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._

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

the patients 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

a similar 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 the same 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.

In selecting foods for St. Elizabeths

Hospital we aim to have meats, milk, eggs,

cheese, sufficient to furnish 20% of the energy needed.

Cereal foods 〃 30% 〃

Vegetables and fruits 〃 20% 〃

Fats 〃 20% 〃

Sugars, sirups 〃 10% 〃

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 the assistance 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.

Social service should have a definite place in hospital organization.

Social service should be the agent of the Commanding Officer for dealing

with; (a) the relationships of the hospital to other groups in the

community; (b) the relation of the patients to their families and their

community; and (c) in the relation of those matters which affect the

social conditions which are involved.

Of course everything in the Social Service Department as in any other

department of the hospital must be under the absolute control of the

Commanding Officer. It has a relation to the administration of the

hospital, and to the patients’ treatment. In its relation to the

hospital the Social Service Department may:

(a) Provide entertainment.

(b) Regulate visiting under the Commanding Officer’s direction.

(c) Receive proper donations previously authorized by the Commanding

Officer.

(d) Stimulate in the adjacent community resources which can be

beneficial to the patients.

In the Navy the funds for our entertainment program are primarily

provided from allotment made by the Morale Division of the Navy

Department and from ships shore or canteen profits. The Red Cross

supplements our endeavors and assigns at certain hospitals other

personnel than Home Service or Social Service Workers, to assist in

recreational measures.

The Social Service Department’s relation to the patient’s treatment:

(a) Securing social histories and other significant data for use of

tuberculosis specialists and psychiatrists.

(b) Securing reports on home conditions for help of physicians in

deciding whether or not to discharge a patient to his home.

(c) Correspondence with home communities to adjust home situations,

thereby making it possible for patients to remain in hospitals.

This sometimes involves financial aid to families.

(d) Arranging through local communities for men who return home to have

proper care and assistance in adjusting him to civilian life.

Then there is the After Care of the patient and one the Social Service

Department should be competent to handle:

(a) Helping to connect men approved for vocational training to get in

contact with the proper government officials later. With a

Veteran Bureau’s representative in the hospital, this should be

much simplified.

(b) Following up patients who leave the hospital A.W.O.L. or against

advice, to see if they return or if leaving against advice that

they are placed under proper supervision in the home community.

Lastly there is the Information service which this Department may

provide:

(a) Communicating with family doctors and others to assist in securing

affidavits necessary to substantiate government claims.

(b) Information to families regarding patients’ personal and family

affairs when advised to do so by the Commanding Officer.

(c) Furnishing information to patients regarding government

legislation.

(d) Furnishing information regarding government insurance.

The Social Service Department of the hospital irrespective of the source

of supply of the personnel must be considered as an integral part of the

hospital, subject to the inspections, rules and regulations of the

hospital.

The Red Cross at present provides the personnel for social service

endeavors and I cannot conceive how any other agency could undertake to

provide this service without providing the cobweb like organization

spread out over the United States with thousands of Home Service

sections as the Red Cross maintains, prepared to furnish information to

the government officials. Until the government can provide a similar,

and an adequate service, I know of no other civilian organization which

enjoys the semi-official recognition imposed by the Congress and to

which we in the government can turn for assistance, than the American

Red Cross.

The social service problem is one of helping the doctor, the man, the

family, and to represent the community.

We as medical men must remember that treatment, if successfully

instituted, must embrace rehabilitation of the mind to a like degree

that it does the body. A cure cannot be affected by the simple

administration of drugs or a stroke of the scalpel. Something just as

important, and in many instances more so, is the attention to the mental

state of the patient. All the medicine, all the most skilled surgery

will not cure unless careful attention is paid to the mental frame of

mind of the patient. The whole social service effort is one to help

bring back the patient to the world of reality and to maintain morale at

a high level.

We must always be conscious that in caring for patients there is a basic

distinction due to the mental depressions resultant from illness,

helplessness and dependency, and protracted convalescence. Sick men have

distorted judgment, reason illogically, magnify trifles, and acquire a

certain degree of negativeness. Their spirit of discipline is stunted.

They resent correction and restriction. They must be retrained to think

logically and coherently. Each patient must be treated separately,

prescribing for his individualism when he is abed and while still unable

to attempt a return to group action. The morale of the patient is just

as important as the administration of drugs or surgical relief. In fact,

I do not believe it too broad a statement to say more so, for every

patient must be treated from a morale standpoint. While some patients

need medical, others surgical treatment, a great many need neither

medical nor surgical attention, but only mental rehabilitation. The last

class are not necessarily pathological cases nor psychiatric cases, but

a peculiar class demanding careful study and definite prescription

usually of a _recreational_ form.

We must not overdo the social service for the good of the man himself,

his family and his community. The greatest service we can render the

disabled ex-service man is to reinstall in him self-reliance. We must

keep his morale high, for morale is the perpetual ability to come back.”

COL. EDWIN P. WOLFE gave the following discussion on “Hospital Supplies”.

“Mr. Spangler has given us a very complete description of the general

method of procurement, storage and issue of supplies required in the

management of hospitals. It may be permissible, however, to elaborate a

few of the details and to call attention to certain common errors on the

part of hospital personnel using these supplies.

It is a well established principle for the efficient distribution of

supplies that the final “break-up” be made as near the ultimate

destination of the supplies as is practicable. This requires, of course,

a sufficient number of supply depots located in suitable sections of the

country from which the individual hospitals can secure their supplies

with the least practicable delay. The question of size and location as

well as rental cost of warehouses is ofttimes the determining factor in

the number of depots from which supplies are to be distributed. From the

standpoint of economy in operation, fewer depots of larger size are the

more desirable; from the standpoint of prompt distribution, the larger

number, more widely distributed are the more desirable. It requires a

great deal of study of transportation lines and traffic conditions to

decide upon the happy mean between these two.

The average person who uses hospital supplies has very little conception

of the great amount of storage space which is necessary in order to

carry at all times in the warehouses a six months’ stock to the end that

requisitions may be filled immediately upon receipt. As an illustration,

the Medical Department of the Army had in operation within the

territorial limits of the United States on November 1, 1918, ten large

distributing depots, with an aggregate floor space of more than

2,000,000 square feet. This area expressed in square feet is so

staggering as to convey a very inadequate conception of its size. To

those of you who are familiar with the methods of describing land in the

central and western states, it may be made intelligible by saying that

the area exceeds that of a forty acre tract. In fact, it is

approximately 45 acres. If you can conceive of such a tract piled ten

feet high with supplies, allowing, of course, for roadways and aisles

you will get some conception of the mass of material which had been

accumulated for the Army at that date. Then bear in mind that there were

thirty-three camps, each with its large general hospital, having three

warehouses, approximately 25 × 125 feet more or less completely filled

with supplies and you can get an idea of the quantity of supplies

required for current use in those hospitals and for dispensary service

of the camp. As a further illustration of the quantities of supplies

necessary it may be permissible to state that the quantity of gauze of

various meshes, from that required in bandages down to the coarsest

grade used in surgical dressings, not forgetting, of course, the muslin,

that was procured by use between April 6, 1917 and March, 1918, was

sufficient to have provided a strip a yard wide around the earth at the

equator and a bow knot consisting of several hundred miles in addition.

If the yarn which was required in weaving this mass of material had been

all made into one single thread, one end of it might have been hooked on

the limb of some giant tree on earth with the other end dropped into one

of the spots on the sun and still had a few thousand miles to spare. The

number of beds actually available for use in the hospitals in the United

States on January 1, 1919, if placed end to end would have stretched

over a distance in excess of 90 miles. If the mattresses had been placed

side by side and end to end to form a square, they would have covered

sixteen acres.

Proper warehousing is a very necessary part of the supply service. For

efficient warehousing as well as for prompt and satisfactory

distribution of supplies, a standard list of articles to be used is

necessary. These articles should be grouped in the warehouse in

conformity with the class to which they belong,—textiles in one place;

drugs, medicines and reagents in another; hospital furniture in another,

and so on through the entire list of supplies.

Warehouses should be located on railroad spurs so that supplies may be

delivered directly from cars into the warehouse and from the warehouse

directly into the cars. Concentration of storage space is desirable on

account of the shorter distance to move supplies when unloading and

loading. To this end a depot consisting of several stories, one above

another, affords the minimum trackage necessary in handling supplies and

it is desirable that such a building be selected when practicable.

The decision in the early part of the year 1917 to restrict the number

of articles, particularly surgical instruments, which would be

manufactured for the use of the hospital services of the Government and

for civilian use made it possible to provide the essentials for hospital

services with the limited manufacturing facilities which were then

available. Such a list had been in use in the Medical Department of the

Army for many years and doubtless similar lists obtained in the hospital

services of other departments of the Government. This standard list

presupposes specifications for the articles enumerated therein;

specifications again presuppose personnel qualified to determine what

those specifications should be. To write concise and adequate

specifications requires familiarity on the part of the personnel writing

them with the articles described therein and not only with the articles

themselves, but with the process of their manufacture. The prime

essential of the efficient supply service therefore is not limited to

the funds provided by Congress but embraces as of equal importance a

personnel trained in the actual purchase, inspection, storage and issue

of the supplies, secured at the cost of the appropriations which have

generally been so liberally made by Congress. The actual buying of an

article and the placing of the contract therefore, is a comparatively

simple matter, but the question of determining whether the articles

purchased will satisfactorily accomplish the object for which they were

procured is an acquirement which comes only with years of observation

and experience, and then in those persons whose inclinations the more

readily adapt them to the routine necessary to acquire this experience.

Whatever may be the standard of any article which may be selected, the

assurance that the article delivered conforms to the article specified

rests solely upon the qualifications of the person designated to inspect

and accept it.

From years of experience in presenting the needs of the hospital service

of the Army to Congress, I am convinced of the urgent necessity for

economy along all lines of expenditure and activities. Economy does not

necessarily mean the elimination of activities nor the discontinuance of

the use of various articles in order to bring the gross expenditure

within the sums appropriated. It does mean, however, that no greater

quantity of any article, however insignificant, which may be issued to

the user, shall be used for that purpose than is actually necessary to

accomplish the results desired. It means that the services of employees

shall be fully and efficiently used. It means that the articles which

are not consumable in character shall be handled with such care and

regard to their future usefulness as will continue them in efficient

service for the greatest length of time. As an illustration, it is

common practice among many physicians when writing prescriptions for

various ailments to prescribe a four ounce mixture and to dismiss the

patient. The same practice has obtained very largely in the hospital

services of the Government. If, instead of issuing the usual four ounce

mixture a two ounce, or a one ounce mixture had been prescribed, equally

good results would have been obtained, since the patient in many

instances actually takes only a quarter, a third or a half of the four

ounce mixture, recovers from the ailment for which it was prescribed and

throws the medicine away. This is particularly true in military

practice. If the lesser quantity be prescribed and further medication be

found necessary, the patient for whom it is prescribed will return to

the doctor, giving him an opportunity for another and more complete

physical examination and consideration of the remedy, of the result

obtained and of any other more suitable, or have the prescription

refilled if it be necessary. A dozen tablets should be dispensed in

place of customary two or three dozen. In other words, in the hospitals

and dispensary services of the Government the medicines issued should be

in quantities not to exceed the retirements of three days. This will

result not only in the saving of drugs themselves, as well as of

bandages and surgical dressings issued, but will result in material

saving in the cost of the containers in which they are issued. We too

infrequently consider the sum which the aggregate saving of the few

cents here and the few cents there will reach at the end of a year in

the larger hospital services. With supplies abundant and seemingly easy

to secure everyone who uses them is prone to become prodigal in their

use and I cannot emphasize too strongly the need for economy along these

lines. The application of the old saying, “take care of the pennies and

the dollars will take care of themselves” to the every day use of

supplies in hospitals would result in enormous savings at the end of the

year.

I was very much impressed with the remarks of Dr. Lavinder on

specialization of medical practice and the tendency in governmental

institutions to carry it to extremes. This is no where more pronounced

than in the demand for hospital supplies. What our patients need is

plenty of attention and simplicity in equipment and treatment.

Efficiency, yes, but simplicity especially. How often it happens that a

medical officer at a governmental institution becomes imbued with the

idea that he requires certain special apparatus which must be obtained

at considerable cost to the procuring agents to carry out his theories

of treatment. In a few months, or a couple of years at the longest, he

is relieved from those duties, at that hospital and goes elsewhere. The

officer who follows him conceives that an entirely different set of

instruments and equipment is necessary for the treatment of the same

class of patients than those used by the former medical officer. The

instruments and equipment of the former officer are returned to the

store rooms where they take up valuable space and new equipment is

secured by the incoming officer to take their place.

The elimination of these personal peculiarities and requirements will do

much to reduce the enormous expenditure which is everywhere being made

for hospital supplies and equipment.

In closing, permit me again to stress the need for economy in the use of

all supplies required by governmental hospitals, for an earnest effort

to use the equipment provided to its utmost efficiency and an honest

effort to get the most out of all the expendable supplies used in the

treatment of the patients committed to our care. If we are honest in

these efforts we will have no difficulty in convincing both Houses of

Congress of the justness of our requests for funds to carry out the

purpose committed to us.”

COLONEL JAMES A. MATTISON, Chief, Surgeon, N.H.D.V.S.

“Of the various papers which have been read this afternoon on the

medical side, nursing side, diet and supplies, the two

words which seem to have been the key-note of each of these papers have

been ‘standardization’ and ‘cooperation’. It seems to me that the matter

of standardization on the subject that I am to talk on is one of the

most important factors that we can consider.” He stated that

standardization could be carried not only through the individual

hospital, but through every government agency which does this type of

work. He continued, reading the following article—“Hospital Supplies”.

“Almost every group of hospitals follows a different system in the

business management, especially from the standpoint of procuring,

conserving, and issuing of supplies. It is believed that a decided step

forward for U. S. Veterans’ Hospitals would be a standardization in the

method of procuring, handling, and issuing of all supplies. At the

present time most of our agencies have different laws regulating the

methods by which supplies are to be purchased and handled.

In some branches of the service practically everything has to be

procured on competitive bids. In some, greater leeway is allowed and

certain articles may be purchased by circular letter, while others give

still greater leeway in allowing the purchase of a large quantity of

supplies in open market. There are advantages in all of these methods

and at the same time there are opportunities, at least in some cases of

some of the methods being greatly abused. This, however, depends almost

wholly upon the personnel responsible for the transactions.

The property officer or employee, whether he is represented by the same

person as the purchasing officer or not, is inseparably connected with

the subject of supplies, and the weaknesses connected with hospital

supplies, provided such an officer is not too greatly handicapped,

depends to a very large extent upon this individual.

The per capita cost of supplies in general is dependent not so much upon

the quantity actually used as upon the waste which takes place, and the

waste depends wholly upon the personnel handling the supplies. It is

therefore, highly important that the personnel in charge of the supplies

must of necessity be thoroughly trained and conversant with the needs

and requirements of the service and at the same time have authority to

question requisitions and demands which are in excess of apparent needs.

This is a fact which I am sure we all recognize.

It is not the policy of the Government in any branches of the service to

furnish inferior quality of supplies. However, the experience of

Government hospitals in general is, that it is quite difficult in many

cases to get the grade of goods delivered that is specified, regardless

of what method is followed in making purchases. This is particularly

true with certain firms who regard U. S. Government agencies as

legitimate prey and have no scruples in unloading undesirable goods or

goods of an inferior quality, provided they are able to get away with

it. I daresay that every branch of the service has to contend with this

condition and it is believed that here again there should be some means

by which other branches of the service may be apprised of information

regarding unreliable firms which has been obtained by them through

actual experience.”

MR. M. SANGER, of St. Elizabeths’ Hospital, gave a further discussion of

“Hospital Supplies”, as follows:

“Mr. Spangler, in a presentation of the question of Hospital Supplies,

has covered in a general way the method of deciding the class of

supplies required, how to procure these supplies, how to decide upon the

quantities needed, and the general scope of standardizing supplies so as

to serve the best interests of the Government, to supply the needs of

the patients, and to procure and conserve the supplies in the most

economic and efficient. manner.

In reference to the supplies themselves, as has been stated, the first

thing is to decide what is needed. The second, as to the best method by

which these supplies may be purchased. Third, the amount of warehouse

space available for storing these supplies. Fourth, as to the best grade

of supplies to secure for the particular purpose for which they may be

required. Fifth, considering warehouse space and the non-perishable

class of supplies, what are the most economic quantities in which they

may be purchased.

There are one or two matters pertaining to the question of supplies,

however, that it seems he has not touched upon, and which I will discuss

for a few minutes. The first is in relation to those which may be

considered the non-expendibles, or more specifically those supplies

which are necessary in connection with machines of various classes;

whether it be automobiles, refrigerating machines, boilers, large tools,

or what not. As soon as a machine of this sort is secured, an entry

should be made showing date of order, date of receipt, cost, name of

make, from whom purchased, and any other information of a similar

nature. This information will be needed in order to purchase repair

parts, and when needed, as in case of a breakdown, it will be needed in

a hurry. Parts may have to be purchased by telegraph. The same

information would be needed in case of inventory, or, if a cost system

were in effect, to show depreciation, wear and tear, or give other

information in order to secure accurate cost figures.

The second item which I would speak of is the manner or method in which

you keep record of your general supplies. To a great extent, your

success or failure will depend upon the extent to which you are able to

keep up a continuity of certain supplies. For illustration, in running a

power plant one must at all times have an ample supply of fuels, oils,

packings, and repair parts. If you are furnishing food, you must at all

times have an ample supply of certain articles of diet. Your dietitian

prepares your menu and lists certain articles. These articles are

required for certain periods. Failure to have these items of supplies

when required upsets the menus. Substitutes must be utilized, which

ofttimes bring duplication of items on succeeding days or meals. This

will often lead to complaints on the part of the patient or student, who

desires a change and who believes his rights are being interfered with.

I would suggest, in order to minimize such occurrences, that a form of

perpetual inventory be installed, with labels in the form of cards or

records attached to each item. On such records, there should be marked

the minimum mount of each item that should be carried before a new

requisition is to be placed for replenishing the supply on hand. The

amount of the minimum of each item will have to be decided upon data

based upon experience covering, (first) quantities used, and (second)

time required for a new supply to be received after the order has been

placed, (third) whether supplies are to be obtained direct from the

contractor or if purchase must be made on the open market, whether

supplies come from the vicinity of the place where required or must be

shipped from a distance.

These things, though they seem small in themselves, as your experience

will doubtless demonstrate, are of such importance that I cannot place

too much weight upon them; and I think that a very early and close study

of these questions will assist you to a material extent in meeting the

problems that will confront you, and enable you to overcome many of your

difficulties.”

MISS RUTH EMERSON, of the American Red Cross, taking Mr. Pearson’s place on

the program, stated that it was because the Surgeon General of the

Public Health Service turned to the Red Cross that they came into being

in this particular connection.

She stated that certain fundamental principles had been written down

between the Public Health Service and the Red Cross, which had been

abided by, and that it had been a great problem which was taken up with

the Commanding Officer to keep out the things that were undesirable and

to bring to each hospital the best things for that hospital, not only

for the patients but for the personnel. She stated further that on the

information side the Red Cross had been a great aid in bringing to the

patients knowledge about various government regulations, but that now as

more and more attempts are made by the various departments to get this

information to the man the need for the Red Cross in this regard becomes

less. Another important function of the social service worker is to find

out the home conditions to which a man with tuberculosis is going when

discharged from the hospital.

CAPT. BLACKWOOD: stated that as the hour was late he moved that the

discussion of this important subject be postponed until tomorrow

morning.

The motion was carried and the meeting adjourned at 4:45 P.M.

_Fifth Session_ Thursday, January 19, 1922.

GEN. SAWYER: “I would like to ask if either of our committees are ready to

report or whether they have any inquiries to make”. He asked Captain

Blackwood for a report.

CAPT. BLACKWOOD reported that the Committee on Forms met yesterday noon and

felt they had a task that was going to take months. As they had no

copies of the forms in use two of the members of the committee were to

get them by noon today.

GEN. SAWYER: urged that the matter be pushed in order that some little

understanding at least might be had before the end of the meetings, that

perhaps some suggestions could be made that could be carried out after

the meetings adjourned. “I am requested to state for the Committee on

Resolutions that there is no special report that they have to make now.”

He introduced Admiral Stitt, to preside.

ADMIRAL STITT: “The first paper is “Discussion of Disciplinary Regulations

of Veterans’ Bureau as they affect the beneficiaries and hospitals,”

which someone will read for Colonel Patterson, who is still ill.”

MAJOR R. W. BLISS, U. S. Veterans’ Bureau, took up “Discussion of

Disciplinary Regulations of Veterans’ Bureau as they affect the

beneficiaries and hospitals”, as follows:

“In a discussion of U. S. Veterans’ Bureau General Orders 27, dated

September 9, 1921 and 27–A dated January 14, 1922, covering the

Disciplinary regulations governing beneficiaries of the Veterans’ Bureau

who are patients in hospital, it is assumed that even before September

1921, all present recognized the advisability and necessity of some

lawful method by which the small lawless element, often present in

hospitals, as it is in any other community might be effectively dealt

with.

It is further assumed that the provisions of the September General Order

#27 are generally well known to this audience.

Therefore, this present paper will be limited to a brief statement of

fact of the numbers of patients discharged under this order, and to a

statement of the essential differences in the September G. O. #27 and

the G. O. 27–A, issued yesterday, leaving any comment to the general

discussion.

I have here a chart showing the name, location and type of every

Government hospital receiving Veterans’ Bureau patients, and giving the

total number of patients in each, and the total number of patients

discharged from each one, under the provisions of General Order #27,

between the dates of the issuance of this order, on September 9, 1921

and January 14, 1922.

This represents 67 Public Health Service Hospitals, 14 Naval Hospitals,

9 hospitals connected with the National Homes for Disabled Volunteer

Soldiers, 6 Army hospitals and St. Elizabeths’ Hospital, under the

Interior Department, a total of 97 Government hospitals.

The total number of patients, to which I shall refer hereafter, mean

Veterans’ Bureau Patients.

Between the dates above mentioned there have been in and admitted to

these 97 hospitals, 44,318 patients. Of this number, 474, or a trifle

over 1%, have been discharged for disciplinary reasons; 732 or 2% have

left against Medical Advice, and 1804 or 4% have been absent without

leave for a period of 7 days or over, and have so been dropped from the

rolls of the hospital. This is a total of 3010 or 7%.

In the 67 Public Health Service hospitals there have been 33,028

patients, of this number 336, or 1% have been discharged for

disciplinary reasons, 520 or 1.5% have left against Medical Advice, and

1233 or 3.5% have been dropped as over 7 days A.W.O.L. This is a total

of 2089 or 6%.

In the 14 Naval hospitals, there have been 2571 patients. Of this

number, 44, or 1.7% have been discharged for disciplinary reasons, 49 or

1.5% have left against Medical Advice, and 44 or 1.7% have been dropped

as AWOL. This is a total of 107 or 4%.

In the 9 soldiers homes there have been 4721 patients. Of this number 56

or 1.2% have been discharged for disciplinary reasons, 111 or 2.3% have

left against Medical Advice, and 437 or 9.2% have been dropped as

A.W.O.L. This is a total of 604 or 12.7%.

In the six Army hospitals, there have been 3076 patients. Of this number

44 or 1.4% have been discharged for disciplinary reasons, 50, or 1.6%

have been discharged against medical advice, and 65 or 2% have been

dropped as AWOL. This is a total of 159 or 5%.

St. Elizabeth’s hospital has had 922 patients and our records show that

none have been discharged for disciplinary reasons, none left against

advice and none have been dropped as A.W.O.L.

In a general way, the large tubercular hospitals show the greatest

number and percentage of discharges under this order. One or two

hospitals show over 30% discharges, these being mostly against advice

and absent without leave.

Since the issuance of the September General Order #27 a great deal of

adverse criticism of it has been received from many sources.

With this in mind and with the knowledge that penalties were prescribed

in the original order which did not conform exactly to the wording of

the Sweet Bill General Order #27 has been rescinded and General Order

#27–A issued in its place.

The essential features and changes in General Order #27–A are as

follows: