Transcriber’s Note:

The cover image was created by the transcriber and is placed in the public domain.

CONFERENCE OF OFFICERS
IN CHARGE OF
GOVERNMENT HOSPITALS
SERVING
VETERANS OF THE WORLD WAR

★★★

HELD IN

AUDITORIUM, DEPARTMENT OF THE INTERIOR

WASHINGTON, D.C.

JANUARY 17–21, 1922, INCLUSIVE

CONTENTS

CONFERENCE OF OFFICERS IN CHARGE OF

GOVERNMENT HOSPITALS SERVING

VETERANS OF THE WORLD WAR

WASHINGTON, D.C.

JANUARY 17–21, 1922, INCLUSIVE

AUDITORIUM DEPARTMENT OF THE INTERIOR

UNDER THE AUSPICES OF THE

U.S. FEDERAL BOARD OF HOSPITALIZATION

PROCEEDINGS OF CONFERENCE OF OFFICERS IN CHARGE OF GOVERNMENT HOSPITALS SERVING VETERANS OF THE WORLD WAR

Opening Session Tuesday, January 17, 1922.

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

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

General Sawyer delivered the following address on the subject, “The Present Status of Federal Hospitalization from the Standpoint of the Federal Board.”

“Commanding Officers:

You are here, as your program indicates, by invitation of the Federal Board of Hospitalization. That you may know your host, the following facts are submitted:

The Federal Board of Hospitalization was created by an Executive Order of President Harding. The purpose of the Board is expressed in the Order creating it, which is as follows:

“Circular No. 44.

TREASURY DEPARTMENT,

Bureau of the Budget

WASHINGTON

November 1, 1921.

FEDERAL BOARD OF HOSPITALIZATION.

TO THE HEADS OF DEPARTMENTS AND ESTABLISHMENTS:

1. For the purpose of coordinating the separate hospitalization activities of the Medical Department of the Army, the Bureau of Medicine and Surgery of the Navy, the Public Health Service, St. Elizabeths’ Hospital, the National Home for Disabled Volunteer Soldiers, the Office of the Commissioner of Indian Affairs, and the United States Veterans’ Bureau, there is hereby organized a Federal Board of Hospitalization.

2. The Board shall be composed of the following officials: An official to be designated by the President, who shall be known as Chief Coordinator and who shall be President of the Board; the Surgeon General of the Army; the Surgeon General of the Navy; the Surgeon General of the Public Health Service; the Superintendent of St. Elizabeths’ Hospital; the President, Board of Managers, National Home for Disabled Volunteer Soldiers; the Commissioner of Indian Affairs; and the Director of the United States Veterans’ Bureau.

3. It shall be the duty of the Board:

(a) To consider all questions relative to the coordination of hospitalization of the departments represented.

(b) To standardize requirements, to expedite the inter-department use of existing Government facilities, to eliminate duplication in the purchase of supplies and the erection of buildings.

(c) To formulate plans designed to knit together in proper coordination the activities of the several departments and establishments, with a view to safeguarding the interests of the Government and to increasing the usefulness and efficiency of the several organizations, and to report to the President thereon.

4. The Chief Coordinator of the Board of Hospitalization shall preside over the Board and be responsible for its efficiency and for developing its activities along practical lines. After a full discussion of any question by the Board, the decision of the Chief Coordinator will be final as to any action to be taken or any policy to be pursued, but any member may appeal from the decision to his own immediate superior.

By direction of the President:

CHARLES G. DAWES,

Director of the

Bureau of the Budget.”

From this you will readily see that the extent of the work under the administration of this Board is very far-reaching and is an innovation in Federal Hospitalization activities, for beside being interested in behalf of reasonable economies in administration, the Federal Board of Hospitalization is particularly and especially interested in carrying out the highest ideals of modern hospitalization for the far advanced Veteran.

The President and his administrative family have in mind, as the basic principle of all hospital service, the very best that can be supplied, measured by real end-results.

The Board of Hospitalization represents all of the Departments of the Government directing and controlling the Federal Hospitals of the United States. Each of the Chiefs of these Departments will speak of his particular relation to the subject of Hospitalization as it refers to the World War Veteran, as the program proceeds.

In order that each of you may understand the magnitude of the entire subject of Hospitalization of the World War Veteran, I wish to present the following facts;

Today there are being hospitalized under Government control, in Federal Hospitals, 22,440 World War Veterans, who are distributed among the various Departments as follows:

This does not take into account patients in contract hospitals which now number 9,066. This enumeration demonstrates something of the scope and nature of the work for which the members of the Board of Hospitalization are responsible.

It may interest you to know that there are now under construction 7,592 new beds, which will be ready for occupancy within the next few months and that the Government is at present contemplating at least 2,500 more beds under the new Langley Bill, so ultimately the Government will have under its direct administration hospital capacity for a minimum of 32,000 patients, which is estimated to be the peak load.

Heretofore there has been no coordinate plan of operation of these various institutions. Under the Board of Hospitalization all of this has been changed and today, you, whether from the Army, Navy, Public Health Service, National Home for Disabled Volunteer Soldiers or the Department of the Interior are all members of one big professional family, each engaged in the same service, under the same regulations, for the care and treatment of the World War Veteran.

The Hospitals engaged in this service number at present 107, distributed as follows:

These institutions are located in all sections of the United States from the Atlantic to the Pacific and constitute one of the greatest hospitalization propositions within the history of any country.

The personnel engaged represents an Army of almost as many more persons. In other words, Uncle Sam, within himself, is today keeping in operation a hospitalization program incomparable with anything with which former experiences are familiar.

With this representation of the subject and its magnitude, I wish to remind you that each one of you personally and individually is a part of this great machine; and upon you rests the responsibility of the carrying out of such policies as are adopted by the Central Administration.

In order that there might be perfect coordination and cooperation in all of these hospitals and that all institutions serving the World War Veteran might be operated upon a standardized basis, the Board of Hospitalization recently adopted the following regulation as to personnel:

Making a total of 182 employees to every 200 patients, or almost one attendant and assistant to each patient.

This arrangement provides that all patients will have equal care and attention of such a similar type as to guarantee to all classes of patients the best of professional, nurse and domiciliary attention that can be given, no matter in what Department they are being treated.

All of the Departments constituting the Board of Hospitalization are now meeting in joint sessions, wherein they take up in detail all of the matters pertaining to the welfare of the Veteran Hospitalization subject. Out of this consideration there is developing a much better understanding, a more complete system of operation, better conduct and much better end-results.

One of the objects of this conference is that you the better understand by personal contact with each other and with the different phases of the work, what the business of caring for these veterans in its entirety means. We know of course that you each have your special problems, you each have certain affairs within yourselves that keep your attention very much engaged in the things with which you come personally in contact, but we thought it would give you a better impression of the magnitude and importance of the subject if we were to have you here where those who are responsible for the direction of the affairs of Hospitalization could meet you individually.

We want you to know that we are greatly interested in you and the service you are rendering. We wish you to feel assured that your interests are our interests. We wish to impress upon you that the conduct of the affairs under your administration means the reputation and the historical record of the Government’s treatment of the World War veteran.

We are anxious indeed that you should get from this meeting inspiration for better work and encouragement in the efforts that you are putting forth, new ideas with which to meet the great and everchanging propositions which are before you, closer touch with those who, like yourselves, are interested in the World War defenders. This accomplished and each of us will have benefited and the expense of time and money in your coming here will be justified.

Your contact here should make you bigger and broader men. If you will take out of the great opportunities that are presented in the privileges of this meeting, the effects which may be obtained, we are sure that you will go back to your respective fields of service better satisfied, more capable and certainly more determined than ever to render the best service there is within you under all circumstances and conditions.

It seems pertinent that I should impress upon you at this time that no matter what kind of institutions the Government may possess, how well equipped with apparatus, or how pleasing in location, without your interest, without the scientific care and attention which you can provide, without your determination and your loyal support and action in all of the affairs pertaining to the conduct of these institutions, they will fail.

On the other hand, if you will give them the best within you, if you will keep yourselves professionally and administratively in the vanguard of such affairs, if you will go whole-heartedly, persistently and determinedly forward to the carrying out of the highest ideals your constructive visions can invent, the world War Veteran will realize that in his Government he has the care and appreciation of the best Government under the sun.

Allow me to again admonish you that upon you individually and personally rests much of whatever is to come to the present Administration, either in the form of complaint or of eulogy. To the end that it may be eulogy, let there ever abide with you the assurance that the President of the United States and all of his administrative assistants will be with you heart and soul in everything that promotes the interest of the rehabilitation of the World War Veteran. Remember that you owe to your country and to yourselves that you practice economy, that you deal fairly, that you act squarely with all of the propositions which come to you. Do not forget that you should be loyal to the Departments to which you belong, ever obedient to the orders of your Chiefs; that you be faithful, earnest and sincere, honest, conscientious and ever active in behalf of the highest principles connected with the maintenance of the institution with which you are connected and finally that you be ever able to register and substantiate yourselves as American citizens, full of an American spirit, loyal to country and to flag.

If you will do these things, you will have the everlasting gratitude of the President of the United States, you will be entitled to and will receive the econiums of our dear doughboys and above all you will have the satisfying consciousness of a noble duty truly done.

In order that the business of the conference may be transacted expeditiously and effectively, the following rules will be enforced by the presiding officer of each session:

1. Those having addresses upon specified subjects are expected to present a typewritten copy to the Secretary that it may be kept for reference in the Office of the Board of Hospitalization. 2. All addresses will be limited to 15 minutes. All special subjects will be limited in presentation to ten minutes. General discussions will be limited to five minutes. 3. Each session will begin promptly on time. 4. Roll call of the attendants will be taken at the beginning of each meeting. 5. Reports of all proceedings of sufficient importance will be recorded by the expert stenographers in attendance. 6. This is a business affair and should be so considered by all present. We are here to develop plans. We are here to receive suggestions and get in line for the execution of orders which will lead to the development of the highest order of hospital care and treatment. With these suggestions we will proceed to the carrying out of the program.”

“I have pleasure at this time in introducing to you Colonel Charles R. Forbes, who will speak to you on the ‘Relation of the Veterans’ Bureau to all Hospitalization Activities’.”

COLONEL FORBES: Addressed the conference as follows:

“Upon the signing of the Armistice on November 11, 1918, there was immediately commenced the demobilisation of the armed military and naval forces of the United States, comprising approximately 4,000,000 men and women. As an aftermath of war service from the result of battle wounds, gassing, injuries and disease it was anticipated that there would be a large number of men and women who would be physically disabled, either temporarily or permanently, partially or totally. While it was known with a reasonable degree of accuracy how many there were who has been discharged from the several services on Surgeons’ Certificate of Disability and the number discharged with disability noted at the time of discharge, it was not possible to foretell the magnitude of that considerable body of men and women who though discharged from the service apparently in good health would subsequently develop a disability traceable to military service. Even at the present time, more than three years after the Armistice it is not possible to state the exact magnitude of the medical problem confronting the United Veterans’ Bureau, since new claims for compensation because of disability are being filed at the rate of approximately 541 per day. As an index however to the magnitude of this problem, gentlemen, let me tell you that to date have been filed more than 762,000 claims for compensation for disability and death incurred in military or naval service. While this total number of claims have not all been allowed, this number does constitute the present potential load for the United States Veterans’ Bureau.

By the original War Risk Act and subsequent acts amendatory thereto,—the United States Government recognized its very great obligation to the ex-service men and women who had become disabled through service, and by these Acts provided not only financial aid to the disabled veterans but also all reasonable medical and surgical treatment and care, whether in a hospital, out-patient office, or at home.

The problem of hospitalization itself soon became of paramount importance. It was initially recognized that, in spite of the meagre governmental hospital facilities then available for the care of beneficiaries of the United States Veterans’ Bureau, it was essential for the best administrative control of veteran patients and for the best professional control over their treatment to place the beneficiaries of the United States Veterans’ Bureau under government supervision in government owned or operated institutions. The carrying out of this policy has been proceeding steadily at a rate commensurate with the rate at which additional government hospital beds have been made available. At no time however has it been possible to discontinue the use to a considerable degree of contract civil institutions. Even at the present time the United States Veterans’ Bureau is utilizing approximately 757 civil institutions for the care of approximately 8,924 of its beneficiaries, and has contracts with a total of 1,524 civil institutions for such care. It is however significant to note while in July 1920 more than fifty percent of Veterans’ Bureau patients were in contract hospitals, on January 1, 1922, but 30 percent of patients were in contract hospitals. Furthermore the number of hospitals being utilized at any time had dropped from approximately 1200 to 757.

The curtailment in the use of private facilities was of course the direct result of increased facilities in government operated hospitals. The United States Government had originally stipulated that the hospitalization of veterans of the World War should be provided for the United States Public Health Service through its Marine hospitals and such other hospitals as it had been authorized to acquire. When however it was discovered that the immediate facilities offered by these hospitals were insufficient to meet the demand for hospitalization, the hospital services of the United states Army, the United States Navy and the National Homes for Volunteer Disabled Soldiers were to a certain extent made available to the United States Veterans’ Bureau.

In March, 1919, the United States Public Health Service was operating but 21 small Marine Hospitals. In order to meet the demand made upon it by the then Bureau of War Risk Insurance, additional hospital facilities were rapidly acquired, so that by November, 1919 there were in operation a total of 38 hospitals with a total bed capacity of approximately 7,625. A year later namely on November 1, 1920 there had been made available a total of 52 hospitals representing 13374 hospital beds. At the present time, January, 1922, there are available 65 United States Public Health Service Hospitals representing approximately 18,200 hospital beds. It is true that due to the necessity of securing with the least possible delay adequate hospital beds, it was necessary to make use of certain Army cantonment hospitals of temporary structure. Hospitals of this type are admittedly unsatisfactory, and it is my earnest desire to close such hospitals just as soon as properly located hospitals of permanent construction are available to take their place.

Although prior to July, 1920, there had been a limited use made of the facilities of the Army, Navy and National Soldiers’ Homes in the case of Veterans’ Bureau patients, it was not until that date and in accordance with provisions of the Sundry Civil Act of the 66th Congress that a systematic and more extensive use of these facilities was proposed. It was perceived that with the general reduction in the Army and Navy personnel a number of large and well equipped government hospitals were not being utilized to their full capacity. The utilization of these facilities would have a two fold result, first, the placing of a larger number of patients under direct government medical supervision, and second, a more pronounced curtailment in the use of contract civil facilities.

In June, 1920, under plans agreed upon by the representatives of the then Bureau of War Risk Insurance and of the several government services there were immediately made available 4181 hospital beds, not including those in operation by the United States Public Health Service divided among the services as follows: Navy Department Hospitals, 1760; War Department Hospitals, 1510; National Soldiers’ Homes, 911. Additional plans contemplated increased facilities by all those services. At the present time, January 1922, in accordance with these plans the following number of beds have been made available by these three services: Navy Department, 3396; War Department, 2917; National Soldiers’ Homes, 3317; Total, 9630.

I have briefly outlined the growth to the present time in government hospital facilities available to the United States Veterans’ Bureau. Combining the figures I have enumerated it is seen that the total number of available government hospital beds has increased during a period of a little more than two years and a half from a few thousand beds in 21 Marine hospitals to a total of 28655 beds in 94 government hospitals.

Let me now outline briefly the growth in our hospital population over this period. In September, 1919 there were recorded a total of 6003 patients of the Bureau of War Risk Insurance, which total had increased by January 1920 to 10907, and by July 1920 to 19,489, averaging over this period a monthly increase in hospital patients of approximately 1225. From July 1920 to January 1922 the hospital population increased from 19,489 to 29,263.

These 29,263 patients are hospitalized to the following extent in the several classes of facilities: United States Public Health Service, 13,874; United States Army, 1530; United States Navy 1473; National Soldiers’ Homes, 2637; St. Elizabeth’s Hospital, Interior Department, 825; Contract Civil Hospitals, 8924. By general class of disease, these patients are divided as follows: Tuberculosis, 11,822; Neuro-psychiatric, 8,414; General medical and Surgical, 9027.

Of the total number of 28,655 government hospital beds available, 20,339 are occupied at the present time, leaving a balance of 8,316 unoccupied hospital beds.

As previously stated, it is the policy of this Bureau wherever practicable, to remove beneficiaries of the Bureau from contract institutions and place them in hospitals operated by the governmental medical services. If it were possible at the present time to fill every vacant government bed by patients in contract hospitals we would still be obliged to continue 608 cases in contract institutions.

An analysis of the vacant government beds shows that they fall under the following category:

An analysis of the patients in contract hospitals shows they are classified as follows:

A review of these two sets of figures shows that although there are apparently ample facilities for the care of general medical and surgical cases, there is a real and serious shortage of government beds for the care of tuberculosis and neuro-psychiatric cases.

In considering the use of government hospital beds at present reported vacant, it is of course entirely impracticable to attempt to accomplish the complete filling up of all government hospitals. As you all realize, this is due to a number of reasons, chief of which are (1) the administrative necessity at all hospitals of maintaining a surplus of beds amounting to from ten to fifteen percent of capacity to allow flexibility in case of epidemic or sudden emergency; and to permit unhampered the routine admission and discharge of patients, (2) the location of vacant beds away from the points of greatest demand, and (3) the fact that the vacant beds available are not of the type required at points where the Bureau needs them.

From an analysis of this whole situation it is believed that we have sufficient beds available for the care of general cases with the exception of two or three areas of the country, such as Memphis, Tennessee, and in the metropolitan district of New York. Some provision must be made to care for cases of a general nature because facilities at these points are totally inadequate. In New York, the existing facilities must be given up by June 1922.

However, the number of general medical and surgical cases requiring treatment will steadily diminish and contract hospitals in many instances would ultimately be able to care for their needs. On the other hand, the Bureau must make provision for the care of tuberculosis and neuro-psychiatric cases for many years to come.

The general medical and surgical cases are a type which justify the use of contract institutions more than the other classes referred to, by reason of the comparatively short length of time that treatment is indicated: emergency conditions which require immediate hospitalization where the patient may be; and the disinclination on the part of claimants to be far from home, especially when a surgical procedure is indicated.

The hospital program of the Veterans’ Bureau is meant to provide approximately 20,500 permanent beds for the treatment of tuberculosis and mental cases. It is estimated that between the present time and the end of 1923 the Veterans’ Bureau will lose the use of approximately 5,400 beds because the hospitals will have to be abandoned by reason of expiration of lease, temporary nature of the structure, or for other cogent reason.

The hospitals being constructed out of the Langley Bill (Act of 4 March 1921) and appropriations for the Public Health Service made either by the Secretary of the Treasury or the United States Veterans’ Bureau which will become available during the two years ending with the calendar year of 1923, will only provide 7,198 beds, while during the same period of the time the Bureau will lose 5,397 beds for the reasons already indicated. The ultimate loss of beds by reason of expiration of lease, temporary nature of the structure, etc., will be approximately 4,875 greater than the beds which will be provided as result of construction now going on under existing appropriations.

From careful studies that have been made, it is evident the Bureau will require additional hospital facilities at the following points:

It has recently become apparent that the neuro-psychiatric hospital at Marion, Indiana, operated by the National Home for Volunteer Disabled Soldiers, can only care for nervous and mild mental cases, and is not prepared to handle definitely insane. Development in the future may make it necessary, therefore, to ask for further provision for insane at that or some other point in the country east of the Mississippi River.

Estimating that we will have approximately 2,000 or 2,500 cases in contract institutions for many years, the Bureau is endeavoring to provide for a maximum load of about 32,000 cases, the peak probably being reached in 1922. It is estimated that the general medical and surgical cases will diminish rapidly, but that permanent beds for the treatment of approximately 13,000 tuberculosis, and 9,500 neuro-psychiatric cases must be available.

Gentlemen, I have attempted briefly to outline the growth and the magnitude of our hospitalization program, and have told you roughly what the expectation and needs of the United States Veterans’ Bureau in regard to hospitalization facilities are. It is all summed up in our earnest endeavor of the United States Government to provide every ex-soldier, sailor, marine or nurse who becomes a beneficiary is the United States Veterans’ Bureau with the best medical treatment available under the best conditions possible. But in spite of our needs for additional governmental hospital facilities, I want to assure you all that to my best knowledge there is not a single veteran of the World War, eligible for treatment and who has applied for hospital treatment, for whom hospital facilities have not been found or who has not been offered hospitalization.”

GENERAL SAWYER:

“Allow me to suggest just one thing. You will notice that on the program there is a time for general discussion of all these subjects, and I wish you would make pencil notes of the things that appeal to you as being of importance enough to be called up during the discussion. We are here really to get out of this all we can, and we want you to feel free to call for any further consideration of these subjects when we get to that hour of discussion.

I have pleasure in introducing Major Merritte W. Ireland, who will address you upon the subject of ‘The Army’s Relation to the hospitalization of the World War Veteran’.”

GENERAL IRELAND:

The treatment provided in our military hospitals for World War soldiers may be summarized in instructions approved by the Secretary of War, which were about as follows: That no member of the military service disabled in line of duty even though not expected to return to duty, would be discharged from the service until he had attained complete recovery or as complete recovery as could be expected he would attain when the nature of his disability was considered. It was laid down, further, that physical reconstruction consisted in the completest form of medical and surgical treatment carried to the point where maximum functional restoration, mental and physical, had been secured. To secure this result the use of work, mental and manual, was required during the convalescent period. This therapeutic measure, in addition to aiding greatly in shortening the convalescent period, retains or arouses mental activities, prevents the state of mind acquired by chronic hospital patients, and enables the patient to be returned to service or to civil life with the fullest realization that he can work in his handicapped state and with habits of industry much encouraged, if not newly formed. Early in 1918, the Secretary of War also authorized the Medical Department to proceed with the scheme for reconstruction of officers and enlisted men of the Army alone without consideration of the other bureaus of the government involved. This reconstruction it was clearly understood would end at the point where the medical reconstruction ceased and the future reconstruction of such cases was to be completed by other agencies of the Government after the individuals had been discharged from the Army.

Patients then were cared for in military hospitals up to the point of maximum functional restoration, both mental and physical. In the case of patients who were ultimately to be discharged from military service, arrangements were made whereby the Federal Board for Vocational Training might have access to these men as soon as it was known that they were to be discharged and the educational officers of the Medical Department were directed to cooperate with the representatives of the Federal Board to the fullest possible extent, in order that the patients concerned might have all the advantages assured them by the Federal Government.

It was recognized that in order to make this program successful for the attainment of the maximum physical and mental condition through complete medical and surgical treatment, it would require the establishment of a policy of extended publicity. This embraced the necessity to educate the public to the need of this physical reconstruction for the disabled men before their return to civil life; to educate the family of the soldier with regard to the need of continued treatment that they might be satisfied to have them remain in hospital, and finally, to educate the soldier himself by placing in his hands at the earliest possible moment after his disability had been incurred the necessary literature which would inform him of his status as a soldier and of the privileges, which were to be his as a disabled man, from the Medical Department of the Army, the Federal Board for Vocational Education, the Bureau of War Risk Insurance, and also to place in his hands such literature as would inform him of facts concerning various trades from which he might choose a vocation, together with all the information in regard to the need for men in the various industries of the country.

As above outlined this policy of treatment was carried out. At the approved time for the discharge of the patients from the military service, they at once became beneficiaries of the Bureau of War Risk Insurance and subject to further physical reconstruction or education, if such were necessary, under the direction of the Federal Board, Public Health Service or the Bureau of War Risk Insurance.

Such facilities as were in our hospitals and were not required for the care of the sick of the active list of our army were placed at the disposal of the discharged veterans of the World War. This was done mainly in two ways: first, by turning over to the Public Health Service which was charged with the medical work of the Federal Board, many complete hospitals and second, by caring for many of the veterans in our own hospitals after their proper discharge from the service.

HOSPITALS RELEASED FOR CARE OF VETERANS

By virtue of Act of Congress in March, 1919, every military hospital, including its supplies, no longer required for the proper care of the sick in the military service was to be turned over to the Public Health Service if the latter service so desired. A detailed classified list of hospitals approximating 2,460 beds turned over under this law follows:

[1]. Indicates buildings constructed by the Army on leased ground.

[2]. General Hospital No. 17 was closed as an Army hospital on March 27, 1919, the Public Health Service having stated that it did not desire this hospital. Later on, however, this hospital was taken over by the Public Health Service.

Hospitals abandoned by the Medical Department, U. S. Army, and available to the Public Health Service, but not occupied by that Service because they were not located where additional hospitalization was needed.

In addition to the foregoing the following permanent military posts have been recently acquired by the Public Health Service from the Army:

VETERANS’ BUREAU CASES TREATED IN MILITARY HOSPITALS

“Now, with reference to assistance rendered within our own hospitals, in an interview with the Director of the War Risk Insurance in 1919, I heard the former Secretary of War say that he considered it an obligation on the Army to assist in caring for the discharged World War veterans and that any vacant bed in Army hospitals was always available for the treatment of these men. To carry out this policy, the Bureau of War Risk and later the Veterans’ Bureau was from time to time advised by the Medical Department of the number of available beds in our hospitals in which we could accept for treatment veterans of the World War. The number of beds thus offered has varied slightly from time to time, but has always been on the increase, particularly since last July. Last May 1450 beds were available to the Veterans’ Bureau; in October 1752 beds were available, and by November 24th 2200 beds were available. The following brief table gives the exact status on January 5, 1922:

Within a few days we expect to open up several hundred beds at Fitzsimmons General Hospital for veterans suffering from tuberculosis. This last large increase has been made possible by funds transferred by the Veterans’ Bureau to the War Department for the specific purpose of enlarging this hospital. When the construction and alteration made possible by these funds has been completed (and the completion is expected almost daily) 700 additional beds for the tuberculosis will have been provided in permanent structures for a little over $1000 per bed.

In addition to the buildings turned over to the Public Health, which have already been enumerated, the Medical Department has turned over to that Service supplies approximating a value of $12,336,000.00. It has been a source of gratification to the Medical Department, and I am sure to the War Department, that the Army was in a position to assist in rendering aid to the American soldier disabled in the World War.

The total number of all cases treated in our general hospitals during the last year was approximately 30,000; of these 10,000 were local cases and 20,000 were general cases, and of the latter 15,700 were our own and 4300 pertained to the Veterans’ Bureau.

A brief summary of the Veterans’ Bureau cases treated in our hospitals may be of interest. Of the 4,300 cases treated during the year (October 1, 1920, to October 1, 1921) 180, or about 4% were suffering from either nervous or mental conditions; 2195 or about 51% with tuberculosis; 770, or about 18% with diseases or injuries of the osseous system; 75, or nearly 2% with heart or vascular diseases, and the remaining 25% was made up of all other conditions combined.

In addition to this work, much assistance has been rendered in making physical examinations for that Bureau to determine the right to compensation or the necessity for hospitalization. Over 2,000 of these examinations were made during the year, many of which necessitated admission to hospital for varying periods to permit a thorough survey in order that correct diagnosis or physical condition might be established.”

GENERAL SAWYER: “I am sure it must be gratifying to you to obtain a more intimate knowledge of the conduct of these affairs. I have pleasure in introducing to you Rear Admiral Edward R. Stitt, Surgeon General of the United States Navy, who will inform you as to ‘The Navy’s Part in the Hospitalization of the World War Veterans’.”

ADMIRAL STITT:

“The Medical Department of the Navy has been able to work with the Veterans’ Bureau along the following lines:

First: the turning over to the Public Health Service for the care of the Veterans of the World War of the Naval hospitals at Philadelphia, Pa., Cape May, N.J., Gulfport, Miss., and New Orleans, La. and quite recently to the Veterans’ Bureau itself of the hospital at Fort Lyon, Colo. used for tuberculosis patients. These institutions were completely equipped when transferred, so that no additional expense was involved. The hospital for tuberculous patients at Fort Lyon has been operated by naval personnel since November first, but this institution will be taken over by the Public Health Service on March 1st. With the great reduction in naval personnel and the discharge from the service of large numbers of the tuberculous, the needs of the Navy did not seem to justify the maintenance by the Navy of so large a hospital, there being at present 735 beds with possibilities of expansion. Upon his return from a recent inspection the Surgeon General of the Public Health Service expressed to me his admiration for the institution. We should not have been able to turn over this hospital had it not been for the generous offer of the Surgeon General of the Army to take care of the naval tuberculous at the Fitzsimmons General Hospital at Denver. The bed capacity of these five hospitals totaled 2229.

Second: The caring for the veteran patients in the same hospitals in which the sick of the Navy are being treated. In assigning accommodations to the patients of the Veterans’ Bureau there are many problem which complicate this matter. Manifestly it is necessary for the Navy to be prepared to receive the patients from its own personnel, and when it is considered that the fleet may at one time be in the port of New York and sending its sick to the New York Hospital during such time and then sail away for another port to then transfer its sick to another hospital the difficulties are apparent. If we could divide the ships between different ports and their sick between different hospitals the matter would be easy of adjustment.

Again we have only a limited number of beds in our three hospitals on the Pacific Coast and at the present time a large fleet is based on this station so that we are unable to offer accommodations in those hospitals to the Veterans’ Bureau and at the same time make adequate provision for the naval sick.

As a general rule we are only able to provide hospital facilities for general medical and surgical cases, but much of our work is in studying cases of suspected tuberculosis and where a positive diagnosis is made the determination of the extent of the process.

At Great Lakes, Ill. owing to the urgent needs of this section of the country, we have agreed to care for approximately 300 neuropsychiatric patients, this in addition to 300 beds for general patients. In order to obtain medical personnel trained in the supervision of such cases it was necessary to withdraw our psychiatric specialists from various stations where their services were needed, but it was felt that this was a greater need. To provide for additional men trained in this specialty we now have a number of young medical officers under training at St. Elizabeths Hospital.

The Navy is not only indebted to Doctor White for this service but it owes him obligations for his many years of instruction to the classes at our Naval Medical School. At the present time there are under consideration plans for the establishment under Doctor White of a school for the training of psychiatric personnel for other services caring for veterans, taking advantage of the abundant clinical material at St. Elizabeths.

At our hospital at Chelsea, Mass., we have been able to offer 539 beds to the Veterans’ Bureau and from the letters I receive, as well as from a personal inspection, I can attest the care that is there being given our veterans.

The Navy is particularly proud of its good food and I think our hospitals lead the Navy in this important service, which not only makes for contentment but aids convalescence. We have just agreed to receive the patients from the Polyclinic Hospital of New York and expect in a short time to be caring for approximately 350 patients in the naval hospital located in Brooklyn. We are very proud of the physio-therapy installation at this hospital, which has been pronounced by experts as one of the most complete equipments in the country.

In our hospital in Washington we are offering 250 beds. In this institution we are peculiarly well equipped for the diagnosis and treatment of obscure cases by reason of its association with the laboratories of the Naval Medical School. These naval hospitals are geographically so situated that large numbers of patients can be treated near their homes. Although most of our hospitals in our island possessions are small yet we can take care of a limited number of veterans who might be in such localities.

The mental environment at these hospitals is admirable from a standpoint of cheerfulness, amusement and when indicated occupational recreation, our rule has been so far as possible to treat veterans and sailors alike. To the Red Cross we owe much of the measures for contentment among the patients, although we also owe obligations to the morale division of the Navy Department for assistance along the lines of recreational and educational opportunities, especially as regards well conducted libraries. The number of beds now available in our hospitals approximates 2900. Adding the 2229 beds transferred to the Public Health Service makes approximately 5172.

THIRD In the transfer to other agencies caring for veterans of hospital supplies and equipment. As noted previously we have turned over not only the beds of five hospitals but in addition surgical, X-Ray, laboratory and other facilities as well as store rooms full of varied supplies. In addition we have from time to time given various medical and surgical supplies. I may state that we are now turning over to the Public Health Service $1,375.00 worth of stock from our Supply Depot and stand ready to transfer another million dollars worth of medical stores when called for.

FOURTH On board ship and at our various stations medical officers have examined claimants by the thousands, assisted them in making their applications and aided them with advice.

In the Bureau of Medicine and Surgery one of our most important activities is in supplying data to the Veterans’ Bureau for use in the adjudication of claims for compensation. The reports at present are more comprehensive than formerly made, and include in addition to the name, rank or rate and claim number, the date and place of birth, enlistment, discharge or release to inactive duty, together with a detailed medical history. The maximum number of reports sent out by the Bureau has been 250 in a day with an average daily completion of about 100 cases. At present we are up to date in answering claims. Notwithstanding the reduction of the clerical force in some divisions to the point of extinction of the activity in the effort to make the furnishing of records to the Veterans’ Bureau our first consideration we should have been far behind in furnishing records had it not been for the hearty and willing cooperation of the Veterans’ Bureau in assigning clerks from their own forces to assist in this most important and imperative work.

Where by reason of law or otherwise we have been unable adequately to provide for the veterans either in personnel or material Colonel Forbes has ever stood by to give us hearty cooperation and assistance. I am also indebted to General Sawyer, the Chief Coordinator of the Hospitalization Board for encouragement and advice whenever asked of him.

In reciting the activities of the Navy in providing hospital care for veterans, I trust it has become apparent that I have the honor to represent an organization, equipped to aid the Veterans’ Bureau in fulfilling the pledges of our government to its veterans, disabled in the Great War, and manned by a personnel actuated in all ranks by an earnest desire to contribute in the discharge of our obligations.”

GENERAL SAWYER: “I do not know exactly what impression you get from this information that is given out here by the heads of these great departments, but to me it seems that here is a spirit, a whole-souled determination to put everything at the command of the Government at your service to help you, that we may help the World War Veteran to the best that can be given. The recitation of these things by this Admiral and this Major General shows how much really comes through a closer affiliation,—how much we get that is worth the while from a better understanding; and that is what we really believe we have in this new Board of Hospitalization.

We have with us this morning the man who has been personally responsible for the largest number of these patients; in fact, he is responsible for more of these patients than all of the rest of the departments together; and if you do not know him, I should like to introduce to you a man whom I have found, by close contact and personal observation during the months I have been in Washington, to be a man who is giving everything within him to make of the Public Health Service of the United States of America the best Public Health Service in the world and to give to the World War veteran the best hospitalisation service that can be rendered.

I have pleasure in introducing to you Surgeon General Hugh S. Cumming, of the United States Public Health Service, who will speak on the subject of “The Service Rendered World War Veterans by the Public Health Service.”

GENERAL CUMMING:

In presenting even a brief outline of the services which have been rendered, and are being rendered, to disabled veterans of the World War by the Public Health Service, it is necessary, for a proper comprehension of the subject, to state, at least in general terms, the genesis of the relationships which the Public Health Service has sustained, and now sustains, to this very important responsibility.

The Congress, before the close of the war, had given consideration to a comprehensive plan for the care of disabled veterans totally unlike the previously existing pension systems, and had passed legislation putting into effect this program.

In doing so, use was made of existing agencies rather than the creation of new ones. Among these existing agencies was the U. S. Public Health Service. This Service, on March 3, 1919, was given authority to furnish medical care and treatment to veterans, acting in this capacity as an agency of the War Risk Insurance Bureau. The Director of that Bureau was charged with the real responsibility, but was permitted, under the legislation, to make use of the Public Health Service in discharging his responsibility with regard to medical care and treatment.

Peace having come unexpectedly and demobilisation following shortly thereafter, the problem of the care for the disabled veteran became at once very pressing. The Public Health Service had under its control only a few hospitals, with a total bed capacity of about 1,500. The Director of the War Risk Insurance Bureau looked to the Public Health Service to supply him with the necessary medical services, and the Public Health Service, therefore, found itself faced with the task of supplying, in a short space of time, an extensive system of medical relief.

It undertook this problem and, under the legislation, sought to meet the responsibility in several ways. By the transfer to its jurisdiction of facilities used by the Army and Navy during the war, by the purchase of such facilities as were available and within the moderate appropriation, by the leasing of fairly suitable places and their conversion to hospital purposes, and by making contracts with civilian hospitals all over the United States for the care of veterans, this Service was able to furnish facilities with rapidity. These facilities were by no means always desirable, but at least it may be said that the Public Health Service was enabled to keep pace with the demand and to supply to all veterans who applied some form of hospital care and treatment.

The administrative organization, which had been formed under the law, for the care of veterans, included three bureaus, namely; the Bureau of War Risk Insurance, the Federal Board for Vocational Education, and the Public Health Service. This organisation, while it was the best that could be formed under the circumstances, left a good deal to be desired, and was the cause of much criticism and no little dissatisfaction.

Matters became so urgent finally that, under the President’s direction, certain changes were made, and later, by act of Congress, even more radical changes were made, all with the ultimate tendency of concentrating in one organisation the entire responsibility for all matters affecting veterans of the World War. This culminated in the passage of legislation creating the U. S. Veterans’ Bureau and charging that Bureau with the full responsibility for all matters affecting veterans. (Aug. 19, 1921.)

In the legislation creating this Bureau, however, the Director of the Newly created Bureau was authorized, in giving hospital care and treatment to his beneficiaries, to make use of certain official agencies, and among these the Public Health Service, which at that time was carrying most of the medical work for veterans, and in fact this Service is still supplying by far the largest number of hospital beds for their care.

Under this new legislation, adjustments were made as rapidly as possible, and are still going on, with the result that the present situation of the Public Health Service in this responsibility is fairly clearly defined for the first time since it has undertaken this work.

The U. S. Veterans’ Bureau has now taken over, or will shortly take over, from the Public Health Service all of the responsibility and all of the work involved, with the exception of the operation of hospitals. The work taken over by the U. S. Veterans’ Bureau includes the entire responsibility for the operation of all outpatient departments for the care of veterans. Thus the Public Health Service is now left simply as a hospitalizing agency for the use of the Director of the Veterans’ Bureau.

The Public Health Service, therefore, stands in the same relationship to this work as other official agencies, namely; the National Homes for Volunteer Soldiers, the Army, the Navy, and St. Elizabeth’s Hospital of the Interior Department. That is to say; it operates independently a system of hospitals for the use of the Director of the Veterans’ Bureau in the care of his beneficiaries. It has no responsibility with regard to meeting the demands for hospital facilities and it has no responsibility with regard to the distribution of patients to those hospitals. Its responsibility is limited simply to the operation of such hospitals as the Director desires, and, to the admission of such patients as he may desire to send to the same.

When the Public Health Service was suddenly charged with the large and important responsibility for supplying medical care and treatment to veterans of the World War, it proceeded at once to organize, on a commensurate scale, to meet a problem the character of which was unknown and the magnitude of which could only be surmised.

The first and greatest problem faced by the Public Health Service was, of course, to determine as soon as possible the character and the magnitude of this problem. In conjunction with the War Risk Insurance Bureau, there was compiled and finally published a public document (481 of the 66th Congress, December 5, 1919). In this document, this entire problem was analyzed, and certain very definite conclusions were stated as to the need for medical and surgical facilities for the proper care and treatment of discharged disabled veterans.

It is unnecessary at this time to attempt any analysis of this document, but it is worthy of some comment. It indicated that within two years from the date of its publication there would be needed for patients of the War Risk Insurance Bureau 7,200 beds for general medical and surgical cases, 12,400 beds for tuberculous cases, and 11,060 for neuropsychiatry cases, making a total of 30,660 beds.

Recommendations in this document were made for the expenditure of a large sum of money for necessary construction, and a draft of a bill was offered which would appropriate the money for this purpose. The bill contemplated that this money should be expended in annual installments, extending over a period ending June 30, 1923. This document also indicated that the peak of the load, at least for neuropsychiatric and tuberculous disorders, would not be reached for some years.

The conclusions reached in this document were the subjects of a good deal of criticism. It was rather generally felt that the facilities which had been provided during the war for the medical care and treatment of soldiers and sailors could be made use of very readily and very satisfactorily in the care of discharged disabled soldiers and sailors at the termination of the war.

It was not clearly appreciated that the war program for the care of sick and disabled could, by no means, be converted into an adequate and satisfactory system of hospitals for the care of sick and disabled persons under peace conditions. At all events, no money was appropriated for purposes of constructing hospital facilities until March 4, 1921.

It is highly significant at the present time to note that the needs foreshadowed in this public document have, since the date of its publication, been more or less verified by subsequent experiences.

Making due allowances for discrepancies, which might have been expected, and for developments, which could not have been readily foreseen, it may be truthfully said that this document indicated quite clearly and more or less accurately the hospital needs for the care of sick and disabled ex-service men and women, if these patients were to receive the character of medical service which, in the judgment of the best medical minds, was necessary for their restoration to health and which could not be satisfactorily given in other than suitably constructed institutions.

Leaving aside these considerations, it was apparent that, when the Public Health Service was charged with responsibility, it was immediately necessary to meet the urgent demands suddenly created by the termination of the war.

The Public Health Service, in the manner indicated above, attempted, therefore, to formulate and put into execution a temporary program for the purpose of meeting immediate needs, leaving a permanent program to be developed in accordance with the appropriations and legislation.

Without going into any more detail, it will suffice to state in very general terms the work which the Public Health Service has done in this connection and which it is still doing.

Since the inception of the work, it has created a hospital system of considerable magnitude, and is now operating some 68 hospitals, with a total bed capacity of over 21,000, and expects, within the more or less near future, to open additional hospitals and increase present facilities by something less than 5,000 additional beds.

This Service now has under its care about 13,500 veterans of the World War in its hospitals. In addition to this, it is also caring for 3,000 to 4,000 Federal beneficiaries, with whose care and treatment it has long been charged, making a total of nearly 17,000 hospital patients under its care at the present time.

In the development of this hospital system, the Public Health Service has divided its hospitals into three large groups, namely; hospitals for general medical and surgical cases, for cases of tuberculosis, and for cases of neuropsychiatry. It has been unable to develop this system of hospitals with the uniformity desirable under the circumstances, and has, therefore, found difficulty in meeting the needs of those suffering from neuropsychiatric and tuberculous disorders. This demand, however, has of late been far more adequately met, especially with regard to tuberculosis.

In addition to the development of its hospital system, the Public Health Service, soon after assuming its responsibilities in this work, created what was designated as the District Supervisors’ organization. The United States was divided into fourteen districts and, in some large center of population in each of these districts, there was established a district headquarters, with a sub-district organization reaching out even to the individual counties.

This organisation constituted a decentralizing agency, and, as such, served a most useful and important function, not only in the work of the Public Health Service, but also in the work of the War Risk Insurance Bureau. This entire organization, which had grown enormously, was transferred to the Bureau of War Risk Insurance in April, 1921, with its complete personnel. It is now operated by the U. S. Veterans’ Bureau as its decentralizing agency and is still performing a necessary and important function in the work of that Bureau.

It was also necessary to create a greatly extended purveying service for supplying the necessary equipment, etc., to the hospital system which had been inaugurated. The Purveying Service has grown enormously and, at the present time, is not only purveying to the hospitals of this Service, but is also rendering assistance to the U. S. Veterans’ Bureau in purveying for its offices and its medical facilities.

The creation of an Inspection Service also became a necessity, in order that the hospitals of this Service might be kept under constant surveillance, and that all complaints might be carefully investigated. This Inspection Service has now been reduced somewhat, but still is functioning satisfactorily and has also rendered a great deal of assistance to the U. S. Veterans’ Bureau in making certain inspections for that Bureau.

In addition to these matters, the Public Health Service also began the creation of a large system of out-patient dispensaries for the care of veterans of the World War and developed this work considerably. Up to recently, it had in operation some 58 of these dispensaries, many of them equipped and staffed for all forms of out-patient diagnosis and treatment.

The development of this dispensary system was a matter of supreme importance in furnishing the medical examinations of veterans required for the purpose of establishing their compensation ratings. This entire Service, as stated, is about to be turned over to the U. S. Veterans’ Bureau and will, in future, be operated by them.

In carrying out all of this work, the Public Health Service has, of necessity, been obliged to assemble a large personnel. The personnel at the present time is somewhat less than it has been previously, by reason of the transfer of certain activities to the U. S. Veterans’ Bureau, but, with the anticipated opening of many new hospitals and the increase of its facilities, this personnel must, of necessity, slowly increase.

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.

The fourth agency, which has been very largely developed recently, but which has always been used, is the agency of work. This has been applied in approximately three ways. The first of these is known as diversional occupation and comprises practically the whole field of what is thought of by many as occupational therapy. The activities in this field consist of such work as basket weaving, leather tooling, bead stringing, rug weaving, and a thousand other similar activities. The object of this activity is to assist in the re-direction of the patient’s interests, to turn them away from infantile and regressive objects, and to project them again into the outer world of reality. Then there is the industrial type of work therapy in which the patient is carried still further along the line of personal initiative and given an opportunity to do creative work which is at the same time useful and which helps him to keep in form pending the time of his ultimate discharge from the hospital. And finally, there is the vocational education work, which undertakes definitely and systematically to give a man training in some specific direction which he can utilize, after he leaves the institution, and which will have a definite economic value. For this latter work of vocational training there is needed such psychological advice and assistance which will at least prevent the wastage of time and effort upon unprofitable or impossible tasks, whereas the vocational psychologist cannot by any rule-of-thumb-tests tell that a man will make a success in this or that direction, he can tell within reasonable limits that a certain patient cannot profitably undertake a certain type of training, that his capacities do not measure up to the minimum requirements that would make success possible. In this way the work of vocational education for the neuropsychiatric case can be narrowed down so that it can be applied more intensively and more effectively to selected groups that can be reasonably assumed to be good risks.

The fifth agency, which can be advantageously brought to bear upon the neuropsychiatric case, is the agency for extra-mural social adjustment, and the personnel consists of the psychiatric social worker. With her help the patient discharged from the hospital can have the maximum amount of assistance for relating him again with the problem of self-support and self-sufficiency. She, through her study of his family situation, his economic status, his industrial placement and social contacts can assist to these ends.

The third group of neuropsychiatry cases is like the second,—a group that has always been with us, but unlike the second it is a group that never before has been systematically hospitalized. It is the group of what might broadly be termed borderland states, comprising all sorts of types of defective, delinquent, psychopathic, neurotic, and mildly psychotic individuals. Whereas they perhaps present no new problems when one is speaking from the platform of neuropsychiatry, they do present a distinctly new group of problems from the standpoint of hospitalization. Here all the agencies which have been described in connection with the second group need to be brought into action, but beyond them there needs to be a definite intensive study of methods for the new hospital problems involved. I mention only one aspect of the problem because it is one which has forced itself repeatedly upon the attention of hospital authorities and that is the need for an intelligent, and I may say, a therapeutic utilization of discipline in dealing with these cases, in this group there very probably are contained a reasonable number of individuals of unusual equipment, who, if our ingenuity and our breadth of vision are great enough, may perhaps be saved for some work of more than ordinary usefulness.

One of the medical agencies which it is contemplated to bring to bear upon this third group of neuropsychiatry cases is the dispensary because it is recognized that there is actual danger in hospitalizing a certain proportion of this group, and therefore it is much better to deal with them as ambulant cases. They can be dealt with in the dispensaries which are equipped not only to take care of them, but for all other medical and surgical conditions, and so will get the very best possible attention. There should, however, be connected with these dispensaries, especially the larger ones in the more densely populated districts, a psychiatrist with psychotherapeutic training who should have a psychiatric social worker to help him. If there are enough patients to warrant it perhaps additional assistance might be needed.

And finally, I would emphasize that in this great scheme, which contemplates the hospitalization of from ten to fifteen thousand neuropsychiatric cases of the general type above referred to there should be included all of the armamentarium for scientific research and all of the opportunity for individual endeavor and initiative which is calculated to bring the brighter professional minds to bear upon the subject and to illuminate it with the light of their genius. In order that such results may be effected as promptly as may be, and with the highest possible efficiency, I believe there should be established a training center for neuro-psychiatrists where our younger men, who are recently graduated from our medical colleges, and who have the inclination to specialize in this branch of medicine, can fit themselves in a minimum period of time to take it up as their life work. And that this result may be accomplished I think it important that in extending an invitation to the younger medical men to enter this branch of the service that it should be possible to give them some assurance of permanency in their respective jobs.”

GENERAL SAWYER: “The subject with which Dr. White has dealt is so important that it will have more consideration later in the program, as you will notice.

It is quite necessary in the operation of all affairs with which Americans or even any of the human family deal, to have somebody who knows something of the legislative procedure that is necessary to the conduct of their affairs.

Honorable Charles H. Burke was added to the Hospitalization Board for two reasons: first, because he does represent in his great family many hospitals, the services of many doctors, likewise of many nurses. He therefore comes to us, being a Congressman of long experience, as a man who can deal with the subject partly from a professional aspect or view of the matter, and again with a thorough and complete understanding of the legal side of the affairs with which we are dealing.

So I have great and special pleasure this morning in presenting to you the Honorable Charles H. Burke, Commissioner of Indian Affairs, who will address you briefly on the statutory regulations affecting the hospitalization of the World War Veteran.”

BURKE: “Mr. Chairman, fellow members, ladies and gentlemen:

I think in the introduction of General Sawyer I learned for the first time how it happened that I was accorded the honor and the privilege of being a member of an organisation made up of such a distinguished membership as is this Board, barring your humble servant.

It would hardly be expected, after listening to these discussions by these eminent experts in their particular lines, that I would undertake to say anything along the scientific side of this proposition, and I am going to be rather general in what I state in the short time I shall talk to you.

Government activities can only exist by reason of the law, and so it will be proper to consider perhaps or discuss briefly the application of the law with reference to the activities that are being conducted, of which you, each of you, are a part.

The responsibility for whatever the Government may do in this or any other matter rests largely upon the Congress. I have hastily gone through the legislation that has been enacted in the last few years with reference to taking care of and providing for the ex-service men, and during the war for their dependents, and for those who might become incapacitated or disabled from any cause. There has been much legislation, demonstrating that the Congress is keenly alive to the importance of the situation. There has been one act after another, and hardly an act but what has been amended within a very short time after its enactment.

The recent law is what is known as the Sweet Bill, the law under which we are now operating. Within the memory of many who are here present the appropriations for all purposes of the Government were under a billion dollars, and there is being and is appropriated at the present time nearly half of that amount for the purpose of caring for the hospitalization, etc. of these ex-service men. Am I correct, Colonel Forbes, in the amount of money that is being appropriated? It is a vast and large sum of money, and it is the duty of those charged with the responsibility of expending that money to see that we get a hundred cents’ value for every dollar that has been appropriated. This requires economy and efficiency, and this gathering and this organization which General Sawyer is the chairman, was created for the purpose of getting better results from the moneys that are appropriated by the Congress; and you, each and every one of you, have been brought here, as I understand, for the purpose of coming in closer contact with those who are charged with the responsibility, in the first instance, of administering the expenditure of this large sum of money; and you owe to this responsibility exactly the same responsibility as does Colonel Forbes or anyone else occupying a higher station than you may occupy.

Therefore, I am confident and I am certain that when this conference shall have concluded, every person that has come here will go back to his respective place where his duty requires him, with a better understanding and with a more determined disposition to try and render better service and get really more for the money that is being expended for the purpose for which it is being expended.

Speaking of legislation, we shall undoubtedly require considerably more legislation because, as I have stated, in the short time since this subject was first taken up by Congress think of the progress that has been made.

As I understand, in 1919 the Public Health Service were hospitalizing something like two thousand persons. General Sawyer stated here today that we are now caring for twenty-two thousand; and I think it has been stated—and it is generally considered—that the maximum will soon be thirty-two thousand. So you see that it is more than likely that we are going to have to have additional legislation and more appropriation; and I may say to you generally that I have that confidence in the American people—I have that confidence in the Congress of the United States—to know that there need be no uncertainty nor hesitation on any one’s part with reference to what may be done to provide for caring properly for these dependents and these ex-service men who are entitled to every consideration.

I believe, as the result possibly of this conference, it may be brought to the attention of this Board that there is some legislation amending the so-called Sweet Bill. I think Colonel Forbes, as the head of the Veterans’ Bureau, has already discovered and suggested some very necessary amendments to the law, and I have no doubt that he will be able to secure those additions to the law. It looks now as if we may have to provide for additional hospitals by the enactment of further appropriations of money. It will not be done unless it is necessary, but I am sure if it is necessary that adequate provision will be made and made promptly by the Congress.

One of the policies of this administration is coordination and cooperation, and endeavor to avoid duplication in administrative matters; and if there is a bureau charged with a certain responsibility and with certain duties to perform, if it may be possible for them to do what may be under the jurisdiction of another bureau, to centralize and have this work done by one rather than two; and so in the work of coordination in the administration of this particular activity there has been a great saving. The Public Health Service, I believe, makes certain provision and takes care of certain persons at the request of the war Veterans’ Bureau and vice versa. I think it has been said,—if it is true it ought to be corrected,—that when the Veterans’ Bureau takes care of patients for the Public Health Service, there has been no provision made for reimbursing the Veterans’ Bureau. That will undoubtedly be taken care of by Congress, either by increasing the appropriation for the Veterans’ Bureau, or providing that when they render service for the Public Health Service, the Public Health will reimburse them for such moneys as they may expend.

Now one of the things that I want to particularly bring to your attention, and to perhaps admonish you, in the two or three minutes I have left, is to remember, as I stated at the outset, that governmental activities exist only by authority of the law, and that we must keep within the law; and remember, if there are some things in connection with your duties that are not operating just as you would have them, that they cannot be changed without changing existing law. The responsibility for the law is upon the Congress of the United States. The responsibility for this great undertaking is upon the Congress of the United States, and if you have not sufficient money to properly take care of these men, the responsibility is not yours; the responsibility is upon the Congress.

It is your duty;—it is our duty to bring to the attention of the Congress the money that is necessary in order to properly handle this subject. Then it is for the Congress to say whether or not that amount will be appropriated. Under this present administration, those of us who are in Bureau positions have been admonished that we must keep our expenditures within the appropriations, and we have had brought to our attention the statutes upon this subject. I am going to read them to you for your information, and I want to say to you who may have charge of an institution and have had a certain allotment of funds for a given period, that it is up to you to see that your expenditures do not exceed that allotment. If you have not sufficient money to do what you feel you ought to do, you must reduce your expenditures for the time being, regardless of its effect upon the service, because under the law you have no right to create a deficiency or incur any liability on the part of the Government in advance of an authorization and an appropriation therefor.

I want to call your attention to the statutes on this subject because they are being brought to our attention not only by the President and the head of the Bureau of the Budget, but by the Congress; and so I want you people to understand that we are expected to follow the law.

Mr. Burke read extracts from: Section 3679 Act of March 3, 1905. Section 5503.

That, ladies and gentlemen, is the law; and so I want to impress upon you that you so conduct your institutions that you will keep within the limit of the allotment that has been made for your institution; and if you have not sufficient money, then bring it to the attention of the head of the Veterans’ Bureau or someone else connected with the administration. They will consider it, and if it shall seem that more money is necessary they will not only recommend it, but I think I can say for the Congress that the Congress will generously respond.

I congratulate this conference upon its start. I hope that there may be a general discussion,—that those who have come from long distances will tell their experiences and make suggestions with reference to anything that will improve this service; and I am very certain that when the conference shall conclude on its last day it will adjourn with a feeling that the time has been well spent, and that in the future we are going to profit, and profit materially, as to the result of what may be done in this conference and by it.”

GENERAL SAWYER: “Fellow workers, I certainly hope that this introduction this morning has given you two things; first, that it has given you the impression that the men engaged at the head of the affairs of this Government in this subject are capable, worthy men. I hope it will have given you the same inspiration that I carry away this morning,—to go on with this conference and with your work after you leave here more earnestly if possible, more sincerely if you may, and certainly with more determination to bring about the results we all have in mind.

This morning you have heard the various members of the Board of Hospitalization make their addresses, brief of course as they have been and in many instances not entirely fair to them, considering the subjects they have to handle; but they have done as well as time will admit.

This afternoon this conference, under the chairmanship of Colonel Forbes will take up a special subject or two, and will then go into the matter of the general discussion of the affairs as they have been presented today. We want you to feel that we are here to listen as you have listened this morning; and so we are going to ask each one of you to participate in the discussions. We want this to be an active meeting, of men in motion, so that when this conference does close we may have the satisfaction that has been expressed here by the Commissioner of Indian Affairs.”

General Sawyer asked that, upon adjournment, the members of the Conference assemble outside the building in order that a group photograph might be made.

The meeting adjourned at 12:15 P.M.

Second Session Tuesday, January 17, 1922.

At 2:00 P.M. the meeting was called to order by Colonel C. R. Forbes.

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

COLONEL FORBES:

“The first paper of the afternoon was to have been read by Colonel Patterson, Medical Director of the Veterans’ Bureau; but in his absence, Dr. Rawls, of the Public Health Service, will deal with the subject of ‘Operation of Dispensary and Dental Clinics’.”

DR. RAWLS:

“I regret very much that Colonel Patterson cannot be here today, because he had some very definite statements to make about the dispensary problem of the Veterans’ Bureau. It was only last night that his physical condition warranted his telephoning to the Bureau his impossibility to come. In his absence I shall attempt to give you briefly a plan of the dispensary service of the U. S. Veterans’ Bureau.

The Veterans’ Bureau plans to establish a chain of dispensaries throughout the United States, located in the fourteen District Offices and in the hundred and twenty six sub-offices.

This is a new idea but is the logical result of past experience in furnishing service to the patients of the Veterans’ Bureau and in providing adequate medical facilities. It may not be amiss to trace the development of this idea from the time when the Veterans’ Bureau was in its infancy as the Bureau of War Risk Insurance and when the problem of securing examination reports on claimants for compensation and providing treatment to patients amounted to a grave emergency.

No ready made medical service existed to which the Bureau could turn for its needs. The problems of demobilisation confronted the Army and Navy. The Public Health Service was presented with the needs of the Bureau of War Risk Insurance and undertook the difficult task of forming a medical organization throughout the Country to meet these needs. The United States was then divided into fourteen districts with the District Headquarters and a medical officer of the Public Health Service in charge, called a “District Supervisor”, who was directly responsible for the organization of a medical staff throughout his District. The first plan for medical service was the appointment of physicians as designated medical examiners on a fee basis wherever there were claimants of this Bureau to be examined and treated, the ultimate object being to have at least one designated examiner in every county of the United States. By January of 1920 this object had been attained and designated medical examiners had been appointed in every city and town and in almost every village of the county.

The District Supervisors soon found this a most expensive method of accomplishing the work. The Bureau concurrently found it increasingly unsatisfactory in its result—an army of physicians widely scattered, whose work was difficult to control and well nigh impossible to standardize. The requirements of the Bureau were very definite. As a result, the Public Health Service developed the medical unit plan of organization, which, in brief, was the formation of groups of physicians in the larger communities to make complete general and special examinations and to give careful study to cases requiring treatment. The results were so far superior to any previously obtained that the Bureau of War Risk Insurance urged the District Supervisors to complete the organization of their Districts along these lines and to use the designated medical examiners as little as possible.

The next step in the development of the dispensary idea was the establishing in the District Offices of large examining clinics staffed by officers and appointees of the Public Health Service devoting their entire time to this work and reinforced by the consultant services of the best specialists which the cities afforded.

The growth of the District Offices had passed all expectation and a serious problem faced the Public Health Service in enlarging these offices in accordance with this plan. However, there was no question of the wisdom of establishing in the District Offices adequate facilities for making examinations, as this feature was one of vital importance to the Bureau because on the accuracy and completeness of the examination reports depended the award of disability and the determination of compensation.

The Public Health Service faced this problem squarely and, loyally supported by the Bureau of War Risk Insurance, demonstrated the wisdom of this move. The Surgeon General went even further and established real outpatient dispensary service in connection with certain examination clinics in the District Offices and hospitals of his Service.

The Bureau of War Risk Insurance then assumed direct control of the entire District organization and the Director, Colonel Forbes, after an extended survey of this organization and the methods of furnishing service to his patients, which took him into practically every District Office and many of the larger cities served by medical units, evolved the plan of extending dispensary service to every section of the Country. With his keen insight into organization problems, one of his first moves was to obtain Congressional authority to further divide the Districts into sub-districts. He appreciated that each sub-district office was a potential dispensary, the examination clinic in each District Office and the medical unit at each sub-office being the nucleus upon which to build a U. S. Veterans’ Bureau Dispensary Service.

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.