Chapter 8

Very truly yours,ROBERT U. PATTERSON,Assistant Director,U. S. Veterans’ Bureau.

Very truly yours,

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

ROBERT U. PATTERSON,

Assistant Director,

U. S. Veterans’ Bureau.

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

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

Rightly interpreted, these orders are in no wise contradictory.

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

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

(2) To determine their feasibility for training.

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

(4) To accomplish everything necessary to adjudicate claims.

(5) Provision for outpatient treatment when required.

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

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

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

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

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

Under date of September 1st, about the time of the issuance of General Order No. 26 there were 9,592 patients in862private hospitals; there were 18,698 patients in92Government hospitals. Today there are8924patients in 757 contract hospitals and20339patients in92Government hospitals. From these figures it would appear as though the clearing out of hospitals, as provided for in General Order No. 26, has not been productive of results. This, however, must be viewed in the light of what is actually taking place in the field. About the time of the issuance of General Order No. 26, or a little before, everyDistrict was putting into the field a Clean-up Squad for practically every state, the function of which Squad was to make contact with all potential beneficiaries of the U. S. Veterans’ Bureau for the purpose of establishing claims, of offering hospitalization for examination, for emergency treatment, and for other situations. These Clean-up Squads served to feed a considerably increased number of patients of all types into hospitals. Anticipating that such period of hospitalization would be brief, they have used contract hospitals because of this fact, and because of their location in the near or immediate vicinity of the patients handled. The turnover has thus been largely increased. The increase of patients in Government hospitals has risen steadily at the rate of approximately 600 a month until it has reached the figure of20339patients, as against18698patients in the early part of September. There has been a slow but gradual decline of patients hospitalized in contract institutions, notwithstanding the very material influx into the hospitals by reason of the Clean-up Squads just spoken of. It might appear to you who are actually caring for patients in your institutions that notwithstanding the explanation of the meaning of General Order No. 26 and 26–A, that the holding of a patient in a hospital until all of the several matters necessary can be taken care of, will result in undue delay in discharge. This doubtless would be true if each hospital were required to assemble data called for and make the other necessary provisions and forward the reports to the District office to await return and receive transportation before a patient could be discharged.

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

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

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

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

Motion:

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

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

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

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

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

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

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

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

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

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

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

COL. EVANS: stated that the matter just referred to was a part of the program had been approved and was now awaiting the signature of the Director; that the individual designated as Vocational Director in a hospital will be responsible for contacting the men with regard to their compensation and their preparation for vocational training; that he will confer with the medical officers and of course should be directed by them, but he is responsible for the work.

DR. GUTHRIE: was of the opinion that the location of these men in the hospitals in connection with the work referred to is most valuable.

DR. DEDMAN: Stated that General Order No. 26 has been a wonderful help. In connection with the matter of discharged he thought that four days would be enough, because a man’s discharge can be anticipated and arrangements made for his vocational training, provided a representative from the Veterans’ Bureau is furnished. He stated that everyone has the same ideals as to the restoration to health of these ex-service men but that this matter cannot function properly and we cannot attain the maximum for these men unless we do work together in harmony and peace in hospitals; that when these representatives come, it should be distinctly understood that they are members of the official family and staff of the hospital; that these representatives should not be medical men as a medical board can determine the means and advisability of training, but that they should be well versed in the subject in order that they may be competent to judge as to what is best for a certain man to take up.

Dr. Dedman added that difficulty had been experienced in getting men to leave the hospital. He mentioned the case of a boy who had been admitted to the hospital with active tuberculosis, who was eventually rated as an arrested case and told that he had received the maximum benefit, that this boy did not want to leave the hospital and made a protest to his Congressman.

DR. COOK: stated that he was going through his hospital one day and met a big husky and asked him where he worked; that he replied he did not work but was a patient; that this incident set him to thinking and he got his discharge board working with the result that he reduced the number of patients from 910 to 500; that in connection with existing requirements to the effect that no patient would be discharged from a hospital without going through a contact man, he was fortunate in having a man assigned to him from the Veterans’ Bureau and every case of discharge goes through his hands; that under this arrangement he has no difficulty in discharging patients.

DR. EVANS: informed the Conference that there was on the Director’s desk a ruling stating that personnel from the Veterans’ Bureau will be under the commanding officers on hospitals.

DR. YOUNG: referred to G.O. 26, authorizing discharges from hospitals and mentioned experiences where difficulty had arisen in this connection due to the lack of adequate means being provided to enforce such order. He mentioned cases that had come up where men who had received the maximum benefit, would state that they were not going to be discharged; that these cases would generally occur on the eve of a holiday, or on Saturday night and the men would go into a ward and get into bed. He believed that in such cases the hospital authorities should be given some means of enforcing this order by the Veterans’ Bureau, as aid can not be had from the local police who will not enter upon a Government reservation; that another way would be through swearing out a warrant, but as these cases generally occurred on Saturday and a warrant could not be sworn out until the following Monday, a man is thereby enabled to stay four days longer.

DR. CHRISTIAN: stated that in his experience the police had not refused to go upon the reservation and that he has had one of his staff sworn in as a deputy sheriff; also, that upon the date named in the discharge order the man affected is not officially in the hospital and is not rated as present for the purpose of being fed.

Concerning transfers, Dr. Christian mentioned that authority for transfers has changed a number of times and was of opinion that it would be advantageous if stations like his could be given blanket authority to transfer mental cases when they are not prepared to take care of them, as it would relieve the medical officers of great anxiety and would save the family of the man a great deal of torture; that this could be accomplished in a few hours by telephoning to the nearest mental hospital and receiving an answer in a short time as to whether or not a bed was available, all of which would expedite the transfer of the patient; that it is now taking too long to get transfers.

He also stated that he appreciated the importance of the Inspector’s Department, which is of wonderful benefit to the commanding officers.

With reference to G.O. 26, he thought that the length of time prescribed is too long, as with the generality of patients who have received the maximum amount of treatment, it does not make a great deal of difference as to how much notice they have as to when they are going to be discharged, as the necessary arrangements can be made in a very short time without any inconvenience; that there is, however, a certain class of cases which very often takes advantage of the four days’ notice; that it has been his experience that when four days’ notice is given it apparently has no effect on the first day, on the second day the patient will begin to develop symptoms, on the third day the symptoms are very much increased and on the 4th day you get a letter from the patient’s Congressman.

DR. LASCHE: was of the opinion that all the authority needed is given by G.O. 27 of the Veterans’ Bureau, which gives the medical officer in charge considerable authority to enforce discipline; that the average patient, however, chafes under the word “discipline”; that the gentlemen from the Army and Navy have referred to the advantages of discipline. He stated that he was on a discharge board for soldiers after they came home from Europe and frequently heard them say: “Well, by Jove, we are away from this —— discipline now;” that with all due respect to discipline that is necessary in Army and Navy organizations, he does not believe that the same degree of discipline is necessary after these men become beneficiaries of the Veterans’ Bureau; that in a year’s time he has only had to apply the provisions of G.O. 27 on one patient who was A.W.O.L. three times for the period of twenty-four hours or more within thirty days; that he finally discharged this man, who, however, subsequently applied for readmission and was successful in obtaining it within two weeks and all the patients at the institution know that this man got back after he was discharged.

With reference to the question of Dr. Guthrie as to whether a layman would serve successfully, Dr. Lasche was of opinion that the layman is the only desirable person, as the medical man’s function is exclusively to determine the vocational disability and after this is determined all the other matters should be left to a layman, as they are more or less in the nature of an investigation and a layman who is properly selected would be much better able to run down and ferret out such matters; that it is important, however, to select a man for this particular function who has shown an adaptability for research along these lines, and, some of the men who have been in charge of vocational centers do not possess the requisite qualifications to decide as to visibility or eligibility in the matter of vocational training.

DR. T. R. PAYNE: thought that the hospital brand had been placed on a great many men in cases where it should not have been; that once you get a man in a hospital he is going to repeat as long as he can. He referred to a class of so-called gas bronchitis patients and stated that it is well known that during the war all a man had to do was to say he had been gassedand receive a wound stripe, and this same man is now coming in to our hospitals; that the office of The Adjutant General of the Army has no record of such men being gassed; that he has no chest pathology. He thought that these men should never have gotten into the hospitals and should have been handled outside more by psychology than by doctors and hoped that the dispensaries are going to keep these men out of hospitals; that there is no doubt in his mind that a great many neurasthenics should never have gotten into general hospitals; that the great trouble is the compensation given those men places a premium upon their hospitalization; that men are in hospital who have been discharged as having received their maximum hospitalization; that these men have been taken out of vocational training; that they would rather go back into hospital and get $80 a month and three meals a day and be entertained several times a week; that more care must be taken by doctors regarding the men they send in to hospitals.

GENERAL IRELAND: stated that it has been found that there is no after effect from gases and that Lieut. Col. Gilchrist, M.C., U.S.A., representing the Medical Department of the Army in the office of the Chief, Chemical Warfare Service, has data relative to this subject, which can probably be obtained by writing him.

DR. LLOYD: offered the following resolution, which, however, was not adopted:

“That it is the sense of this body that the Federal Board of Hospitalization recommend to the Director of the Veterans’ Bureau and to the Surgeon General of the Public Health Service the designation of an officer of each service to receive special suggestions and recommendations from the field, criticisms also of instructions contained in field orders, circular letters and similar communications; these designated officers to constitute a board for the consideration of these recommendations, with the view of recommending to the Director the adoption of such as are believed to be of value.”

DR. CHRISTIAN: offered the following amendment to Dr. Lloyd’s resolution:

“That these officers be detailed to the Veterans’ Bureau for a limited period, say six months; that they be field officers.”

DR. JOHNSON: moved that the resolution of Dr. Lloyd be laid on the table indefinitely, which resolution was adopted.

DR. LLOYD: suggested that it would be well to have one man of each service who could be advised as to what is the matter with certain general orders and know that such matters will not be pigeon-holed but will receive action.

COL. BRATTON: was of the opinion that all suggestions relating to improvement of service should go through the chief of the service. He stated that no difficulty was experienced in this connection in the Army and that it seemed to him that the chief of a bureau should know what was going on.

GEN. IRELAND: stated that contemplated changes affecting the hospitalization of patients of the Veterans’ Bureau in the Army are always referred to his office for review before they are issued.

DR. BLISS: thought that there should be a representative of the Veterans’ Bureau in all Government hospitals where there are Veterans’ Bureau patients, which representative would not have anything to do with the internal administration of the hospital.

DR. WILLIAMS: with reference to the matter of bed space in hospitals offered a resolution to the effect that the question of floor space and distance between beds be reconsidered by the Veterans’ Bureau, with a view to the revision of the present requirements; that unnecessary bed space is being provided and it should be cut down; that he believes the allowance of six feet is necessary in respiratory cases and in infectious cases, but that in the ordinary general ward he believed that a little less space would be quite sufficient, as the larger requirement will cut down the hospital capacity very materially. This resolution was duly seconded.

DR. BARLOW: With reference to space allowed per patient, thought that there should be a difference in accordance with the classes of patients; that he has charge of a hospital for mental cases, and it would be necessary to arrange for 100 square feet; these men are not suffering from physical disabilities. He stated that the State Hospitals cannot provide even fifty square feet of floor space and that it was absolutely necessary for the Veterans’ Bureau to take out of the State hospitals every insane patient they have.

DR. BLACKWOOD: concerning the allowance of six feet between beds, asked if this was not intended to mean six feet between bed centers.

The following motion was adopted:

“That the Federal Board ask the Veterans’ Bureau to reconsider the question of bed space.”

A motion was offered, which failed of adoption, to the effect that the Director of the Veterans’ Bureau set aside a certain amount for the reimbursement of unavoidable losses of property of ex-service men in hospitals.

DR. KRULISH: was of the opinion that if the foregoing resolution was adopted, that more trouble would be experienced than before.

It was further brought out that such a motion would carry no weight; that it was thought the service had this question up once before and the Comptroller’s office advised that no money arrangements could be made and it was not believed that the Veterans’ Bureau could make allowance for losses of clothing.

It was also stated in this connection that in some institutions steel lockers had been provided, a small deposit being required, which was given back when the key was returned, under which arrangement very little clothing was lost.

DR. HETERICK: stated that his institution is equipped with steel lockers and a small deposit required, which is returned when the patient is discharged; that the patient is told that due preparation has been made for taking care of his clothing and it is in his custody; that the installation of these lockers has reduced the theft of personal property to a minimum; that some times, however, lockers will be broken into.

The meeting adjourned at 12:30 p.m.

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