determine their feasibility for training.

(3) To arrange for training when eligibility and feasibility are established.

(4) To accomplish everything necessary to adjudicate claims.

(5) Provision for outpatient treatment when required.

“All of these matters ought to be attended to before the patient leaves the hospital, and with close co-operation and efficient administration, both in the field and in the Bureau, this can be done, and of course must be done without keeping the patient in the hospital after his treatment is completed. Manifestly there is only one way to accomplish this, and that is, to anticipate the discharge of the patient a sufficient length of time in advance to provide for these objects.”

“_Feasibility_ of training is to be determined preferably by the Medical Officer in Charge of the hospital, or his assistant, and means only that, in his opinion, the patient is physically and mentally fit to receive vocational training.”

“The other requirements must be met by the Bureau or its field representatives, but with the co-operation of the hospitals. A representative will shortly be named at each hospital, who will keep himself informed of the status of each patient’s claim to the benefits enumerated and who will follow up all cases in which there may be delay.”

“Again reminding all concerned that anticipation is the key-note of the action desired in these General Orders, the hope is expressed that the objects outlined may be obtained, as nearly as possible, before the patient is ready to be discharged.”

Any discussion of the instructions of General Order No. 26 and No. 26–A must take into consideration the reasons which led to the issuance of those orders. The officials in the U. S. Veterans’ Bureau had been convinced for sometime that a high percentage of patients were being cared for in hospitals, and this applies particularly to contract hospitals, whose necessity for remaining in hospital was not based upon sound medical reason, and in many instances upon no real medical indication at all. A number of factors were responsible for this situation,—the rapid growth and development of the District offices required the personnel therein to work at high pressure at all times; it has been a continuous struggle to keep abreast of the volume of incoming correspondence, with requests for hospitalization, application for compensation, claimants crowding the doors, and a thousand and one other subjects. It has been a struggle on the part of the District personnel to keep from being swamped by the tremendous and ever increasing daily load. Hospitalization was authorized and carried out both in contract and Government institutions in cases of all character for treatment where the indications for such were great and immediate, or were slight or nil, for ailments, objective and subjective, imaginary and real, for physical examination and report, for determination of compensability, and for information concerning the connection with military service of a claimants disability. The list grew so rapidly that patients were lost sight of. Many claimants were hospitalized for examination and treatment, and overlooked after examination and treatment had been completed. Contract hospitals particularly, through lack of a proper and direct connection in channels of communication between such hospitals and the District offices, were carrying patients over long periods of time. Patients got into contract hospitals for whom no proper authorization was ever provided, and the records of whom were never clearly defined in the District offices. The scattering of patients anywhere from one to a considerable number in several hundred contract institutions in each District extended the lines of communication between the Government and the District Offices until it was practically impossible to keep the contact clear. The Central Office in Washington felt that it was time to take stock, and stock-taking at almost any time is an enlightening process. The Director desired to remove claimants from contract hospitals; he desired further to utilize as much as possible the existing Government facilities which have been provided for this purpose.

Under date of September 1st, about the time of the issuance of General Order No. 26 there were 9,592 patients in _862_ private hospitals; there were 18,698 patients in _92_ Government hospitals. Today there are _8924_ patients in 757 contract hospitals and _20339_ patients in _92_ Government hospitals. From these figures it would appear as though the clearing out of hospitals, as provided for in General Order No. 26, has not been productive of results. This, however, must be viewed in the light of what is actually taking place in the field. About the time of the issuance of General Order No. 26, or a little before, every District was putting into the field a Clean-up Squad for practically every state, the function of which Squad was to make contact with all potential beneficiaries of the U. S. Veterans’ Bureau for the purpose of establishing claims, of offering hospitalization for examination, for emergency treatment, and for other situations. These Clean-up Squads served to feed a considerably increased number of patients of all types into hospitals. Anticipating that such period of hospitalization would be brief, they have used contract hospitals because of this fact, and because of their location in the near or immediate vicinity of the patients handled. The turnover has thus been largely increased. The increase of patients in Government hospitals has risen steadily at the rate of approximately 600 a month until it has reached the figure of _20339_ patients, as against _18698_ patients in the early part of September. There has been a slow but gradual decline of patients hospitalized in contract institutions, notwithstanding the very material influx into the hospitals by reason of the Clean-up Squads just spoken of. It might appear to you who are actually caring for patients in your institutions that notwithstanding the explanation of the meaning of General Order No. 26 and 26–A, that the holding of a patient in a hospital until all of the several matters necessary can be taken care of, will result in undue delay in discharge. This doubtless would be true if each hospital were required to assemble data called for and make the other necessary provisions and forward the reports to the District office to await return and receive transportation before a patient could be discharged.

In the issuance of General Order No. 26–A and the supplementary instructions it was contemplated in the Bureau here in Washington that a representative of the District Manager would be necessary in each hospital, at least, in those of considerable size, and some distance away from the District office, in order that direct liaison between the District Manager and the hospital in question might be maintained, it being the business of this representative to see that matters of after-treatment, convalescent care, feasibility for training, and necessary adjustments of compensation matters will be properly taken care of prior to the time that it is actually necessary to discharge the patient. This representative will keep contact with the appropriate District office and handle transportation for returning a claimant home or to point of hospitalization. Anticipation on the part of the medical officers actually taking care of claimants in hospitals, of the needs of each patient in respect to these necessary details would enable the District Manager’s representative located in the hospital to carry out the proper adjustments of these important matters and the patient made ready for discharge at the proper time without delay. To make effective the services of the Government hospitals in the functions which they are carrying out, a thorough understanding of the problems involved is very necessary and a sympathetic understanding of each other’s problems, as between the District Managers and Hospitals together with a spirit of co-operation and fair play is essential to the desired results, if not an absolute prerequisite to the success of the undertaking.

Many features of our work are, I recognize, trying and a thousand and one annoyances are a part of each day’s work. Keeping before us at all times the meaning of the work involved is a great aid to the elimination of misunderstanding, and personal conferences serve to smooth out and adjust overlapping of authority. One ex-service man maimed or injured, replaced into his particular niche of our social fabric should make us feel appreciative of what our work means, and the knowledge that we are rebuilding men who have suffered in the service of our country, should fortify us very strongly against the annoyances and trials which must sink into insignificance when compared with the work done. I know that you all realize this and that your every effort and energy is bent to the accomplishment of the purpose for which we are all working together; that we are making headway in the proper direction is beyond question; that we are helping to rebuild the disabled is becoming more apparent as our work goes along, and we all, I know, are not only proud that we are having a part in this work, but feel privileged that our services are helping to bring about these ends.”

Upon the conclusion of Dr. Guthrie’s paper, the subject-matter of the several papers read during the morning session was thrown open to discussion, the presiding officer remarking in this connection that full opportunity would be given to all to freely express themselves. With reference to the matter of the issuance of so-called conflicting orders, which had been referred to, he stated that the administration of the Veterans’ Bureau is regulated by certain laws upon which these orders were based, and that when such laws are changed, it of course becomes necessary to revoke certain orders in force at the time. He added that the matter of hospitalization, thrown suddenly upon the Public Health Service and the U. S. Veterans’ Bureau is a tremendous undertaking and that those who carry on this work are entitled to the sympathy of all good people.

COL. BRATTON: wished to place himself on record as saying that there is nobody who is in greater sympathy with the wounded soldier, whom he would like to see receive all that a grateful Government can give, but that due to the very liberality of the Sweet Bill, cases have crept in whereby compensation is being received for disabilities in no way connected with the service. He stated that the Sweet Bill does not clearly define what the line of duty shall be and that he is amazed at the number of cases that are being carried along and hospitalized; that he is of the opinion that the gentlemen in Congress do not realize how liberal this act is and that men would receive compensation for diseases which existed prior to their coming into service. He offered the following motion amending section 300 of the Sweet Bill, to be incorporated in a resolution to Congress as coming from this body, which resolution was adopted:

Motion:

RESOLVED, that in considering the question of line of duty, it should be understood that an officer of the Army or Navy, or an enlisted man of the Army or Navy, who has been accepted on his first physical examination after arrival at a military station as fit for service shall be considered to have contracted in line of duty any subsequent determined physical disability, unless such disability shall be shown to be the result of the patient’s own carelessness, misconduct, or vicious habits at any time, or to have been contracted while absent from duty without permission, or unless the history of the case shows unmistakably that the disability existed prior to entrance into the service.

DR. G. H. YOUNG: stated that it has frequently been a shock to his sensibilities to see the manner in which compensation has been awarded to certain ex-service men who are not in any sense deserving; that assuming John Doe had a disability when he came into the service, it is now going on four years since his discharge and if such disability was exaggerated in service he should be compensated just as if he had been wounded in action; that the question comes up as to how it can be determined as to whether the exaggeration of his disability arose say during six weeks, six months or eighteen months of his military service or in the period of nearly four years which has since elapsed? That he is of opinion that this applies especially to the in-patienthiatric cases.

DR. COBB: suggested that general discussion of the other subjects be taken up and that this very important matter be brought up later.

DR. BREW: referred to the case of a man in hospital with a fracture of the thumb, which was operated upon with the result that it functioned properly and the man was not handicapped in the least. After the operation, which resulted in his total rehabilitation the man was awarded vocational training and drew $80 a month. He referred to the case of another man who had been in every hospital he could reach, obtaining transportation from the Red Cross when he could not otherwise obtain it; this man was inducted into service at Jefferson Barracks and had a military service of 28 days, of which 28 days he was in hospital 14 days, and his disability was amoebic dysentery, which he could not have incurred at Jefferson Barracks; this man was in hospital for 18 months and has been drawing $130 a month for training, which he has been taking for two years. Dr. Brew also referred to the case of a negro, who had syphilis before he went into the service; that he is as well as the average man of his type and is receiving a compensation of $110 a month; that this man has benefited by his military service because he has had a line of treatment that he would not have received in civil life.

DR. WHITE: (Speedway Hospital) thought that the matter of allowing the space of six feet between beds should be adjusted, as this space will greatly reduce the hospital capacity. He also referred to the matter of rations for absentees and stated a man may be away a matter of seven days without leave and asked whether or not the hospital shall charge for that patient’s rations, as the dietary service must prepare for him whether he is there or not, and there is always the possibility of his return the next day; that it also happens that a patient on leave may return two days before he is expected. He thought that if meals are prepared they ought to be paid for.

Dr. White also referred to losses of clothing which take place and thought it was unfortunate that individual lockers were not supplied for use of patients, as if they were supplied they could be rented to patients at a nominal cost, thereby relieving the institution of the custody of the clothing.

The large amount of paper work was also mentioned by Dr. White. He stated that he understands that when a patient is sent to a hospital he receives a compensation of $80 a month automatically, in which case he cannot see the necessity for making additional physical examinations.

With reference to the matter of admissions, transfer and discharges, Dr. White expressed the opinion that officers should require a patient to state whether or not he is receiving compensation; that in the matter of transfers as well as admissions, officers should be required to state in writing, specifically and distinctly, the reason why they desire cases transferred. He mentioned one instance wherein it was stated that a patient had a gunshot wound of the left thigh, and he simply had a scar to show for it. He thought that officers should be required to state in writing the hospitalization needed. Dr. White also referred to cases where it is desired to discharge a man from a hospital for certain offenses, stating that if this is done, compensation of course would be stopped and the man will not feel kindly toward the particular hospital which discharges him. He was of opinion that in such cases a hospital should be required to terminate its own cases and not dump them off on other institutions and stated that at the Speedway Hospital there is no hesitation about reporting such cases as they are found, and if officers who transfer patients would give specific reasons as to why patients need hospital treatment, there will not be so many men coming into hospitals who do not require treatment anywhere.

In regard to G. O. 26, Dr. White inquired as to who is to decide the feasibility and eligibility of patients who are ready to be discharged, stating that he had been waiting for a representative of the Veterans’ Bureau to be sent to his hospital empowered and authorized to make awards of compensation, as if medical officers are expected to do it, their number will have to be increased; that a man should be sent from the Veterans’ Bureau to attend to matters relating to training and who could say definitely to a patient that he can have such and such training, as it is absolutely necessary to have such a man and if he is provided it will prevent a large number of complaints.

DR. GUTHRIE: stated that he would like to have some discussion as to whether the representative referred to by Dr. White should be a medical officer or a layman; that Dr. White stated that he had expected the arrival of such a representative for some time, and as the doctor is a young-looking man, he thought that if he lived long enough he will see this representative get there.

GEN. SAWYER: mentioned that the Board of Hospitalization has an understanding with the various Departments and the Veterans’ Bureau that these things are to be settled by the Vocational Director, who, it is understood, is to become as quickly as possible a part of the hospital personnel; that he was of the opinion that the Board of Hospitalization came to the conclusion that it was not material whether the vocational representative was a layman or a medical man, but that he personally was of the opinion that upon the judgment of a medical man a great deal depends for the answer that is finally given; that he would like to encourage Dr. White with the thought that the Hospitalization Board has this matter very definitely in mind in order that the man needed may be provided.