“The neuropsychiatry problem which the World War created and presented
to the medical personnel of the various branches of the Government for
solution, may be advantageously considered in three parts.
The first part of the problem consisted of dealing with the conditions
which developed in our armies during the war, more particularly those
conditions which developed as a result of the stresses of actual
service, particularly, of actual fighting. This large, and as you well
know, very heterogenous group, in some mysterious way came to be
labelled with the diagnosis of “shell shock”, a term which
neuro-psychiatrically was most unfortunate, and which continues its
vexatious existence.
This group of cases, while a very heterogenous one, consisted largely
and perhaps most characteristically, of a multiplicity of types of
conversion hysteria, cut aside from any attempt to diagnose in detail
the various forms that “shell shock” took, it is sufficient to say that
this group as a whole was a group of acute psychoses developed under the
severest of stresses of service conditions and that when these stresses
were relieved, and particularly after the signing of the Armistice,
these patients got well and to all intents and purposes this group as a
whole ceased to exist and so is not today one of our problems.
The second group is the group of what I shall call the ordinary State
hospital type of psychosis. This includes the type of individual that we
ordinarily find in State hospitals, that has always been recognized,
that is usually called “insane”, and that for the most part was
discovered by the army rather than created by war conditions, although
it must be recognized that a certain number in this group might, under
the ordinary circumstances of life, have remained stable, at least much
longer than they did. However, there is nothing unusual or extraordinary
or unfamiliar in this group to the average physician of State hospital
experience.
With regard to the treatment of this group, however, it should be said
that the great stimulus which came to psychiatry because of the war came
because the country discovered, and was astounded by the discovery, that
it had distributed throughout the length and breadth of its population a
vastly greater proportion of defective and mentally ill individuals than
it had the remotest dream of. Because of this stimulus which psychiatry
received, the matter of treatment has received very much more intensive
thought with the net result that there are today more well recognized
agencies for dealing with this class of patients than ever before. Very
briefly these agencies may be considered under the following heads, some
of which of course are not only well known and well recognized, but have
been used for many years, whereas others that are perhaps equally well
recognized have only received wide application recently.
The _first_ of these agencies, perhaps, is the application of the
general principles of medicine and surgery to the treatment of the sick
individual. In other words, the patient’s general health becomes a
problem for inquiry and appropriate consideration, irrespective of his
mental state, on the general theory that physical health is at least the
best condition precedent for undertaking a restoration to mental
equilibrium.
The _second_ of these agencies is the complement of the first, and is
best designated under the general term of psycho-therapy and consists in
the recognition of the mental disease as such irrespective of whether
there can be found any physical foundation for it or not, and on the
basis of such recognition endeavors to deal with it as a thing in
itself. In passing I may say that theoretically the best results would
come if these two agencies could work hand in hand each with sufficient
understanding of the other.
The _third_ agency, which has been very much broadened in its activities
in recent years, I may designate as the social agency. It recognizes
implicitly at least, if not consciously, that mental disease at any rate
the kind of mental disease included in the second group, the so-called
“insane” is a disorder of the individual as a member of the social group
and that it manifests itself largely by disturbances of his relation to
his fellows, and therefore it becomes a legitimate therapeutic endeavor
to attempt a readjustment of these relationships. To this end the social
agency has been developed in many directions. In the first place, we
have amusements. The simpler amusements may be called, speaking from the
point of view of the patient, the passive variety,—the type of amusement
that is brought to the patient, such as theatrical performances, moving
pictures, and the like, whereas the second type of amusement, which is
more advanced and more valuable, is the type in which the patient
himself takes part, such for example as theatrical performances in which
he is a performer, musical programs, in which he plays or sings. Then
there is the group which is not after all very widely separated from the
amusement group and yet is somewhat different, and that is the group
which we might term athletic activities and which demand upon the part
of the patient some initiative. These range all the way from the
simplest activities, which are imitative in nature, such as calisthenics
under the instruction of the athletic director, to mass games, where a
large group of patients are all engaged together in a common purpose,
such as push ball, to games of contest requiring not only initiative but
a relatively high degree of efficiency, such as the tug-of-war and the
various types of races and stunts, boxing and wrestling, and which are
from time to time advantageously staged on a field day and receive the
added stimulus of an audience. In addition to such activities as the
above there are also many minor ones of a similar nature, the principle
of which, however, is the same,—the social give-and-take of patient
between ward and ward, the instruction in such things as folk-dances,
and the like.
The _fourth_ agency, which has been very largely developed recently, but
which has always been used, is the agency of work. This has been applied
in approximately three ways. The first of these is known as diversional
occupation and comprises practically the whole field of what is thought
of by many as occupational therapy. The activities in this field consist
of such work as basket weaving, leather tooling, bead stringing, rug
weaving, and a thousand other similar activities. The object of this
activity is to assist in the re-direction of the patient’s interests, to
turn them away from infantile and regressive objects, and to project
them again into the outer world of reality. Then there is the industrial
type of work therapy in which the patient is carried still further along
the line of personal initiative and given an opportunity to do creative
work which is at the same time useful and which helps him to keep in
form pending the time of his ultimate discharge from the hospital. And
finally, there is the vocational education work, which undertakes
definitely and systematically to give a man training in some specific
direction which he can utilize, after he leaves the institution, and
which will have a definite economic value. For this latter work of
vocational training there is needed such psychological advice and
assistance which will at least prevent the wastage of time and effort
upon unprofitable or impossible tasks, whereas the vocational
psychologist cannot by any rule-of-thumb-tests tell that a man will make
a success in this or that direction, he can tell within reasonable
limits that a certain patient cannot profitably undertake a certain type
of training, that his capacities do not measure up to the minimum
requirements that would make success possible. In this way the work of
vocational education for the neuropsychiatric case can be narrowed down
so that it can be applied more intensively and more effectively to
selected groups that can be reasonably assumed to be good risks.
The _fifth_ agency, which can be advantageously brought to bear upon the
neuropsychiatric case, is the agency for extra-mural social adjustment,
and the personnel consists of the psychiatric social worker. With her
help the patient discharged from the hospital can have the maximum
amount of assistance for relating him again with the problem of
self-support and self-sufficiency. She, through her study of his family
situation, his economic status, his industrial placement and social
contacts can assist to these ends.
The third group of neuropsychiatry cases is like the second,—a group
that has always been with us, but unlike the second it is a group that
never before has been systematically hospitalized. It is the group of
what might broadly be termed borderland states, comprising all sorts of
types of defective, delinquent, psychopathic, neurotic, and mildly
psychotic individuals. Whereas they perhaps present no new problems when
one is speaking from the platform of neuropsychiatry, they do present a
distinctly new group of problems from the standpoint of hospitalization.
Here all the agencies which have been described in connection with the
second group need to be brought into action, but beyond them there needs
to be a definite intensive study of methods for the new hospital
problems involved. I mention only one aspect of the problem because it
is one which has forced itself repeatedly upon the attention of hospital
authorities and that is the need for an intelligent, and I may say, a
therapeutic utilization of discipline in dealing with these cases, in
this group there very probably are contained a reasonable number of
individuals of unusual equipment, who, if our ingenuity and our breadth
of vision are great enough, may perhaps be saved for some work of more
than ordinary usefulness.
One of the medical agencies which it is contemplated to bring to bear
upon this third group of neuropsychiatry cases is the dispensary because
it is recognized that there is actual danger in hospitalizing a certain
proportion of this group, and therefore it is much better to deal with
them as ambulant cases. They can be dealt with in the dispensaries which
are equipped not only to take care of them, but for all other medical
and surgical conditions, and so will get the very best possible
attention. There should, however, be connected with these dispensaries,
especially the larger ones in the more densely populated districts, a
psychiatrist with psychotherapeutic training who should have a
psychiatric social worker to help him. If there are enough patients to
warrant it perhaps additional assistance might be needed.
And finally, I would emphasize that in this great scheme, which
contemplates the hospitalization of from ten to fifteen thousand
neuropsychiatric cases of the general type above referred to there
should be included all of the armamentarium for scientific research and
all of the opportunity for individual endeavor and initiative which is
calculated to bring the brighter professional minds to bear upon the
subject and to illuminate it with the light of their genius. In order
that such results may be effected as promptly as may be, and with the
highest possible efficiency, I believe there should be established a
training center for neuro-psychiatrists where our younger men, who are
recently graduated from our medical colleges, and who have the
inclination to specialize in this branch of medicine, can fit themselves
in a minimum period of time to take it up as their life work. And that
this result may be accomplished I think it important that in extending
an invitation to the younger medical men to enter this branch of the
service that it should be possible to give them some assurance of
permanency in their respective jobs.”
GENERAL SAWYER: “The subject with which Dr. White has dealt is so important
that it will have more consideration later in the program, as you will
notice.
It is quite necessary in the operation of all affairs with which
Americans or even any of the human family deal, to have somebody who
knows something of the legislative procedure that is necessary to the
conduct of their affairs.
Honorable Charles H. Burke was added to the Hospitalization Board for
two reasons: first, because he does represent in his great family many
hospitals, the services of many doctors, likewise of many nurses. He
therefore comes to us, being a Congressman of long experience, as a man
who can deal with the subject partly from a professional aspect or view
of the matter, and again with a thorough and complete understanding of
the legal side of the affairs with which we are dealing.
So I have great and special pleasure this morning in presenting to you
the Honorable Charles H. Burke, Commissioner of Indian Affairs, who will
address you briefly on the statutory regulations affecting the
hospitalization of the World War Veteran.”
BURKE: “Mr. Chairman, fellow members, ladies and gentlemen:
I think in the introduction of General Sawyer I learned for the first
time how it happened that I was accorded the honor and the privilege of
being a member of an organisation made up of such a distinguished
membership as is this Board, barring your humble servant.
It would hardly be expected, after listening to these discussions by
these eminent experts in their particular lines, that I would undertake
to say anything along the scientific side of this proposition, and I am
going to be rather general in what I state in the short time I shall
talk to you.
Government activities can only exist by reason of the law, and so it
will be proper to consider perhaps or discuss briefly the application of
the law with reference to the activities that are being conducted, of
which you, each of you, are a part.
The responsibility for whatever the Government may do in this or any
other matter rests largely upon the Congress. I have hastily gone
through the legislation that has been enacted in the last few years with
reference to taking care of and providing for the ex-service men, and
during the war for their dependents, and for those who might become
incapacitated or disabled from any cause. There has been much
legislation, demonstrating that the Congress is keenly alive to the
importance of the situation. There has been one act after another, and
hardly an act but what has been amended within a very short time after
its enactment.
The recent law is what is known as the Sweet Bill, the law under which
we are now operating. Within the memory of many who are here present the
appropriations for all purposes of the Government were under a billion
dollars, and there is being and is appropriated at the present time
nearly half of that amount for the purpose of caring for the
hospitalization, etc. of these ex-service men. Am I correct, Colonel
Forbes, in the amount of money that is being appropriated? It is a vast
and large sum of money, and it is the duty of those charged with the
responsibility of expending that money to see that we get a hundred
cents’ value for every dollar that has been appropriated. This requires
economy and efficiency, and this gathering and this organization which
General Sawyer is the chairman, was created for the purpose of getting
better results from the moneys that are appropriated by the Congress;
and you, each and every one of you, have been brought here, as I
understand, for the purpose of coming in closer contact with those who
are charged with the responsibility, in the first instance, of
administering the expenditure of this large sum of money; and you owe to
this responsibility exactly the same responsibility as does Colonel
Forbes or anyone else occupying a higher station than you may occupy.
Therefore, I am confident and I am certain that when this conference
shall have concluded, every person that has come here will go back to
his respective place where his duty requires him, with a better
understanding and with a more determined disposition to try and render
better service and get really more for the money that is being expended
for the purpose for which it is being expended.
Speaking of legislation, we shall undoubtedly require considerably more
legislation because, as I have stated, in the short time since this
subject was first taken up by Congress think of the progress that has
been made.
As I understand, in 1919 the Public Health Service were hospitalizing
something like two thousand persons. General Sawyer stated here today
that we are now caring for twenty-two thousand; and I think it has been
stated—and it is generally considered—that the maximum will soon be
thirty-two thousand. So you see that it is more than likely that we are
going to have to have additional legislation and more appropriation; and
I may say to you generally that I have that confidence in the American
people—I have that confidence in the Congress of the United States—to
know that there need be no uncertainty nor hesitation on any one’s part
with reference to what may be done to provide for caring properly for
these dependents and these ex-service men who are entitled to every
consideration.
I believe, as the result possibly of this conference, it may be brought
to the attention of this Board that there is some legislation amending
the so-called Sweet Bill. I think Colonel Forbes, as the head of the
Veterans’ Bureau, has already discovered and suggested some very
necessary amendments to the law, and I have no doubt that he will be
able to secure those additions to the law. It looks now as if we may
have to provide for additional hospitals by the enactment of further
appropriations of money. It will not be done unless it is necessary, but
I am sure if it is necessary that adequate provision will be made and
made promptly by the Congress.
One of the policies of this administration is coordination and
cooperation, and endeavor to avoid duplication in administrative
matters; and if there is a bureau charged with a certain responsibility
and with certain duties to perform, if it may be possible for them to do
what may be under the jurisdiction of another bureau, to centralize and
have this work done by one rather than two; and so in the work of
coordination in the administration of this particular activity there has
been a great saving. The Public Health Service, I believe, makes certain
provision and takes care of certain persons at the request of the war
Veterans’ Bureau and vice versa. I think it has been said,—if it is true
it ought to be corrected,—that when the Veterans’ Bureau takes care of
patients for the Public Health Service, there has been no provision made
for reimbursing the Veterans’ Bureau. That will undoubtedly be taken
care of by Congress, either by increasing the appropriation for the
Veterans’ Bureau, or providing that when they render service for the
Public Health Service, the Public Health will reimburse them for such
moneys as they may expend.
Now one of the things that I want to particularly bring to your
attention, and to perhaps admonish you, in the two or three minutes I
have left, is to remember, as I stated at the outset, that governmental
activities exist only by authority of the law, and that we must keep
within the law; and remember, if there are some things in connection
with your duties that are not operating just as you would have them,
that they cannot be changed without changing existing law. The
responsibility for the law is upon the Congress of the United States.
The responsibility for this great undertaking is upon the Congress of
the United States, and if you have not sufficient money to properly take
care of these men, the responsibility is not yours; the responsibility
is upon the Congress.
It is your duty;—it is our duty to bring to the attention of the
Congress the money that is necessary in order to properly handle this
subject. Then it is for the Congress to say whether or not that amount
will be appropriated. Under this present administration, those of us who
are in Bureau positions have been admonished that we must keep our
expenditures within the appropriations, and we have had brought to our
attention the statutes upon this subject. I am going to read them to you
for your information, and I want to say to you who may have charge of an
institution and have had a certain allotment of funds for a given
period, that it is up to you to see that your expenditures do not exceed
that allotment. If you have not sufficient money to do what you feel you
ought to do, you must reduce your expenditures for the time being,
regardless of its effect upon the service, because under the law you
have no right to create a deficiency or incur any liability on the part
of the Government in advance of an authorization and an appropriation
therefor.
I want to call your attention to the statutes on this subject because
they are being brought to our attention not only by the President and
the head of the Bureau of the Budget, but by the Congress; and so I want
you people to understand that we are expected to follow the law.