Third SessionWednesday, January 18, 1922.

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

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

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

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

Committee on Resolutions.

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

Major General Merritte W. Ireland, U. S. A.,

Rear Admiral Edward E. Stitt, U. S. N.,

Surgeon General H. S. Cumming, U.S.P.H.S.

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

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

Committee on Forms:

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

Captain Norman J. Blackwood, U.S.N.,

Surgeon M. C. Guthrie, U. S. Veterans’ Bureau,

Asst. Surg. Gen. J. W. Kerr, U.S.P.H.S.,

Colonel James A. Mattison, N.H.D.V.S.,

Major L. L. Hopwood, U.S.A.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

File No. 89960

UNITED STATES VETERANS’ BUREAU.September 9, 1921.

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

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

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

LEON FRASERActing Director,U. S. Veterans’ Bureau.

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

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

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

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

I fully realize that my subject is an extremely important one and that it is in a measure connected with nearly every benefit extended to the ex-service man or woman, and with every service that is rendered in his or her behalf. On the intelligent administration of the functions of admission, transfer and discharge to, or from our hospitals, as the case may be, depends, in great measure, not only the economical and efficient administration of our entire hospital program, but in equal measure the recovery, the health, the happiness, the future usefulness, even the very lives of men and women, many of whom have made great sacrifices and passed through great agonies.

When I make these assertions, do not think for a moment that I am comparing these functions with the actual volume of work that is done in the hospitals, with the relief that is given therein, nor with the benefits which accrue to the patient, but, just as victory in a great battle may depend on the placing of the right troops in the right place at the right time, so victory, in the struggle of the disabled ex-service man for rehabilitation, for health, or for life, may depend on his being sent to the right hospital at the right time. Neither must he be discharged too soon, nor kept too long, and when he is transferred from one hospital to another there should be sound medical reasons therefor, barring those unfortunate cases, where the beneficiary may be transferred to a hospital near his home when it is seen that death is inevitable.

Going back now to the contact which hospitalization makes, or should make, with the other benefits extended to the ex-service man, let me picture to you the state of our past, and to a great extent, our present organization, by recalling to your minds the old story of the six blind men of Hindustan who went to see the elephant, each trying to tell what the elephant was like. The first man got hold of the elephant’s ear and said that the animal was very like a fan; the second got hold of his leg and said, “No, I can’t agree with you; this elephant is like a young tree.” The third man got hold of the elephant’s trunk and said, “The elephant is like a snake.” The fourth man grasped a tusk and said that the elephant was like a spear; the fifth fell against his side and said he was like a wall; and the sixth got hold of his tail and said he was like a rope. Now all were partly right and each was mostly wrong, and a somewhat similar condition exists with regard to our work.

This meeting, gentlemen, is an attempt to further co-ordinate the efforts of all the agencies that are at work for the ex-service man. Ours is a tremendous responsibility, both from the standpoint of our duty to the ex-service man and of our duty to the taxpayer as well.

No man except the man in the field knows better than I do that you have been circularized and regulated and instructed and uninstructed, informed and misinformed, ordered and dis-ordered, until I have no doubt you have been tempted to slam your fist down on your desk and say, “Well, for Heaven’s sake, how many bosses have I, anyway, and which lead had I better follow.” And as for reports, no doubt you have wondered, “Well, whatwillthey want to know next?” And yet there has generally been a fairly good reason for every question you have been asked and a reasonably intelligent, honest, and often an enthusiastic, and sometimes an efficient man or woman behind the interrogation point.

In addition to having all these things done to you, I suspect that you and your colleagues in the hospitals, some of you at least, feel that you have been libelled and slandered by newspapers whose editors thought they were telling the truth, and by newspapers whose editors probably did not stop to consider whether they were telling the truth or not. You probably feel that you have been libelled and slandered, unintentionally of course, by men inside of legislative halls, and also, again perhaps unintentionally, if carelessly, by men and women outside of legislative halls, and by men and women both inside and outside of well-meaning civic organizations. And, I may say that in the Arlington Building in this city there are reams of evidence which might be cited in support of your beliefs, and at “C” Building at 7th and B Streets, there are tri-remes of such evidence, and these reams and tri-remes of evidence have cost the Government of the United States thousands, tens of thousands, yes, hundreds of thousands of dollars for investigations, when, as a matter of fact, the majority of the complaints that have been filed against hospital administration need never have been investigated by theGovernment at all if the individual who submitted the complaint had taken the trouble to do a little honest investigating on his or her own account.

The fact that these statements have been made with the best intentions in the world does not lessen the injustice contained in many of the charges, nor does it remove the sting which has accompanied these charges, and you, gentlemen, have listened to the soft pedal on the inside and to jazz on the outside until you have probably said, “For the love of justice, is there not some man who has grit enough to get up in public and tell the truth and say what he thinks?”

But, gentlemen, it will not always do to talk back. Actions speak louder than words, even though they do not make as much noise, and Solomon was right when a few centuries ago he remarked that “A soft answer turneth away wrath.” We mustalwaysmaintain a courteous, gentlemanly, dignified attitude. We must never for a moment allow our sympathies for the deserving unfortunate ex-service man to become in the least weakened, and we must continue to give him the benefit of the doubt in border-line cases, and finally we must maintain our equanimity under the most trying circumstances.

And now that we have you here, we are going to ask you some more questions, and I hope you know the answers, because I don’t know the answers to some of these questions myself, nor do I intend to answer them.

In passing, I might remind you of the fact that in times past we have spent money very freely on our hospital program, and that while we still desire to give our beneficiaries what is perhaps a little more than reasonable medical and surgical care and treatment, at the same time we must be able to show Congress that we are operating economically under present conditions, and certainly, when not in conflict with the patients’ rights or interests, the question of economy of administration must be considered in admitting, transferring and discharging. Are we giving this question of economy of administration the proper consideration in performing these functions, and if not, what are the reasons? We want to know. This I will label “Question No. 1,” and let you think it over for a while. It is perhaps not the most important question I shall ask but it is important.

Now, having delivered myself of this question, and not having answered it, I suppose you are ready for Question No. 2. Well, I am not. I want to talk a little before I spring the next question. Of course we all know that the primary object in placing a man in a hospital is to give him a chance to get well, or as nearly well as possible. This, however, is not the only thing to be accomplished in the hospitalization of patients of the Veterans’ Bureau, and, if I mayspeak frankly, I may say that, while theoretically, hospitalization, rehabilitation, and the awarding of compensation ought to dovetail into each other without any overlapping or getting in each other’s way, as a matter of fact they won’t do it,—at least they haven’t done it so far; but, nevertheless, we’ve got to make the best possible connection between these functions.

Let us hark back to Regulation No. 57 of the old Bureau of War Risk Insurance, which gave temporary total disability to the beneficiary whose disability showed Service connection, together with compensation at this high rate as soon as the man entered the hospital, and which cut down this compensation anywhere from $80 per month to nothing at all as soon as the beneficiary left the hospital. Although this Regulation has been somewhat modified recently, it is still a very strong incentive for men to seek hospitalization. It takes an unusually patriotic citizen to take$30 to $60 a month or less when he can get $80 a month and board and lodging if he can remain inside of a hospital.

Apropos of this provision, I recall the circumstances of a young man who came to me quite some time ago, having left the hospital at Fort McHenry. He presented himself in a courteous, dignified way, was perfectly serious and absolutely frank. He began the interview by handing me the card of a U. S. Senator. Then he told me his story, and it was a good story. I shall try to recall it as nearly in his own language as possible. “Doctor”, said he, “I have just left your hospital at Fort McHenry. I do not like it. I realize that the Public Health Service is not to blame for conditions which I found there. It is not suited for a hospital. It is badly located. There are odors which it seems impossible to overcome. The walls and floors are dingy, and while they are clean, they cannot be made to look clean.

“I was shot through the stomach by a machine gun. Here are the scars. If I do not work hard I feel fairly comfortable, and yet I am not well, I receive $30 a month when I am outside the hospital, I receive $80 a month and my board and room when I am in the hospital. Personally I would much prefer to remain at home, but when I work hard enough to make a living I break down. I have seen so many men in the hospital who are receiving their board and lodging and their $80 a month who are not as deserving of this as I am that I do not propose to remain at home and work on my present compensation, and I would just like to see you keep me out of a hospital. And furthermore, I demand to be sent to the hospital of my choice. What are you going to do about it?”

I replied, “Young man, you have been unusually frank in what you have said. I shall be equally frank with you. If I had been wounded as you have, and if I had the information which you have gained from your stay in different hospitals, I should probably make the same demands. You can have your transportation whenever you want it.”

I saw this young man later at No. 38 in New York and he told me that he was about to get what he considered a satisfactory rate of compensation, and that as soon as he could get it he would go home.

Question No. 2. How many men are there in our hospitals today who would voluntarily leave if we did not, by providing total disability rating and compensation while in the hospital, place a premium on their remaining there? How many of those who would leave really ought to leave? What can be done to correct the defects in the operation of Regulation No. 57, modified as it has been? Perhaps you think I am giving you several questions in one, but we will still label if “Question No. 2.” I am not alone in desiring to know the answer to that question.

Before I go any further let me say that I regard admissions, transfers and discharges as such closely related operations that I shall not attempt to treat them separately, but shall discuss them in any sequence that may be convenient.

I assume that all of you have been advised that under General Order No. 59, the allocation, distribution and transfer of patients of the Veterans’ Bureau are functions and prerogatives of that Bureau. Theoretically, none of the Services has anything to say about these matters. Practically, if I have not misunderstood the intent of this General Order, it does not mean that, altogether. The actual authority for and the right to refuse transfers certainly is vested in the Veterans’ Bureau and its representatives, but the Veterans’ Bureau and the District Medical Officers and District Managers depend on you to tell them when you think transfers ought to be made. Admission to a given hospital is the prerogative of the Veterans’ Bureau within certain limits; that is, the Service concerned must be able to take and care for the class of patient sent by the Veterans’ Bureau.

With regard to the discharge of patients from hospitals, the Veterans’ Bureau is continually encroaching, perhaps unavoidably, on what was once the prerogative of the Medical Officer in Charge and the Service which operated the hospital. Blanket authority for field transfers from one district to another has been entirely withdrawn, and District Officers must either place immediately in an authorized hospital in an adjacent district, as specified in General Order No. 59, or, having placed for observation or diagnosis a patient in a hospital within their own districts, must apply to the central office if it is desired to transfer later. It is, or should be, understood that under the present regime, that Medical Officers in charge of hospitals who regard transfers as necessary must request the District Office to make these transfers if within the district, and must request the District Offices to obtain authority from the Central Office if it is desired to transfer outside of the District.

Several questions suggest themselves with regard to General Order No. 59, and perhaps I should label this series of questions “No. 3.”

(a) Has General Order No. 59 lessened the number of ill-advised and unnecessary transfers, which is one of the objects, I believe, that were intended to be accomplished.

(b) Has General Order No, 59 caused any marked fluctuation in the patient personnel of any of the hospitals? I notice, for example, that Public Health Service Hospital No. 53, Dwight, Ill., has recently dropped from occupied beds to 65 in number, giving a surplus of 165 unoccupied beds. Houston, Texas, has dropped from occupied beds to 443 beds, giving a surplus of 528 unoccupied beds. At No. 32, Mount Alto, Washington, there is a ward for colored patients which will accommodate 30, in which there are only 6 colored patients at the present time. Are these fluctuations coincidences or are they the effect of the Veterans’ Bureau having assumed the functions under discussion. Of course if we could be sure that these reductions in-patient personnel are going to be permanent it would not make any difference. We could cut down our working personnel at a hospital like Houston, Texas, and with the consent of the Veterans’ Bureau we could close a hospital like Dwight, Ill., but will the pendulum swing in the other direction again, and what advance information can the Veterans’ Bureau give these fluctuations and of their approximate duration?

(c) Have you received very many patients who, owing to their condition or to the nature of your facilities, or both, should never have been sent to your hospital?

(d) Has General Order No. 59 tended to delay the turnover in those general hospitals having special wards for psychoneurotic and psychotic patients, who are detained for a short time only until they can be otherwise disposed of?

(e) Should General Order No. 59 be modified, and if so, in what particulars?

Having delivered this third volley of questions, I shall talk a little more. I have no idea what opportunities you gentlemen have had to become familiar with the facilities at hospitals other than your own. I have no idea what information District Managers and District Medical Officers have of hospitals and conditions in Districts other than their own. General Order No. 59 of course attempted to convey some idea of the facilities in all of the hospitals used by the Veterans’ Bureau, but it was impossible to incorporate anything like a comprehensivestatement with regard to these facilities. Quite recently, at the request of Dr. Guthrie, and with the assistance of men in both Bureaus, I prepared a questionnaire for all the hospitals, asking what your general conditions and facilities were like. Most of the hospitals have answered this questionnaire, and the information obtained is exceedingly valuable. Practically without exception the answers have been concise, complete and exactly what was asked. Those of you who have not answered please do so as soon as you can. I wish it were possible to print or mimeograph these reports and distribute them. Certainly anyone who is charged with the responsibility of placement and transfer of patients should have access to these reports.

While I am on this subject of facilities, let me invite attention to the fact that there are marked differences in the kinds of facilities offered by different hospitals and by the hospitals of the different Services. Let me also invite attention to the fact that we have patients who, if properly distributed, would fit into these different institutions possibly in a much more satisfactory way than at present and at a smaller expense. Particularly I suspect that there are many patients in Public Health Service hospitals that do not need the highly specialized and necessarily expensive care that these hospitals are giving, and I also suspect that there are many vacant beds in our Soldiers’ Homes where these patients can be given all they need at a much less expense than is possible in the highly developed hospitals of the Public Health Service, and possibly those of the Army and Navy as well. Why would not this be a good time to arrange for the prompt transfer of such patients? Europe has found the Convalescent Home to be an economical institution, being much less expensive than the hospital. Why may not our Soldier’s Homes be used for convalescents and those who need relatively little medical care and treatment, but who are still not well enough to be thrown on their own resources? These questions I shall not number. They just crept in.

There is one class of beneficiary that none of the Services seems to be prepared to handle satisfactorily, possibly due to the fact that legislation is needed to deal with this class. There may be a solution other than legislation but none of us has thought of it as yet. I refer to the drug addict who is entitled to hospitalization for some Service connected disability. We haven’t any place to put such patients and we do not know what to do with them after we put them there. We do manage to take care of some of them but at great inconvenience, and without being able to treat them for their own best interests. We cannot get them admitted as irresponsibles by the Courts. We have no such thing as involuntarycommitment, and if one of them desires to walk out of the hospital, out he walks if he is persistent enough about it, and we cannot stop it. This is a good time to say something about what we might to with these cases.

I have said very little about discharges for the reason that disciplinary discharges are to be treated by another speaker, and Regulations Nos. 26 and 26–A, bearing on this subject are to be discussed by Doctor Guthrie, who follows me on the program. I will say, however, that this subject is an important one and I can easily understand that from the standpoint of the man in charge of a hospital present procedures with regard to discharges are unsatisfactory. On the other hand, I can understand that when a man is in a hospital it affords an excellent opportunity to settle once and for all his claims for the various benefits provided by law, and yet I think it is right that the Veterans’ Bureau should accomplish these objects before the man is ready to be discharged. As yet this is not being done.

In conclusion, Gentlemen, I may say that as I see it, those of you who are in charge of hospitals are, if you will pardon the expression, between the devil and the deep blue sea. You are told one minute that if you exceed your allotment you will go to jail, and in the next breath you are told to go the limit if it is for the ex-service man. You have been told that there is room for improvement in your hospitals. No doubt there is, but in my humble opinion there is also room for improvement in the laws providing these benefits, in the orders, regulations and procedures designed to administer these laws, and last but not least, there is a crying need for some means of creating a sane public sentiment that will enable the public servant to discriminate between the man who really has a serious disability which he got in the Service who deserves our help and our sympathy, and to whom you and I would give the shirts off our backs if need be, and the man who spent a few days or a few weeks in camp who is not really disabled but who proposes to live at the expense of the tax payer just as long as he can get away with it.

We, Gentlemen, are not responsible for the law, nor is the Director, and the Director has men who tell him what the law is and he has to obey it and so do we, but it is our duty to point out defects in the law and try to get them remedied.”

SURGEON M. C. GUTHRIE (U.S.P.H.S.) had for his subject, “Discussion—General Order No. 26”, and spoke as follows:

“The subject assigned to me for discussion is General Order No. 26. This refers to U. S. Veterans’ Bureau General Order No. 26, dated September 6th, 1921, the subject of which is: “Admission to and Treatment in Hospitals of the U. S. Veterans’ Bureau Beneficiaries.” You are doubtless all familiar with the general provisions of this order.

It goes without saying that any definite order or instruction which effects the policies and functions of the U. S. Veterans’ Bureau and which may be issued to the field is sure of a series of return re-actions from various parts of the country, both as to the manner in which such an order is applied and as to the consequences of its application. These reactions are naturally good, bad, and indifferent; exact and truthful statements or colored as to the manner in which they affect the various individuals in its application, but coming from all parts of the United States they afford many valuable and effective criticisms of the order in question and are illuminating as to the original intent of the order and the amount of deviation or variation from its original purpose brought about by the manner in which it is put into effect.

The criticisms of General Order No. 26 had to do very largely with the “Four Days’ Notice” clause, and because of the fact that large numbers of beneficiaries in hospitals were being discharged without provisions having been made for out-patient care, dental care, physiotherapy, or other treatment where such was indicated and necessary; that patients were being discharged without having proper arrangements made for vocational training where the patient in question was feasible for some kind of training and was anxious to get it; that many such patients had to leave a hospital when they were receiving no compensation or where adjustments or readjustments of matters related to compensation needed to be carried out here.

These were the dominant and outstanding criticisms which followed the issuance of General Order No. 26, and as a result of these criticisms, it was considered advisable to issue a supplemental order correcting the defects complained of. Accordingly General Order No. 26–A came out under date of November 17, 1921.

The re-actions to General Order No. 26 were as I have just stated and came largely from the Bureau beneficiaries, from friends, relatives, and allied agencies working in the field. The criticisms of General Order No. 26–A, however, came largely from the hospitals and the District offices, the hospitals particularly. There was an apparent contradiction between the two orders. No. 26–A seemed to largely or entirely contradict the provisions of the original Order No. 26. General Order No. 26 stated that patients not requiring further hospital treatment should be given four days to complete personal arrangements and then be discharged.

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

October 14, 1921.PSR/jcs L 10–DMO

October 14, 1921.

PSR/jcs L 10–DMO

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

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

District Manager,

District No. 1,

U. S. Veterans’ Bureau,

101 Milk Street,

Boston, Mass.

Dear Sir:

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

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

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

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

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

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