Fourth SessionWednesday, January 18, 1922.
GEN. CUMMING, presiding, called the meeting to order.
DR. WHITE called the roll, and read the following announcement:
“It is requested that, at the first available opportunity, the following officers confer with Dr. Maddox, “C” Building, Room 1–319, concerning urgent construction work going on at their stations:
Dr. W. H. Allen, of Boise, Idaho.Dr. W. C. Billings, of Ellis Island, N.Y.Dr. R. L. Allen, of Arrowhead Springs, Cal.Dr. A. P. Chronquest, of West Roxbury, Mass.Dr. E. R. Marshall, of Detroit, Mich.”
Dr. W. H. Allen, of Boise, Idaho.Dr. W. C. Billings, of Ellis Island, N.Y.Dr. R. L. Allen, of Arrowhead Springs, Cal.Dr. A. P. Chronquest, of West Roxbury, Mass.Dr. E. R. Marshall, of Detroit, Mich.”
Dr. W. H. Allen, of Boise, Idaho.Dr. W. C. Billings, of Ellis Island, N.Y.Dr. R. L. Allen, of Arrowhead Springs, Cal.Dr. A. P. Chronquest, of West Roxbury, Mass.Dr. E. R. Marshall, of Detroit, Mich.”
Dr. W. H. Allen, of Boise, Idaho.
Dr. W. C. Billings, of Ellis Island, N.Y.
Dr. R. L. Allen, of Arrowhead Springs, Cal.
Dr. A. P. Chronquest, of West Roxbury, Mass.
Dr. E. R. Marshall, of Detroit, Mich.”
GEN. CUMMING: “This afternoon we are going to consider administrative policies. The first paper will be “Professional Service,” by Dr. Lavinder,”
ASST. SURGEON GENERAL C. H. LAVINDER:
“The subject that has been assigned to me is very broad in its scope, and the time is so limited, that if I may be permitted I wish to tender a written paper.” Dr. Lavinder read the article on “Professional Service”,
“In a discussion of professional service, however brief, no thoughtful medical man could forbear some comment on the present general status of clinical medicine and its developments within the last few years. The steady trend towards greater educational requirements, the development of refinements in diagnosis and therapy and the straining after what are believed to be higher scientific standards, creates in many minds some uneasiness as to whether the medical profession may not, by such things, be led astray and forget the very purpose for which clinical medicine exists, that is, the comfort, welfare and relief of the patient. Such a fear is by no means a groundless one. There is always a possibility that the medical man may become so enamored of his refinements and of his scientific methods as to forget that his business is the treatment of the sick. It is a truism so trite as sometimes to be overlooked, that all organization and all methods in clinical medicine have for their ultimate end the care of the patient and everything else must be subordinated to his interests.
Leaving this aside and omitting much, there are some things which may be stated in a general way concerning professional service, understanding that it is presumed such service is administered in hospitals properly constructed, properly located and equipped, and operated for the particular purposes which we have in mind.
1. There are certain broad policies in this matter which are worthy of some comment.
The flexibility of hospitals is a matter of importance. The Public Health Service has divided its hospitals into three general groups, that is, hospitals for general medicine and surgery, for pulmonary tuberculosis and for neuro-psychiatry. We have striven, however, even in these broad groups to make such hospitals available, at least temporarily, for any class of case which seeks admission. This has been especially true with regard to pulmonary tuberculosis and we have been rather insistent that every general hospital should set aside a certain number of its beds for the care of such cases. A similar policy has been followed with regard to neuro-psychiatric disorders. Even if the general hospital can be made no more than a distributing point for these special classes of cases it is, nevertheless, wise that such provision should be made. Consideration has been given to the possibility of adopting a method which was followed by the Army during the war, that is; specializing in hospitals to much greater degree and organizing certain hospitals on such a basis that they might be especially prepared, both in personnel and equipment, to care for one or two classes of disorders. The patients with which we have to deal, however, are by no means so easily transported and so easily congregated in special groups. This method, therefore, while it deserves much consideration, has not been found feasible in our work. Consideration has also been given to the establishment of convalescent hospitals, and while such institutions have much to commend them, they also possess some very serious disadvantages, especially with the class of patients with which we are now dealing. We have opened one such hospital which is still in operation and is giving satisfactory service.
It has been a general policy of the Public Health Service, of course, to seek in every way to establish in all of its hospitals standards of professional service in full accord with the best modern practice. At the same time we have sought to avoid the fostering of radical methods which might verge on the field of fads. We have preferred to adopt a somewhat conservative attitude in this regard and have been unwilling to make use of methods until they had been fairly well tried out and established as useful.
It has also been a policy, as far as possible, to establish a uniformity in professional service, at the same time doing nothing which might interfere with individual initiative. General Uniformity in professional service is desirable not only for administrative reasons, but for professional ones as well.
It goes without saying that we have felt the absolute necessity of establishing a professional service which would be reasonable in cost. The expenditure of money in professional service is, of course, wise. At the same time it has seemed to us that any professional service which could not be justified on the basis of economy was probably more than necessary.
There is one other matter of general interest, which seems to us of the highest importance, and that is the creation in all hospitals, so far as possible, of a broad spirit of human charity and the stimulation of any agency which would help in the creation of such an atmosphere. We have, therefore, done everything we could to assist in the formation of an efficient medical social service and in the furtherance of recreational activities. It has seemed to us that the creation of such an atmosphere in any hospital is a matter worthy of every effort.
One other consideration of general significance is the ideal of not discharging a patient from hospital until he has reached the maximum benefit to be derived from such a form of treatment, and was ready for discharge in a condition which would permit him to return to the outside world prepared to assume, as far as possible, the burdens of daily life and ready to make social readjustments. In other words, it has seemed to us unwise simply to discharge a man upon recovery from an acute or chronic illness without taking pains, through a medical social service, to see that he was readjusted to the community on a basis which would prevent his reversion to a state of ill health and perhaps his readmission to hospital.
2. With regard to the application of professional service to the actual treatment of sick in our hospitals, we have had in mind, in a general way, some rather definite things. In the organisation of our hospitals, whatever the type, we have arranged all of the professional services to meet the demands of the institution. We have attempted to adjust these professional services, so for as possible, to the need of the particular hospital and the particular class of patient treated therein and then properly to coordinate all of these various services under competent chiefs, supplemented by attending specialists. An organization so established should, we feel, meet any reasonable demands which might be made upon the institution without an undue expenditure in the matter of professional personnel.
We have established many highly specialized services, including dentistry. We have not overlooked such things as occupational therapy and physio-therapy and, of course, have taken care to supply the necessary modern laboratories, X-ray equipment and other matters which are essential in the best modern professional service.
We have, of course, not neglected such necessary accessories, in the proper care of a patient, as good nursing and an adequate system of supplying a well balanced ration, properly prepared and served.
We have believed in doing much of this work that it was a matter of economy as well as expediency to furnish as complete medical examination as possible. These cases are compensable cases and the matter of records as to their physical condition is of especial importance.The veterans’ Bureau has felt the need of careful and complete examinations as well as records which are dependable. Pains have been taken, therefore, so far as possible, to take such examinations and keep such records of all cases.
In some of our hospitals we have felt the need of establishing special services for special classes of cases, but have not extended this any further than was necessary. For example: we have in one of our general hospitals a special service on gastro-enterology. In another we may have a special service on surgery, as applied to tuberculous processes. Similar special services have been located in several places to meet special demands and such a policy will, of necessity, continue.
Most important of all we have striven in every way to secure a qualified medical personnel, a matter of no small difficulty. The demand for competent medical men is greater than the supply. In the operation of such a large hospital system it is by no means easy to secure men skilled in special lines of endeavor. We have, therefore, felt the need many times of establishing some system of educating our medical staffs in various matters and, while funds have not permitted the extension of this system, we have availed ourselves of educational methods as far as possible. Schools of various kinds have been held for short periods of time and men have not infrequently been transferred temporarily to situations where they might acquire a special knowledge. We have also encouraged staff conferences and attempted to supply working libraries and medical magazines to each of our hospitals—all with the idea of stimulating among our entire medical personnel the desire to increase their professional efficiency as much as possible.
3. Finally, we have not overlooked the necessity for research. Our funds have been too limited to do a great deal in this line, but we have felt keenly the responsibility which rested upon us to do all that was possible. Such activities have been carried on in a very small way with the exception of one or two hospitals which might be really called research hospitals, notably such a hospital as the one at Waukesha, Wisconsin, where every effort is devoted to the diagnosis and treatment of a definite class of Neuro-psychiatric disorders. This hospital has been so organized as to permit the very highest type of modern diagnosis and therapy.”
GEN. SAWYER: “This seems to me to be on opportunity to say a thing or to which have been in my mind that I wish to express now. First, this present administration has as one of its ambitions the best Public Health Service in the world. I want you to know that, in your engagements here, trying as they are, behind you is a determination to help to develop an ideal Public Health Service, and every man who is engaged in the service of the Public Health of the United States should feel that he is engaged in the greatest service that can be rendered to his country.
For myself, I have a great ambition that somewhere there should be established a post-graduate training department to which the members of the Public Health Service of the United states could come for post-graduate training. We want to be the highest type of doctors that are to be found anywhere, and so today we have in contemplation the establishment of a post-graduate training school in the city of Washington, to which you can come to provide yourselves and equip yourselves with all the new and better things that from time to time must develop.”
SURGEON DEDMAN: stated that he felt that Dr. Lavinder’s paper was too important to pass up without a comment or two; that one thing he was struck with was the personal contact to be made with the patients themselves. He said he believed this was a very important matter, as the services of a doctor are absolutely worthless until he has gained the patient’s confidence. He felt that the doctor should be looked upon just as the family physician at home. He stated further that when he first entered the work he made the following hospital rules: 1—Kindness, 2—Cheerfulness, and, 3—Duty. Said that the doctors should inject the feeling of friendship into the minds of the men as much as possible. He stated that there ought to be a system of uniform hospital regulations, that some hospital rules are not so drastic as those of other hospitals, and that he believed there should be a uniform regulation so that the disciplinary regulations would be the same in one hospital as in another.
ASST. SURGEON. L. L. WILLIAMS: stated that in reference to uniform disciplinary regulations the character of the patients, the location of the institutions and the construction of the premises are all factors that affect the privileges to be given the patients. Believed there could be no highly organized uniformity of regulations.
In regard to specialized attention, the hospital should be prepared to furnish any sort of special care possible. He stated further that he believed that the specialized patient in a general hospital is better off than if in a special hospital, but that if he had a son who had a special ailment he would much prefer him in a hospital which had upon its staff men in active practice of the kind he was going to need.
CAPT. LOWNDES: said there was always some patient who would go out and make trouble, that he had been investigated by the American Legion, by ladies’ committees and by religious societies, all of whom he invited to come to the hospital, as there was trouble if they were told not to come. He said he had met with two criticisms: one was that the nurses were particularly harsh, to which he replied that he generally had trouble getting the patients to go out as some of them generally fell in love with the nurses; the other that the patients would not pay any attention to the Commanding Officer when he made inspections.
GEN. CUMMING: “The next subject “Nursing” will be presented by the Superintendent of Army Nurses, Major Julia C. Stimson.”
MAJOR STIMSON: read the paper “Nursing”, as given herewith:
“The subject of nursing in relation to the care of the ex-service man is a very big one and can scarcely be handled adequately in the ten minutes allotted to it. There are, however, certain phases of it that can be mentioned.
The response of the nursing profession to the call of the country during the time of war is well known, and the character of the achievements of the 25,000 trained women who entered the government services at that time has been often recounted, but little has been told of the patriotic devotion to duty that has been exhibited by nurses since the Armistice. I have not come today to bring bouquets and laurel wreaths, but I do wish to call attention to the marvelous development of one branch of governmental nursing work under conditions that in many instances were harder to bear than most war conditions, and to ask for the service the recognition and cooperation it deserves. At the present time there are more nurses in the U.S. Public Health Service, (1796), than there are in the combined nursing departments of the Army, (774), and the Navy, (488). The figure given me for the present Public Health nursing staff is about 1800, an expansion from forty odd at the time the service was authorized to care for ex-service men, on March 3, 1919 by Act of Congress. To realize the full meaning of this expansion and the development of the organization required to manage the service, it is only necessary to recall the fact that in the spring of 1919 when the Public Health Service called for volunteers for its Nursing Service, the Army and the Navy were both discharging from their Nurse Corps great numbers of women. In one month alone in that year 2500 nurses were demobilized from the army. They were all tired, worn-out women. You all recall the state of mind of both the soldier and the officer during those months, when morale was at its lowest ebb, because of homesickness, fed-upness, and desire to get back to civil life. Nurses as well as men were full of complaints, and to be freed from governmental control was the thing that to all of them seemed the ultimate good. Moreover, many who came from overseas had been marking time for weeks, awaiting orders for the breaking up of their units, and embarkation, and upon their arrival home they found their communities, which they had left so short of nurses, were clamoring for their services.
Under such conditions was presented the need of the ex-service man. A new federal nursing department asked them to give up their personal desire for freedom, their longed-for plans, and to enter—what? and to do—what? It is hardly necessary to describe the kind of hospitals these nurses were asked to enter, nor the conditions under which they were to live.You would scarcely believe the details that I could tell you unless you, too, have heard the accounts of the able Superintendent of Nurses of the Public Health Service. You know, perhaps, what some of the old Marine hospitals are like, and some of you know some of the old Army hospitals taken over by the Public Health Service were like. You don’t know, I am sure, about the utterly unworthy and unsuitable quarters and messing arrangements for nurses which many staffs have had to endure, and still do endure in some instances. The fact that there are now 1800 nurses in the service bears witness to the clearness of her vision of the need on the part of the Superintendent of the Corps, and her valiant presentation of it, and to the assistance given her by the American Red Cross Nursing Service which has spread the call and facilitated recruiting.
The Nurse Corps of the Army and Navy were old, established departments, with traditions and customs behind them, with a status recognized by all in the service and honored by officers and men alike for their many years of efficient work.
The nurse in the U. S. Public Health Service had no such advantage, and to her and her associates and to the officials who have championed her cause against what have at times seemed almost unbearable difficulties too great praise cannot be given.
General Sawyer has asked me to present the difficulties that lie in the way of the kind of nursing service to the veteran that ought to be given, and to suggest if I can, a plan for meeting these difficulties.
The greatest problem of the nursing care of the ex-soldier is not in the Army and the Navy, because the proportion of the veterans patient to the regular Army and Navy patient in those services is so low that it presents no particular problem. It is, of course, in the U.S. Public Health hospitals that the problems exist most noticeably.
First we must consider the type of patient. We are told that neuro-psychiatric, contagious, and tuberculosis cases predominate. Right here is one difficulty as far as nurses are concerned. To contribute the highest type of service to people so afflicted requires that the living conditions, the mental and physical recreation and up-building of the nursing staff, be of the finest order. I think that this is conceded by all who consider the long hours during which the nurse is in close contact with the patient and who realize that no individual, barring none, has so large an opportunity for personal influence upon patients as the nurse.
Nurses who are employed for the care of the veteran should be of the highest grade. Not only should they meet all the professional and technical requirements, but they should be especially qualified in all phases of rehabilitation and reconstruction, both mental and physical.They should have an especial knowledge of the problem of the tuberculosis patient, not only as an individual sick man, but in his relation to society. They should be thoroughly cognizant of the magnitude and urgency of the problem of social diseases, and without an ability to help the neuro-psychiatric patient redirect his interests into the world of reality and to correlate himself and his environment, they are failing in their whole duty to their patient.
Under the present conditions it is probably not an easy matter to get such super-nurses in any great numbers, and even were it possible to secure them, it is not likely that they could be long retained. The turnover in the nursing service in hospitals caring for veterans is unduly large, the reports show. This has been due in some degree to physical breakdown, and also to dissatisfaction with conditions, including uncertainty as to their status and fears for its future. What, then, is to be done? The answer is not so hard to find. Locally, it is comfortable living quarters, reasonable hours, good food, the right sort of recreation, adequate pay, and opportunity for advancement and improvement. Nurses, like all other professional workers, are coming to recognize that in order to live up to their highest ideals and to give their best services to afflicted humanity, it is essential to make provision for continual growth, and that from time to time added inspiration and education are necessary. Courses of special study are advocated, therefore, for all nurses, especially for those caring for veterans or any other particularly difficult group of patients. Opportunity for post-graduate study is considered a necessity in the Army for both officers and members of the Nurse Corps, and it is even more important in the U.S. Public Health Service. In some hospitals of this service special courses have been conducted for nurses with marked success, but particular emphasis should be given to this phase of meeting the nursers’ problems. For before a nurse can help to reconstruct a distorted mental outlook and restore a normal attitude toward life, she, herself, must have an understanding and a sympathy and a power to help that can only come from steady inspiration, constant study, and serenity of mind.
Second in importance locally is the recognition on the part of the commanding officer of each hospital and each member of the hospital staff of the real place of nurses in the endeavor to return the patient to normal health and life, and emphasis upon an attitude of helpfulness and cooperation in all matters concerning them. Only those who have served in hospitals where the commanding officer was heart and soul in sympathy with the problems of the nursing staff and concerned with every detail that might work for its well-being, can know what a harmonious, helpful atmosphere can exist, and how the spirit of courteous recognition and mutual respect can permeate from the commanding officer to every member of the personnel. For is not the nursing group usually the largest group in every hospital, and will not the attitude of the nurses give the tone to the hospital?Commanding officers should remember that in their hands and their’s alone rests the regulation of this tone.
In all the presentation of the general subject of the care of the ex-service man, at this conference, little if any mention has been made of the part of the nurse. Right here in this very fact, perhaps, rests one of the largest snags that lie in the way of the best service to the veteran. Think for one moment of the situation if there were no nurses to work side by side with the medical man and to cooperate with him in securing for the patient that which he, with his special preparation, considers necessary for his healing. What results would be obtained? The time has passed when the need of professional nursing in the care of the sick is a debatable question. And yet nursing, as vital to the modern scientific restoration of the war veteran, has not been mentioned.
Here at headquarters is where the greatest progress toward the solution of the nursing problem can be made,—1st, in the recognition of the problem and its importance, and 2nd, in a sympathetic, concerned, business-like attempt to solve it by the method that is most sure to bring about success,—namely the conference method, the collecting of advice from experts on the subject, the formulation of their suggestions, and an endeavor on the part of all concerned to put these suggestions into practice.
You, in this new governmental organization, which has for its aim the highest type of service to veterans and their restoration to complete living, have a chance to develop a nursing department that should set the standard for all the departments of federal nursing as well as for civilian institutions.”
GEN. CUMMING: “Discussion will be offered by Mrs. Higbee”.
MRS. LENAH S. HIGBEE, Superintendent, N.N.C.: stated that the subject hardly needed discussion, that it would almost seem that she could not amplify it, but that was what she was going to attempt to do. She spoke on “Nursing”, as follows:
“Since the nurse viewpoint of the treatment of patients under the Veterans’ Bureau is considered sufficiently important to be discussed, it is a matter of regret that the chief nurses of the hospitals have not been summoned to this important conference. Of course, the nursing subject comes directly under the Commanding Officers of the hospitals but in presenting the more intimate views of the nurses, the opinions of the chief nurses would be more helpful than the opinions expressed through the medium of the superintendent whose knowledge of the situation is obtained from reports.
My knowledge of the situation we are discussing is obtained from reports. Letters have been sent to the various chief nurses requesting definite information on this subject and asking if any particular presentation could be made to this important body which would be helpful.
NURSING.
NURSING.
NURSING.
At the Naval Hospitals which have had the greatest success in treating the Service beneficiaries, the Commanding Officers have put a frank presentation of the situation to the patients, pointing out the necessity for certain restrictions and discipline, and urging cooperation. This preliminary presentation by the Commanding Officers when followed by the kind yet firm supervision of the ward officers and also by the tactful, helpful attitude of the nurses, who in turn cooperate with the welfare and vocational workers, in time break down the attitude of opposition, resentment, and destructive criticism which many patients have when first hospitalized. The chief nurses have stated that the care of the patients means only “more patients.” There is no special problem in dealing with them and under the above conditions, they accept the necessary discipline and restriction which are fundamental if hospital treatment is to succeed.
It would seem, therefore, that the problem, as has already been pointed out, exists chiefly in the U. S. Public Health Hospitals where the greater number of patients from the Veterans’ Bureau are receiving care and treatment. A large percentage of these patients would correspond to our Navy ambulant cases and among the remainder (as has already been stated) the neuro-psychiatric and tuberculous patients predominate.
There is considerable discussion among doctors, at present, regarding the fundamental qualifications which the trained nurse should possess; and there have been charges of over-education and a tendency to commercialism which result in unrest and in losing sight of the basic principles of their profession. The charge of commercialism is so unworthy of the medical profession that I shall let it pass without comment but I do not consider it beside the present question to touch upon the statement of over-education. It may be conceded that a nurse, possessing a preliminary graded school education, who has been carefully taught for two or three years in an accredited hospital, is able to give nursing care, under medical supervision, to the sick bed patient. Her greater value to the physician and to the patient because of greater knowledge due to higher educational standards need not be discussed here. However, it should be conceded, also, that the influence of nurses on the patients of the Veterans’ Bureau is more constructive mentally and morally than is the influence of nurses who care for the acutely sick; which is, usually, particular personal care for a comparatively brief period. To care for convalescent and Veterans’ Bureau patients is to serve long hours of duty in which little change in the physical condition of the patients is noted; and yet so great is this responsibility, so important is the work from humanitarian and economic viewpoints that the nurses must ever be on guard against the insidious lack of interest which comes from routine care; and they must keep themselves so alert that their great opportunities for personal influence among these men shall not be neglected in any particular. With any degree of sickness, there is distorted judgment and predisposition to give undue stress to trifles. The educated nurse knows this and knows also that the semi helplessness of protracted convalescence and the resultant sense of dependency, are among the chief factors which must be considered in dealing with these special patients. She must influence thepatients to be receptive to hospital restrictions; she must counteract the tendency to destructive criticism and disloyal statement; she must be sympathetic but not maudlin; she must recognize that they are ill but she must not encourage helplessness: she must suggest activity and encourage pride in endeavor and accomplishment. She must present the best viewpoint to the particular patient and this means an individual understanding of him and his needs. Only educated nurses (meaning that the aim of education is to develop the faculties of the mind and body) who have courage, refinement and dignity, who are loyal to their country without the stimulus of war, and who strive to maintain the high ideals of their profession can be definitely successful in co-operating with other agencies to restore these men to health. Reconstruction and Rehabilitation of the ex-Service men cannot be an affair of merely rearranging tangible elements, such as food, money and clothes: It is by example, by encouragement to make an effort to overcome helplessness, an explanation of the reasons for necessary treatment and restrictions, that the nurse will succeed in helping to replace quiescent dependence with the unsleeping desire and motive of service as active citizens. More and more it is recognized that we must look to education to destroy irrational suspicion and to restore to health and sanity.
The Public Health Nursing Service has been established a comparatively short time and yet under the Surgeons General of that Service and due in a great measure to the indefatigable efforts of the present superintendent and because of the high professional standard she has always maintained, more qualified nurses are attached to this Service at the present time than in the combined older services of the Army and Navy Nurse Corps. Having procured these nurses who, for the most part, it is believed, accept the additional responsibilities which the care of such patients involve, every effort that is made to retain them is worth while; since their value increases with length of service. From an economic viewpoint, if for no other reason, efforts should be made to give these nurses adequate payment for trained service; to provide living conditions which they require as educated and refined women; to recognize that rest and recreation are necessary if the physical standards and morale are to be maintained; to acknowledge their professional status and to give recognition to them as co-workers with the medical profession. With these requirements satisfactorily adjusted by those who have the power of formulating the necessary rules and regulations, the work of the nurses who care for the maimed bodies and sick minds of the patients of the Veterans’ Bureau will be productive of even greater beneficent results than have already been obtained;—for such nurses seek to maintain the fabric of the world; and in the result of their unselfish efforts is their prayer.”
MISS LUCY MINNIGERODE, Superintendent of Nurses, U.S.P.H.S., gave a further discussion of “Nursing”, as follows:
“Major Stimson has placed before you some of the most urgent problems and difficulties existing in the Nursery Service of Public Health Service hospitals dealing with the ex-service men.
The difficulties of the problem can be realized and understood only by those who are in close association with the Services, and that the Nursing Department of the Public Health Service has been able to accomplish even a measure of success has been in a large manner due to the co-operation, counsel and advice given by the Superintendents of the established Nurse Corps of the Government.
On March 3, 1919, the Public Health Service had available 1500 beds in 23 hospitals, and practically no nurses. Chief nurses were unknown in any of the hospitals. There was no machinery for the recruiting of nurses. In regular Service hospitals, there were no quarters for nurses, and the Service is still concerned over a solution of these difficulties. At the present time, there are 1796 nurses in the hospitals operated by the Public Health Service.
As has already been said, the problem of giving the most efficient care to the disabled ex-service men in the hospitals of the Public Health Service is a little different from that of the Army, due to the fundamental differences in the organization of this corps of nurses.
The Nurse Corps of the Public Health Service is a civilian organization, pure and simple, though 99%, probably, of the nurses now serving in the Public Health Service are ex-service nurses and familiar with the problems of the care of ex-service men.
The aim of the Nursing Department of the Public Health Service is to give as efficient nursing care to the patients in these hospitals as can be given, to see that the nurses cooperate in every possible way with those responsible for the care of the patients—that is, the Medical Officers in Charge,—to recruit a sufficient number of qualified nurses to meet the needs of the Service, and to recommend the establishment of such policies in the Nursing Department as will increase the efficiency of the nursing corps. The co-operation of the Medical Officer in Charge is essential; his sympathy with and support of the Chief Nurse must be unquestioned, if the nursing service is to reach the greatest efficiency. The place of the nurse in the administrative unit of the hospital should be clearly and definitely defined, understood and observed.
One great difficulty confronting this department is the lack of nurses specially trained in the care of neuro-psychiatric and tuberculosis patients, who constitute a large proportion of our patients. To partly meet this need, a school for nurses conducted at Oteen in September 1921, was organized and, while this school was most successful, it barely touched the fringe of our necessities. The Service is considering asimilar course in neuro-psychiatric nursing as soon as there is established a station where all conditions, quarters, lecturers and teaching facilities can be guaranteed to produce the desired result.
One piece of nursing work which has been far-reaching in its effects, was the establishment of a Public Health Nursing Unit in the office of the Supervisor of District #4, for the purpose of making contact with the claimant of the then Bureau of War Risk Insurance, with a view to giving the claimant, who for any reason was not hospitalized, the benefit of health supervision and health instruction. The success of the work of this unit more than justified its establishment by the U. S. Public Health Service.
The type of nurse needed for this Service is the broad-minded woman, cultured, well trained, with those qualities of mind and heart which would enable her to grasp the tremendous responsibilities in the work we are trying to do—who will be sympathetic, but firm—who will be able to emphasize the need for obedience to orders for treatment—who can be friendly, without familiarity, and loyal to the highest ideals of her profession.
The turnover is too large, by far, and is due in some measure to conditions which are unavoidable, since they are the result of the sudden expansion of the Service, the need for immediate action, and the great difficulty in securing desirable hospital stations, both from the standpoint of construction and location. These conditions are adjusting themselves gradually, and a distinct improvement in service and morale in the Nursing Department, a clearer understanding of the many problems which confront the administration and the Service in the effort to give the best medical care and treatment to disabled veterans of the World War, is evidenced; and, at the present time, the U. S. Public Health Service is able to keep the nursing force up to the necessities of the Service.
It is believed, however, that uniformity, throughout the organizations caring for these patients would go far toward establishing a more satisfactory service, and it is hoped that this meeting of all connected with and interested in the care of ex-service men will succeed in bringing about this desired result.
In the final analysis, however, it is conceded that the responsibility for the proper and successful conduct of these hospitals rests with the Medical Officers in Charge, and I can truly say in behalf of the nurses of the Public Health Service, that the nursing section will cooperate in every possible way to promote the successful organization of the hospital program, and to assure this meeting that the nurses of this Service will continue to “carry on” and to render all assistance in their power toward the accomplishment of this result.”
GEN. CUMMING: asked for discussions, stating that only two minutes would be allowed for each.
GEN. SAWYER: stated that the women were very anxious to have their suggestions.
CAPT. BLACKWOOD: stated that he wished to pay his tribute to the splendid work that has been done by the nurses. He said he had experienced hospital work when they were dependent upon the most undesirable man that could be found to take care of the sick. The man who could not do anything else was the one that took the place of the nurse. He also told his experiences in Boston when the influenza epidemic came, how in less than a month over 1300 cases were being treated by a staff of nurses scarcely larger than before, how the women worked day and night without rest and often without food, and how many of them lost their lives in the struggle.
He stated that one of the most important questions confronting us today is the question of pay of the nurses, that they had not been recognized in the way that they should be, that stenographers whose work is not as valuable receive from $100 to $150 a month and nurses from $60 to $100, and that effort should be made to pay them more in proportion to their qualifications. He stated that the charwomen received more than the nurses.
He stated further that the ratio of nurses to the number of patient which had been stated as 1–10 was too much to expect in hospitals such as his, where only about 15% of the patients were bed patients.
COL. EASTMAN: stated that this should be one nurse to every ten bed patients.
SURGEON STITES[STITT?]: said he did not believe any Commanding Officer could run a successful hospital without the cooperation of the Chief Nurse. He spoke also on the statement previously made “Kindness without familiarity”, stating that if too friendly some patients think others get more attention because of familiarity with the doctor, nurse or attendant.
SURGEON HEDDING: gave the situation at Ft. Bayard, ten miles from anywhere, with 1100 patients and 86 nurses taking care of them. He stated that the Public Health Service had authorized the keeping of 50 riding horses. He said that the nurses were happy, that the men were happy, and that many nurses were asking to come to Ft. Bayard.
GEN. CUMMING: asked Captain Wieber to talk.
CAPT. WIEBER: stated that he was from Ft. Lyon, Colorado, 7 miles from the nearest city, an establishment with 400 patients at the present time and nurse corps of 21. He said that the nurses were happy and content with the work given them. He also wished to give his tribute to the field and other nurses in the service. He stated he had had thesame experience as Dr. Blackwood in the early nursing service, and that some of the men who took care of the sick were half idiots. He said he fully realized now the value of female nurses, and believed he could not get along without them.
GEN. CUMMING: “That next subject is a very important one—‘Diet’—to be presented by Miss Clara M. Richardson, Asst. Supt. of Dietitians, U. S. P. H. S.”
MISS CLARA RICHARDSON: read the following paper—“Diet”.
“The subject “Diet” is a rather broad term and would suggest a variety of different phases, all of which might be equally interesting. Let us consider the subject however in its relation to the ex-service man and the care given him in hospitals established for his benefit.
Among these patients we find the necessity for a wide variety of diet, ranging from the more common types as liquid, soft and light to the more complicated pathogenic diets. In what are termed the General Hospitals are found patients suffering from many ailments such as nephritis, diabetes, colitis and many gastric disturbances. In some Public Health Service Hospitals, as many as four hundred special diets are served daily. In planning and equipping new buildings provision should be made for such a volume of work. It is impossible to satisfactorily serve many special diets from a general kitchen without proper facilities. Careful planning is not only necessary in the kitchen, but also in the serving and dining rooms. The patient on regular diet who may, perhaps, be eating corned beef and boiled potatoes is not likely to see his neighbor eating broiled steak and mashed potatoes, without making some comment. If this is not handled carefully, serious trouble may result. Where there are a number of small dining rooms it will be found wiser to use some of them for special diets.
In one hospital the large mess hall was divided into sections. There happened to be a number of doors, over each of which were placed signs reading—Diabetic Diet, Nephritic Diet, etc. This arrangement worked very satisfactorily, the patients filing in in an orderly manner wherever their particular diet was indicated. This is a matter which is entirely dependent on the construction of the hospital however.
Of course, care must always be taken that patients on regular diet who want a few extras do not slip into a special diet dining room. In a hospital too large for the dietitian to easily recognize her patients, this may be regulated by a pass of some description. Often times the Officer of the Day in making his inspection of meals may discover one of these visitors.
Not only must we consider the patient who comes to the dining room, the bed-ridden patient is perhaps worthy of even greater consideration. His appetite must be coaxed, his tray must be attractive, and above all, his food must be hot or cold, as the case requires. The satisfactory conveyance of food from kitchen to patient is a problem in all hospitals. Many institutions are so arranged that it is necessary to serve a few trays in almost every corner of the building. In such cases, it is well nigh impossible to attain the desired results. The ideal arrangement is one whereby the sick patients are focussed at a point near a kitchen. If Medical Officers would arrange this, other conditions permitting, they would find that many of the difficulties of food service would be eliminated.
A very successful development of this method in a hospital of a thousand bed capacity was recently brought to my attention. There were probably about two hundred patients on special diet, all served from a central diet kitchen. Trays were all set up under the direct supervision of the dietitian—a card bearing the patient’s name was placed in one corner, and the tray was immediately taken from the kitchen directly to the patient. As a result, patients from other parts of the hospital made every effort to be put on wards thus served.
The preparation of satisfactory menus and procuring of the requisite foods for special diet cases of course necessitates buying certain fruits and vegetables out of season. It also increases the number of chops, steaks, etc. used. It must be expected that the ration expenditure of a general hospital where such cases are cared for will be proportionately higher than where few special diets are served, as for instance in a neuro psychiatric hospital. It must also be expected that the ration of a hospital caring for tubercular patients will be higher in accordance with the increased amount of eggs and milk consumed. It is usually necessary to make special effort to tempt the appetite of this type of patient—he often is not hungry and is apt to waste his food. The market conditions in different localities will also be found to have a very direct bearing on the cost of the ration. The central northwestern states provide the best and cheapest market in the country. A menu which might cost 54¢ in this section would perhaps run 20¢ higher in some other locality.
In the preparation of menus, too much stress cannot be laid on the value of fresh fruits and fresh vegetables. Of course, it is necessary to use dried and canned goods to a certain extent, but care should be taken that the fresh articles are not entirely eliminated. The patient will probably say that he does not like salads. They are good for him, however, and after a little persuasion he will learn to like them, and will often ask for them. The personality of the dietitian counts for much. If she will go among the patients, talk with them in the dining room and let them know that she is really interested in them, they on their part, are ready to cooperate. Such cooperation is absolutely necessary, for upon the attitude of the patient depends the atmosphere of order and quiet in the dining room. An undercurrent of dissatisfaction is sure to result disastrously.
Another important factor in the success of the dining room service is the appearance of the room itself. I once saw a group of patients moved from a big barn of a mess hall, which was too large for the number accommodated and which could not be made attractive, to a smaller dining room, new and freshly painted, with curtains at the windows, and flowers on the tables. Those boys who had been noisy and boisterous in the first room, were as quiet and orderly as one could wish in the second.
We find in these hospitals every kind of patient from the boy who on account of religion does not eat certain foods, to the boy who eats anything he can procure, regardless of whether he is on a diet or not. Dietetic treatment in the latter case is practically impossible, while the former is usually very reasonable and gives little trouble.
Again we find the patient who is earnestly trying to improve his condition. If his ailment requires careful feeding, he may come to the dietitian to talk over with her the question of his diet. Here is an opportunity for the trained dietitian to give helpful instruction concerning the dietetic value of different kinds of food as they pertain to his particular case.
The ward surgeons may in may cases render valuable assistance to the dietitian in her problems, by instilling in the patient a confidence in her judgment. Of course, the doctor must himself feel sure that his confidence is not misplaced. There should be the closest cooperation between the ward surgeon and the dietitian. She should confer with him as to special diets, and thru him should ascertain the progress of the patients on those diets.
There should also be a complete understanding of just what is meant by liquid, soft and light diets. Experience has taught us that doctors, nurses and dietitians from different localities do not always give the same interpretation to these terms. It will save much confusion for all concerned if some standard is agreed upon.
The question of diet in these hospitals therefore resolves itself into three problems—first, an effort to secure the foods necessary for a wide variety of diet; second, an effort to serve these foods in a wholesome, appetizing manner amid attractive surroundings; and third, an effort to instill in the ex-service man a feeling of contentment and satisfaction which will go far as an aid to dietetic treatment.”
MR. J. D. SULLIVAN, of St. Elizabeths Hospital, gave the following discussion “Diet and the Service of Foods, at St. Elizabeths Hospital”.
“In preparing menus and estimating the amounts of foods needed for the population of St. Elizabeths Hospital, we base our calculations on the standard dietary tables, as published by the office of Home Economics, and the experimental stations of the department of Agriculture.
From extensive investigations carried on by the experts on dietetics, it has been found that the average man using much muscular energy in work or play, will require food sufficient to supply 4000 calories of energy daily; the average woman using much muscular energy, will require 2700 calories; the average man doing little or no work 2700 calories; the average woman or girl doing little or no work, will require 2100 calories.
Many of our patients are engaged daily at some work, and they lead a fairly active life; their food requirements, together with the employees of the hospital, can safely be calculated from the standard dietary tables.
Those amongst the hospital patients whose mental and physical condition is such that they require special attention and care, the food for them is prepared and served under the direct supervision of Dietitians specially trained for this work, and the amounts and kinds of food used is in accordance with each patient’s individual needs as ascertained by observation from day to day.
A diet made up of foods in this proportion will be sufficiently bulky, and will furnish the right proportion of protein, fats, carbohydrates, mineral matter, and vitamines.
As the report of the daily average per capita consumption of foods used will show we use slightly more than the amounts considered sufficient according to the standard dietary tables, because of the mental condition of many of our patients there is apt to be a considerable amount of food unavoidably wasted; also approximately three-fourths of the population are male adults, and for this reason they require more food than would be needed for an evenly mixed population.
From the investigations carried on in the office of experimental stations, the conclusion has been drawn that the total amount of protein needed every day is estimated to be 100 grams; one-half or 50 grams is taken in the form of animal foods, the remainder is taken from the cereals and vegetable foods.
It is well to encourage the use of cereal foods, especially where economy is to be considered, and they should be used as freely as can be without making the diet one-sided.
The use of cereals and vegetables increase the wholesomeness of the diet, by providing the minerals, and the bulk necessary for the normal digestion of the more concentrated food materials, and makes the diet more varied and attractive.
In the use of the cereal foods, bread should have the first consideration; the best bread that can be obtained should be provided; bread that is well flavored, light, of good texture, and well baked.
It is also well to remember that large quantities of cereal foods may not seem attractive if served alone; they may be made very appetizing if combined with small amounts of the more highly flavored or seasoned foods. A well seasoned soup may lead to the eating of a large quantity of bread. A little savory meat or fish, or a small quantity of cheese, may be used to flavor a fairly large dish of rice or macaroni.”
MISS FLORENCE D. HANKS of the U.S. Naval Hospital at Annapolis: She stated that cooperation is the big thing, that without it the dietitian is helpless. She said she has received the most hearty cooperation from the Chief Nurse and Commanding Officer, and stated further that in different hospitals liquid, soft and regular diets are different, and that it must be immediately understood just what the doctors mean.
MISS GENEVIEVE FIELD, Head Dietitian of the Walter Reed General Hospital:
At Walter Reed there are all kinds of patients to deal with. They have at least one dietitian present at every meal, and the patients feel free to bring comment or criticism to them at any time. In the wards the nurse is directly responsible for the service of food. If any food is not just as it should be the nurse is expected to telephone to the kitchen and report it, and it is immediately corrected. The nurse also knows just what is appetizing to certain patients and may request certain foods for them. One big problem is the patient who has been in the hospital for a long time and needs special attention, and it is these patients that the dietitians try the hardest to please. The menus are sent daily to the ward, and the nurse makes out her diet request list. She stated also that for the regular diets 1 pt. of milk and 1 egg are allowed per day; for light diets 1 qt. of milk and 1 egg; for soft diets 1½-qt. milk and 2 eggs; and for liquid diets 1½ qt. milk and 4–6 eggs.
CAPT. EARL P. GREEN, Mess Officer at Walter Reed: Stated he had been three years at the Walter Reed and that during that time many problems have come up. He stated that food and service are the two principle things about feeding people, but the greatest difficulty is service. It is very important to get the people serving the food confident that it is all right. He said a nurse could take the best food to a patient and if she thought it was not good the patient would not eat it. Good food can be bought with money, but service cannot. He said he used to get his complaints from the Post and Star, but this has been eliminated by requiring the nurse to report anything which she thinks is wrong in the diet, and that no complaint is too small to investigate. He believed the mess department could hide nothing, but should be fair and above board.
GEN. SAWYER: “Recently the White House and my office have been bombarded with what seems to us to be a propaganda against the reduction of the ration cost in one of the hospitals of the Public Health Service. This brings to my mind two thoughts: first, in the matter of administration of the affairs of your hospital be sure that you do not take too many people into your confidence in considering any changes you have in mind to make. The fewer people that do the talking and the more that do the acting the better you are off. Also, I would like to express the feelings of Mrs. Harding, who has given a great deal of attention to the matter of the world war veteran and the matter of his feeding. This is what we would like these veterans to have—a generous diet of wholesome food, well-prepared and neatly served.”
MR. L. C. SPANGLER, Associate Medical Purveyor of the public Health Service presented the subject “Hospital Supplies”, reading as follows:
“The term Hospital Supplies may be construed in its broadest sense to mean everything used in a hospital. A fully equipped modern hospital in its various departments will use approximately 5000 different articles.
In the selection, purchase, inspection, storage, and distribution of such a wide variety of supplies in the quantities used by the government lies an opportunity to effect the saving of large sums. Careless or inefficient handling of any branch of this work may result in heavy losses. As it is obviously impracticable to purchase all articles for which individual officers have a preference it becomes necessary to have a standard list of supplies. This list is revised from time to time eliminating such items as can be replaced with more serviceable articles. Through frequent revisions all new medicines, instruments, etc., of proved worth find a place on the list.
By referring to the standard list requisitioning officers can ascertain the articles kept in stock at supply depots. Requisitions for articles not appearing on this list should be reduced to a minimum and when such requisitions are submitted they should be accompanied by a detailed explanation as to the necessity for the supplies requested.
Standard specifications are in course of preparation for all supplies which are purchased in large quantities. Such specifications enable the Supply Section to obtain wider competition from manufacturers and insures the delivery of a uniform and satisfactory product.
Commodities purchased in relatively small quantities can be obtained more advantageously when manufacturers stock articles are specified, as lower prices will be received and earlier deliveries secured.
The careful test and inspection of all supplies purchased either during their manufacture or after delivery has been made is an important function of the Supply Section. The inspection of supplies shipped direct to hospitals by contractors devolves upon the receiving officer who is furnished with either specifications or samples to enable him to protect the interests of the government.
Satisfactory distribution of hospital supplies is extremely difficult unless suitable warehouses are available which should be centrally located at points having good shipping facilities, preferably both rail and water. To attempt to use buildings for a supply depot which have not been constructed for that specific purpose delays the work and appreciably increases the cost of administration.
Approximately 25 per cent of the supplies now being issued from Public Health Service Supply Depots were received from surplus Army stores. These supplies will be issued on approved requisitions until the stock is exhausted and no further surplus is obtainable. Every effort should be made by service officers to use these materials and avoid the purchase of supplies as far as possible, as with few exceptions such supplies are in good condition. Such items as rubber goods, suture materials and others of a perishable nature received from Army surplus are occasionally found defective due to the fact that they were purchased several years ago. Attempts have persistently been made to eliminate such deteriorated articles from stock by examination at the Supply Depots before shipment is made. This process has been successful in preventing the issuance of inferior goods except in a few instances in which the material forwarded was in original unbroken packages.
In the interest of economy substitutions of articles received from Army surplus will continue to be made for special items requisitioned for unless some compelling reason requires a purchase be made. The necessity for the continuance of this practice will be understood when it is considered that sufficient funds have not always been available to lay in stocks of standard supplies to permit us to intelligently anticipate and arrange for our future requirements, or even at times, such as during the last quarter, to enable us to make purchases for actual and urgent needs of the Service, a condition of very serious concern to the efficiency and proper functioning of the work of purchase and supply.
The proper care and economical use of hospital supplies should be insisted upon by officers in charge of hospitals and the officer who permits loss through excessive breakage, negligence of theft fails in the performance of one of his most important duties. To delegate this duty to a subordinate and fail to require its strict enforcement does not relieve the officer in charge of his responsibility.
It may be interesting to you to know the procedure through which a requisition passes after being dispatched by a station.
As soon as it is received in the Purveying Service it is numbered, record is made of it and notice of receipt forwarded to the station where it originated with the statement that the receipted requisition bears a certain number to which reference should be made if inquiry is later necessary concerning items appearing thereon.
The second step is to the approving officer. Here it is carefully scanned, its contents noted and it is found to include articles of a non-standard or unusual character the requisition is forwarded to that section of the Marine Hospital Division interested in supplies of the class involved, such as Laboratory and X-ray, Physiotherapy, etc., for recommendation as to furnishing, after which it is returned to the approving officer who approves it without change or with amendments deleting certain items entirely or reducing the quantities requisitioned, in each case notifying the station whence the requisition emanated of action taken. In some instances he may request, as you are fully aware, further information relative to the necessity for certain materials.
After approval the requisition is returned to the Purveying Service. If the supplies desired are in stock, the Supply Depots are instructed to forward them to the station. Information of this action is sent them at the same time by mailing a carbon copy of shipping order. If not in stock, but covered by the General Schedule of Supplies, articles are purchased under the contracts contained in that schedule.
Circular proposals are then prepared for the remaining items which are not carried in stock at the Supply Depots or for whose supply contract has not been placed by the General Supply Committee. Bids are requested from as many firms as are able to supply articles and after a period of from 5 to 10 days award is made to the contractor agreeing to furnish the most suitable article at the lowest price.
Before, however, any article can be purchased, unless specifically exempted, inquiry must be made through the Office of the Chief Coordinator, General Supply, as to whether or not the articles desired by the station can be secured from the surplus stocks of any Government Department. Action is this regard is taken prior to issuance of the circular proposal. If the Chief Coordinator states that it is possible to secure the supplies from surplus of a particular department, we must then communicate with the department mentioned to inquire if the articles desired are at that time available. A statement regarding their condition, price and location is also requested. Upon receipt of this information order is placed with the particular department.
For the procuring of certain items of which there is no supply in stock or which are not usually stocked, authority is given the station to obtain proposals locally either because the quantity is insignificant, the value small, not justifying the cost of transportation, or because the station can more advantageously obtain the particular item requisitioned.
Of course this routine regarding requisitions does not apply to emergency requests. They are always cleared without delay and every effort made to furnish the supplies called for as expeditiously as possible.
It is not a part of the functions of the Purveying Service to approve or disapprove requisitions for hospital supplies. This duty is performed by an officer who represents the Marine Hospital Division and who works in the office of the Medical Purveyor that the prompt handling of requisitions may not be delayed. It is greatly in your favor if you have in the eyes of the approving officer a reputation for practicing economy in the use of supplies. Many of you have not met this approving officer, but you are all old friends of his. He has made you acquaintance through handling the requisitions prepared under your direction and he has formed a very accurate idea of your ability to foresee your needs. He knows whether your requisitions are closely scrutinised before you approve them, or whether your chief aim in life is to have the contents of the Supply Depot shipped to your station before the other fellow gets it.”
LIEUT. JOEL T. BOONE, U. S. NAVY: presented the next subject—“The Social Service Worker”, as follows:
“Mr. Chairman, members of the Federal Board of Hospitalization, and fellow guests—
The subject given to me to present is worthy of more expert and more specialized elucidation than I an able to furnish with meager knowledge of the functions of the Social Service Worker. We are interested to know just what position the Social Service Worker should advantageously occupy in our sincere efforts to provide the very best care and the very best care and the very best treatment for those unfortunate individuals who have been disabled in the service of our country or who have suffered disabilities as a result of or traceable to that service during the World War.
My knowledge of the Social Service Worker for the most part is limited to his or her duties associated with Naval institutions. For almost three years I have represented at National Headquarters of the American Red Cross the Surgeon General of the Navy, who is the Navy Department’s representative on the National Executive Committee. My official position has been one of liaison but, in the organization of the Rod Cross, I am the Director of the Bureau of Naval Affairs. In that position it has been my privilege to assist in the adoption of a Naval-Red Cross program for the carrying out of one of the purposes of the Red Cross Congressional Charter, which obligates the Red Cross to act, “in natters of voluntary relief, and in accord with the military and naval authorities as a medium of communication between the people of the United States of America and their Army and Navy.”
In my investigations as to the sphere of the Social Service Worker, I have found two schools of thought or two groups interpreting the meaning of the Social Service Worker differently. One group limits the definition to that personnel which deals with purely personal and community problems of individuals, and also to those who are trained medical social service workers; while the second group, sees no limitation to the field of operation by a highly specialized worker in dealing with an individual’s welfare. The first group separates the recreational, amusement, entertainment and athletic directors from the strictly medical social service workers; while again the second group consider the amusement personnel as properly placed under the category of social service workers.
We are not particularly interested here in this academic discussion but we should be mindful of it in giving consideration to the organization and administration of our hospitals. There is a limit to all things so the social service worker is limited in his or her field of activity. We seem to be living in an age of specialization. We need sanity in the practice of our professions irrespective of their nature; and what is just as essential, we need good practical common horse sense and not too much theory.
I believe the Commanding Officer can be rated a skilled social service worker more competent to deal with the problems of his patient than any other individual, if he is a keen observer of human nature, if he has the interest of the patient at heart, if he searches for, what we call, the soul of the man and not merely observe his flesh and blood, if he is determined to correct the mental restlessness as well as the physical agony, if he considers his patient individually and not as a case, and if he impresses on his patient that no one is as much interested in him as his Commanding Officer. No one in an institution should be able to take the Commanding Officer’s place in the sympathetic understanding of the patient. Of those in the military and naval service it has been said, that the uniform stands like a closed door between officer and patient. There should be no reason for this. If it exists, the officer is responsible.
You will appreciate why I make the foregoing remarks. The Commanding Officer cannot perform all the duties incident to the operation of a hospital and the care and treatment of a large number of patients, but, while he must have various types of personnel to care for the patient, he cannot delegate his responsibility for the patient’s welfare.
In the organization of our hospitals there is a proper place for social service the detail operation of which must be left to personnel which devotes its entire time to matters of a social nature, and to matters touching the personal, family and community problems of the patient. Obviously it would be most desirable to have all classes of personnel working in our governmental hospitals to be paid governmental employees. We are working toward the millennium but we are far distant from it, hence, we must avail ourselves of what we find at hand. The United States is populated with a kindly, sympathetic and generous people, which fact makes it possible for the unfortunate hospitalized to enjoy the generosity of our citizenry, much of our social programs in hospitals is made possible by the great membership and charitable organizations of our country. Through these organizations the American people can and do desire to assist constituted governmental authorities to provide for the welfare of the war disabled as well as the regular service man. As I have stated in the first part of my remarks, the Congress has legalized theassistance the American Red Cross can render the Army and Navy. When the veteran is hospitalized in Naval institutions he is given every consideration and treated as a naval patient. We cannot and have no desire to make any distinction between him who is serving his country today, and him who went to its defense yesterday. The truly patriotic would not have it otherwise. The service man of today has been actuated by just as high patriotic motives to serve his flag as the man who stood willing to sacrifice his all in the days when our beloved land was outwardly threatened by a visible enemy.
To those of us who are intensely interested in every phase of the veteran problem and who do not look upon the veteran as merely a medical or surgical case, the testimony given and the tribute paid to welfare endeavors and all forms of social service by Doctor White yesterday morning, was most gratifying. Those of us of the medical profession have the highest regard for the keen insight of a patient’s mental condition, possessed by Doctor White.