I might say that out of every fifteen cases sent in with diagnosis of
epilepsy, about twelve or thirteen of them proved, after careful
observation for a period of from two to three months, to be hysterical.
That was about our ratio on cases sent in.
Our procedure was much like Dr. Kolb’s at Waukesha. The man was given
complete physical, neurological, examination first. We had a special
consultant who visited the hospital about once a week. After a man had
his examination, he was checked as needing further examination in eye,
ear, nose and throat, or x-ray,—whatever was indicated in the case, and
that was tabulated on the chart and checked against his examination. At
the end of that time each ward surgeon prepared a summary of the case
and a decision was made as to whether the patient needed a short term of
treatment in our own hospital,—we had there occupational therapy and
other methods of treatment,—and then be discharged and sent back to his
home.
In connection with the in-patient hospital work, we had a committee at
the district supervisor’s office made up of one representative at the
Bureau of War Risk Insurance, one from the Federal Board, the
neuro-psychiatric contact officer and one representative from the Public
Health Service. We tried to place the men in some definite schedule,—the
Federal Board, if possible, after he was discharged from the hospital,
and we would bring our problem cases to this meeting, where they would
be taken up and such arrangements made for their further treatment as
necessary. The contact man visited the station once or twice a week to
familiarize himself with the problems of each man.
The out-patient department was naturally on a different schedule; that
is, certain hours of the day were set aside and definite offices
assigned to the out-patient department; they kept track of their own
patients, who reported in at intervals of two or three times a week,
every two or three weeks, according to the needs of the case. If the man
needed some special treatment, he came into the hospital for that
treatment and at the same time he saw this ward surgeon and talked the
case over with him. Just as soon as that patient was ready for
vocational training, he was put into touch with our contact officer and
a schedule was made out for him.
In regard to the vocational training for epileptics, a great many cases
during the year I was at Chicago, came up to that board for
consideration. We tried the epileptic at various occupations; kept him
away from machinery so as no injury would come to him, and we succeeded
in rehabilitating only two epileptics out of the whole group. These two
were given positions in factories that were owned or governed by some
relative or friend who had taken an interest in then, disregarding the
compensation laws and disregarding the inability of the men to work when
they would have a seizure. In two instances only have we succeeded in
putting men into training where it proved a success.
DR. MCLAKE: I represent the National Sanitorium in Marion, Indiana. Presume
all of you have heard more or less about it. It was organized about a
year ago; opened on the first of January as a sanitorium. During the
past year we have cared for about 1500 patients. The present Census is
800.
Now this institution was opened under a provision that it was to be used
for the hospitalization of reasonably curable cases. In other words, it
was not to be an asylum. It was not a place for merely domiciliary
residence or custodial care. The needs of hospitalization, however, this
year, have been such that we have taken all sorts of cases. As this has
been a matter of discussion for many hospitals and in many districts, I
want to take half a minute to show you that during the past year and at
the present time, I am hospitalizing at Marion nearly every variety of
n.p. case which we have.
Up to the present time we have had no special accommodation whatsoever
for n.p.-t.b. patients. Our institution is built on the cottage plan and
in the preliminary survey and construction no provision was mode for
t.b. patients. However, at the present time I have one ward which is
filled with eleven of these cases. I may say in this connection that we
are expecting to build a t.b.-n.p. unit of eighty beds and will start
construction in about five or six months, which will be gratifying to
you men who have these combined cases and would like to unload them and
as soon as we can take these cases off your hands we will be glad to do
so.
In that connection I want to emphasize one thing: that in your general
hospitals and in your t.b. hospitals you get many cases toward the end
of this t.b. condition, which present n.p. symptoms. Now I know from
experience at Fort Bayard and in other t.b. sanitoriums, especially at
Fort Bayard, where I was associated several years with Colonel Burke,
that these patients become exceedingly troublesome and exceedingly
annoying. However, if you are perfectly frank with yourself and
perfectly frank with the n.p. man, you will admit that these cases are
not primarily n.p. cases, but cases of terminal toxemia. I don’t believe
myself that these cases should be hospitalized as n.p. I believe in your
t.b. hospitals you should set aside a ward or two or three wards where
you can take care of your terminal toxemias whose symptoms are
principally mental; they should not be unloaded on the n.p. hospitals
which are built and equipped for reasonably curable cases of n.p.
disease.
As to what General Sawyer said about many of these n.p. cases living
outside. I want to most heartily indorse that attitude, and I will say
in that connection that during the past year I have turned out between
two and three hundred men because I firmly believe in that view. My
method for turning out these n.p. cases is as follows:
After a final conference on a man after preliminary observation, if we
feel that he has come to the point where he should be given a chance, we
give that man a thirty-day parole. If he has a guardian, his guardian
must report every ten days. If he has not a guardian he is placed in
communication with the Veterans’ Bureau officer, or a Red Cross worker
in the District, in which he is paroled.
In other words, during the first thirty days I get three reports as to
his condition. If after thirty days he is still doing well, I grant an
extension of thirty days. During the second thirty days he reports in
twice. If he is still doing well at the end of sixty days, the parole is
extended to ninety. I believe in the majority of our cases that if a man
makes good for ninety days, it is reasonable to suppose that he is going
to make sufficient adjustment to stay outside of the institution. If, as
I said, his report at the end of ninety days is a good one, he is then
discharged from the Institution, with the privilege, of course, of
returning. Now of all the men I have sent out under that scheme this
year, I have had less than eight per cent of returns, and I consider
that in the first year a fairly good average.
I want to commend that scheme to every man who has charge of an n.p.
hospital and after this conference adjourns, I would like to correspond
with you on that subject. I would like to compare notes because I
believe it is worthy of attention.
There is one other thing brought up in a previous meeting and that was
the question of our constitutional psychopath, and drug addict and the
building of special hospitals for these men. I personally am not in
favor of such a scheme and I will tell you why. I have a considerable
number of these men. I believe that every complete n.p. hospital should
have a department with definite numbers assigned from the staff who are
particularly clever in handling this line of case. I think that they
should be handled in your regular n.p. hospital as a separate unit.
Now there is just one thing in connection with that statement I wish to
emphasize. There are a certain number of these men who do eventually
make an adjustment. For the sake of that percentage alone we should not
place the stigma upon them of being sent to practically a penal
institution, and that is what it means if you set aside a place and
brand it as a place for those of criminal tendencies and drug addicts.
We tried that in New York and you all know from the papers what it
resulted in.
There has been another plea. Dr. Treadway spoke of the shortage of
personnel. It is acute everywhere in every department. Then on top of
that comes the plea from the general hospital men, from the t.b.
hospital men, for neuro-psychiatrists to be assigned to his staff. That
is a physical impossibility. There are not enough n.p. men to go around
and I have a solution of that which I have put up to numerous men and
that is just this. Along with what General Sawyer said today about every
one’s being a well-rounded out man, every man who has charge of a
hospital, every man who is on the staff of a hospital taking care of
ex-service men ought to go down and buy a copy of White’s Outlines and
study it for the next six months. If you will do that you don’t need
specialists on your staff. You can make a near enough diagnosis so you
will be reasonably certain in 95% of your cases as to whether they ought
to be sent to an n.p. hospital or not.
DR. FULLER: I an particularly interested in the question of personnel. The
shortage of neuro-psychiatric trained personnel and physicians is a real
and very acute problem. We have any number of vacancies for such men in
the Public Health Service at the present time. I dare say the same
conditions exist in the Army and Navy. I believe that the only way of
solving the problem that Dr. McLake spoke of is for the Commending
Officers of those hospitals who have one psychiatrist on their
staff,—and practically all the large hospitals have one on their
staff,—to insist that these psychiatrists interest other members of the
staff. The fact that Dr. Treadway brought out, that most young men are
not interested in psychiatry is due to the fact they do not know
anything about it. I was one of the men who visited the schools last
year. I was suddenly confronted by statements made by the deans or their
assistants: “Oh, neuro-psychiatry, I don’t expect you will get much
enthusiasm from any of the schools on that subject, because that is a
post-graduate subject and we don’t make any attempt to teach it during
the under-graduate years.” Any number of young men who will state a
preference for general medicine can be interested in this subject about
which they know nothing. The solution, therefore, depends upon the
commanding officers of these hospitals and upon the psychiatrists on
their staffs; depends upon their willingness to detail one or more young
men to the psychiatrists, who are interested in the subject. I don’t
believe that the problem is going to be solved in any other way because
there are not enough men outside who are willing to come into the
Government service, who are interested.
DR. MILLER: We have a specialist at Oteen who lectures to our entire medical
staff Tuesday and Friday of each week. They are very much interested in
it and we think it is a very great benefit to the institution and the
patients.
COL. EVANS: What are you going to do with the group the doctor describes
that ought to be in a colony? What are you going to do with the mentally
deficient who will never be able to carry on? There is no appropriation
available for that group. If the Soldiers’ Homes are not properly
supplied with means or some other special effort made, every community
will have these individuals as a reproach upon them, and it occurs to me
there is no group of men that would be as able as this group to have the
propaganda go forward that there is a problem to be solved in these
cases.
DR. WHITE: I had this in mind about some of these difficult problems, some
of these border-line cases I didn’t have a chance to speak of the other
morning. I suggested there in just a word that in connection with these
disciplinary measured such as have recently been promulgated in this
order we got this morning, No. 27–A, probably we shall have to come to
some form of disciplinary treatment with a considerable group of these
border-line cases, and the plea I wanted to make was that discipline
should not be used as discipline per se, but that we should seek for all
of the possibilities that are incorporated in disciplinary measures
which can be brought to bear upon the patient for his welfare; In other
words, if we can make out of discipline a therapeutic tool.
Now we are dealing for the most part, in these border-line cases and in
the delinquent group, with types of individuals that are more or less
defective. Almost all of them are defective in some sort of way, not
necessarily intellectually defective but frequently on the affective
side; but there undoubtedly has to be some kind of disciplinary pressure
brought to bear.
I have in mind a fellow who is a high-grade defective, who has passed
through a praecox attack, who has come back to comparative normality. He
is a reasonably useful citizen around the institution but he can’t get
on outside the institution and he has periods of not getting on well in
the institution, because every once in a while he will go out and get
drunk. Now what are you going to do with that sort of fellow? Such an
individual does not always stand discipline very well. A doctor came to
me and talked to me about him the other day and wanted to know what
should we do with this fellow. I said, “Shut him up; take his privileges
away from him and watch him very carefully, because I don’t believe he
will stand shutting up very well. When you have made the maximum
impression upon him from that discipline, let him cut.” You have
constantly to shift between severity and almost lack of discipline with
these people to keep them at their level, and you have to realize all
the time it is a matter of very fine adjustment and that after all you
can very easily do them a great deal of harm. Therefore I am always more
or less disturbed by the constant effort that is being made in bodies
like this to standardize all kinds of rules and regulations, because I
realize that in this class of cases particularly there are individual
problems and they must be left for the individual judgment of the
physician who has charge of them.
I have, for example, a clerk in the office, a man who is probably sixty
odd years of age. When he is sober he is as efficient a clerk as we have
in our office, but he persistently gets drunk and stays drunk for days
at a time. Now the easiest thing on earth is to discharge that man. What
is going to become of him? He can’t take care of himself. He has a
family dependent upon him. That would mean to pauperize him and make him
a public charge. I developed some time ago a method of dealing with him.
I penalized him every time he got drunk by taking away a certain amount
of his pay. It was hard punishment. He does not get much pay. The result
was I pushed him to the limit, because it cost him too much to drink.
The result was he had longer periods of sobriety than he ever had
before, but he did break down once in a while, and when he did we had to
forgive him.
Now we have to deal with that sort of problem among our employees and
patients, and we are put to it constantly to devise out of our ingenuity
how best to meet it; and one of the agencies at our command is the
disciplinary measure, which, if wisely enforced, can be used to push the
patient to the highest possibility of his adjustment.
Then, in that connection, as to our friends, the morons and epileptics.
I am fond of saying that practically everybody, no matter how defective
he may be, has a certain capacity for usefulness. There is almost nobody
who is, under proper arrangements, a total loss socially. A Moron, of
six or seven years of age, may be ten per cent efficient. He may be ten
per cent efficient under one set at social conditions, maybe fifteen per
cent efficient under another set. He may be total loss under other sets
of conditions.
Now a lot of these people, like the young fellow I spoke of a while ago,
are very useful citizens in the hospital community. They would be a
total liability outside that community. We have always had these people
in the community and we always shall have them probably. It is perhaps a
worth-while endeavor to try to get the community, through these various
social agencies, to appreciate them for certain values. One of the
medical officers of the Army was discussing with me, a while ago, this
problem in the South, in the cotton mill districts, where there is a
large number of mentally deficient people. They do not do much of
anything, except perhaps, drink whiskey, breed and make trouble. They go
into the mills and either get injured or discharged. A lot of that
material is really capable of utilization. The mental defectives, as a
whole, are fairly good natured and tractable. There were lots of mental
defectives in the Army, enlisted men, who carried on and made good
soldiers. Some young fellows went into the Army from the School of
Feeble Minded, in Massachusetts, and had excellent records. The
Superintendent there kept track of his feeble-minded boys in the Army,
and they made excellent records because they belong to that type of
individual which has a very strong leaning upon persons in authority and
will follow his officer like a Newfoundland dog his master, will obey
orders to the letter and they make most valuable persons. So this
officer suggested to me that these feeble-minded groups running around
might be assembled into industrial units. They could be worked in
factories. In order to avoid the possibility of exploiting that type of
labor they could be employed under proper social conditions and placed
under the eye of a neuro-psychiatrist; and where there was an immense
shortage of labor, perhaps factory owners would be pleased to get these
men.
In other words there is a lot of this defective material which exists in
our society today which has absolutely lost motion, which could be put
to a great deal of use if we were wise enough to do it, if public
sentiment would support us and assist. It is easy to talk of that here.
It is another thing to get public sentiment to help us. There is no
longer hospitals organization than this in the world and perhaps the
hundred hospitals represented here might do something to bring about
that public sentiment. So I am disposed to look at people not from a
strictly diagnostic point of view to look at them from the social point
of view as to the possibility of their becoming useful to a certain
degree as social units and the possibility of society metabolizing them.
Just one more word. There has been an enormous amount said the last few
years on heredity, and there is a great deal of feeling that there is a
great deal due to heredity. The study is very interesting,
scientifically very important, but the only attitude we should assume is
to practically throw out of consideration the whole question of
inheritance. If you are going to say this fellow has got a certain
disease, and you are going to conclude it is inherited, that is a
fatalistic diagnosis and the tendency of the diagnosis is to hamstring
any effort that may be made in his behalf. The only way we can find out
the percentage of salvageable material is to endeavor to make the
adjustment. If we put them down as hereditary, our inclination will be
to throw them out of the possibility of consideration. We should rather
stress the possibilities to the utmost and find some solution or partial
solution of a great many of these problems.
DR. CHRONQUEST (U.S.P.H.S.): So much has been said that I shall not go on
with the problem. I would mention the Compensation side. I have been
wondering for some time, especially among the neuroses, if by our
present system of compensation we are not tending to make crystallized
neuroses. I do not pretend to answer the question. Take, for example, a
chap who has been in the service, who has done good work, whose social
scale has not been high, whose life prior to service has been, as you
might say, from hand to mouth. He has come out of the service with a
definite, known disability acquired by service. By being hospitalized he
has been compensated justly by the Government; he has received the
treatment to which he is entitled; but during the days of his treatment
he has found that he is able to get along more easily under these
conditions than he did prior to service, and decides that one of the
best ways he can make a living is by Compensation. I do not say that
that is true with all, but it is with some of the cases.
I have wondered whether or not our present system of compensation to
that type of individual was the best, or whether the system of Canada or
England would be better. In other words, they do not put a premium on a
man to go to a hospital. If I am correct, a man gets less money when he
goes into a hospital than when he is out. It is my meagre opinion that
in that type of neurosis, he would tend to fight harder as an individual
to put himself back into a financial, gainful pursuit; and with the
advantages the Government offers him now, especially through
rehabilitation, I feel he could be put on a much better adjustment than
he was before.
Another point which has recently come to the attention of us locally is
the question of guardianship; and I am going to ask Dr. Guthrie if it is
a known fact that two men in the same hospital, with the same
disease—that one will draw his compensation without a guardian, the
other is required to have one.
DR. GUTHRIE: It was our understanding that a man who is a psychotic by
reason of service should at least have a guardian. If that is not true,
I suggest to the Hospital Committee that it is a point for
consideration, as it puts the man in the field between the devil and the
deep, blue sea.
DR. W. A. WHITE: I think the man who has a guardian has one usually because
his people have applied for such. I believe the Bureau never
relinquishes the right to control of the funds, and is not obliged to
pay the funds to the guardian. Legally the patient can be paid if he is
competent.
DR. CHRONQUEST: In looking over histories of cases that come to West Roxbury
and information received, I believe that a point that would be of help
to the service as a whole is the getting of accurate histories. We find
patients being transferred to N.P. hospitals, who have a diagnosis which
is not correct according to the past histories taken, due to the fact
that careful search has not been made in gathering the facts of the
men’s disabilities. At times it may be the fault of the examining
physician. It may be the fault of the social service department. Again,
it may be the fault of the individual, or of the family itself in trying
to protect the patient in question. I believe that those errors, which
are seen every once in a while, should be overcome; and I feel that all
of us, whether Neuro-psychiatrists or not, who have anything to do with
either neuroses or psychoses, should be extremely careful of the
histories and get them complete, detailed and accurate.
COLONEL MATTISON: (acting for General Geo. Wood) The Tuberculosis Section
has to deal with a group of patients,—the largest group that the
Veterans’ Bureau has to handle. I am sure that we have many men here who
are interested in this subject, and I hope we shall have a very free
discussion of the subject. We shall begin by having each subject opened,
and then the program will be given to general discussion. We shall ask
Dr. Stites to open the session on “The Segregation of Cases”.
SURGEON T. H. A. STITES (R) U.S.P.H.S.: This question of segregation of
Tubercular cases is one that has been vexing all of us for a long while.
To understand it at all we have got to review the history of T.B.,—from
the ancient times when T.B. was looked upon as a sort of visitation from
Heaven, and looked upon as a disgrace to the family, on down to the
period when Koch, with his great discovery, found the disease to be
infectious. During that time there came on an organized propaganda for
the control of T.B. upon the ground that any infectious disease is a
preventable disease. This propaganda, as is true of all propaganda, ran
to an extreme. It was so hard for those interested in proving that T.B.
was an infectious disease to impress it upon the public and to compel
them to accept the proposition of its infectiousness, that we went to
the extreme of leading everybody to the idea that it was a virulent
infection; that it was as contagious possibly as some of the acute
infections like scarlatina.
There were those who believed that every case should be sent to a T.B.
hospital, absolutely isolated from his family and the world in general.
Then the pendulum began to swing back, and we came to a sensible
conclusion,—that while T.B. is an infectious disease, it is only
slightly so to the adult; and if virulent at all, it is so only among
children and the adolescent. This being so, we had to change from the
separate and isolated hospital for T.B. It has been accepted that every
general hospital should receive its quota of T.B. patients, T.B. being
one of the most common forms of illness, and that in sending out
patients to a strictly T.B. hospital; they should be sent only after the
presence of the disease has been fully well proven.
The control of T.B. is after all the big problem before all of us in
T.B. work today. I have often heard it said that any benefit that comes
to the individual is necessarily more or less incidental, and that the
big object we are laboring for is the control of the disease and the
care of the general public health. Be that as it may, the problem that
faces us in the care of the veteran of the World War is the actual care
of the sick.
The question of prevention of T. B. must be dealt with, first, upon
educational grounds,—to educate the public and the individual to the
point where we can more or less limit the spread of the infection;
secondly, and perhaps more important,—by a campaign for the improved
living conditions of our people in general, especially in childhood.
As a matter of fact, when you get right down to it, T.B. is a social
disease; it is a social problem even more than it is a medical problem.
We know that when the good Lord made us, he put into us a certain amount
of quality which, for lack of a better term, we have called natural
resistance. If we can keep that natural resistance at a high
point,—build it up,—the infection, though it may strike us, will not
produce the clinical disease, T.B.
In the second place, we come to the actual treatment of the sick. This,
too, is largely a hygienic measure. Since time immemorial, those
interested in T.B. have been searching, have been praying for a specific
cure. Every now and then somebody bobs up with a story of how he is
going to cure T.B. overnight by this or that injection, treatment, etc.
In each of these cases there is a grain of fundamental truth. We have
got to put these things together; and when we get down to the final
conclusion we can not get away from the fact that the treatment of T.B.
is the building up, the bringing back to normal, and in fact if you can,
the reaction to the point beyond the normal, of that quality I spoke of,
natural resistance.
In order to accomplish this, I believe one of the most important points
lies in the word, morale; and to encourage your morale, it is wise to
get your classes classified, and to get your T.B. patients working
together in classes in sufficiently large numbers so that you get that
inspiration that comes from what my friend used to speak of as “the
psychology of the crowd.” The thing the soldiers know as the touch of
the elbow; there is a certain magic in it. It is easier to get farther
when you know that somebody besides yourself is going through the same
thing. I think we men in charge of hospitals feel that. That is one of
the inspirations that comes to me from meeting with such a crowd of my
fellows here. Away off there in the swamps of Louisiana there comes a
sort of feeling, “We are here alone; it is hopeless”. When we are all
here together exchanging experiences, there comes the inspiration, “We
are not alone”.
In your general hospitals you have T.B. beds; have them in sections by
themselves,—not because you are afraid of the spreading of the disease,
not because the T.B. patient is an outcast,—but because you can do more
successful work for the patient, not by segregation, but by classes.
In your T.B. sections, have your sub-divisions; have your places to
which you are going to send your ambulatory cases, your far advanced,
etc. Keep them far apart. Use the class system, but be sure that your
personnel is sufficient, so as not to get away from the personal touch.
Perhaps a little outline of the organization of at least two of the
hospitals with which I am familiar will illustrate my point.
The first essential thing when a patient enters a hospital is a complete
examination. Do not let that examination be routine because it is a T.B.
patient. Do not be satisfied with punching the man in the chest and
sticking your ear to his heart. Have somebody who understands
neurological conditions, test his nerve reactions; have someone to test
his mental reactions, as well as the surgical and general medical. Have
your examination ward in which this can be done.
Next is your general medical and, possibly, observation ward. I don’t
care how you try to keep observation cases out of T.B. hospitals,—they
are going to get in. If a patient, after being in a month, is found to
be a T.B. case, he is apt to say, “I caught it here”. Put him where you
can answer, “You did not get it here. You have not been in sufficiently
close contact with the disease to catch it.”
Have your surgical ward; and then your strictly T.B. section.
Have first your infirmary or hospital.
The T.B. man needs special treatment, nursing care and dietetic care.
One of the chief things to give to a T.B. infirmary is good dietetic
care;—place the food before your patient in an appetizing manner; too
much will disgust him.
Then have your ambulant section and sub-divide it into the section in
which there is clinical activity of the disease, and into the section in
which the clinical condition of the disease is quiescent. By doing this
you can give your people graduated exercises, whatever diets they may
need, periods of rest, and occupational therapy; and you can do it in an
organized, scientific way, and get away from the everlasting complaint,
“You let the fellow in the next bed do it; why won’t you let me do it?”
You have got to study the psychology of your patient. It may be a little
out of the line of segregation of cases. We have heard the talk here of
cases, of hospital management, and all that; but be sure in dealing with
the ex-service man, or any other case, that you do not treat him merely
as a case; that you do not segregate the medical officer in charge. I
find there in the South that one of my life-savers is the fact that my
office door is open to any patient. When I first got to be understood
there was a line-up. I gave an hour every day. Now, since the patients
know that everyone can come to me, I have possibly three or four in a
day. And I don’t do it either by reversing the decisions of my ward
surgeon and my executive officer; I back them up.
* * * * *
DR. KLAUTZ (N.H.D.V.S., Johnson City, Tenn.):
The subject of occupation in connection with T.B., is not only an
extremely important one but an extremely difficult one to administer,
particularly in the large government institution, and especially in
connection with the psychology of the ex-service man, which has been
referred to a number of times. He is apt to misunderstand and to be
resentful toward any application of work; and yet at the same time, if
we are going to measure the results of the sanitarium treatment of T.B.
by the functional restoration to activity and usefulness, we still find
that it results in a great many failures. That has been one of the
complaints on the part of T.B. workers not only in government but in
civil institutions as well.
We still find relapses occurring after the patient has been discharged
from the sanitarium or T.B. hospital. Men go into training, and in a
short time undergo another course of treatment, and so on. The reason
for that is that they have not been given the necessary physical
rehabilitation while still in the sanitarium, while under institutional
protection and medical supervision.
The question of occupation is so broad that it is impossible to take it
up extensively here today. We can point out one or two of the basic
principles in connection with its application in the treatment of T.B.
One very important feature brought out this morning is the
psychotherapeutic object,—the point of view of relaxation or recreation,
that is, giving the man something to occupy his mind and improve his
morale, helping him to forget his home anxieties and anxiety about
compensation.
The second point, or 2 A, deals with muscular reconstruction,—conversion
of recently acquired adipose tissue into working force by rebuilding
flabby muscular tissue which has resulted from the long period of rest.
2 A is the acquiring of a tolerance for T.B, toxins. This is important.
We do know that in the recently toxic stage, exercise or work does
produce a reaction which is shown by a rise in pulse rate. We know that
if exercise is begun in small doses and gradually increased, the time
will come when the patient can be made to take a fairly large amount of
exercise continuing over a fairly long period of time, without
manifesting the symptoms of reaction. Formerly we gave Tuberculin in
gradual doses until we reached the point where the man could take an
injection which surely would have killed him at the beginning of the
course. The main point is if a man leaves the sanitarium before he
reaches this toxin tolerance, he is more likely to break down. This is
the reason for the man’s frequently returning to the sanitarium for
treatment.
The third point deals with applying occupation as a means of training or
retraining the man for some new occupation or modification of his former
occupation; and here is where a great deal of judgment and study of the
individual case becomes necessary. It is very difficult to find out just
what is the best kind of work for the man from a physical and mental
point of view; but the important thing is to have the man try it out and
test it, and begin this physical reconstruction and rehabilitation if we
are to get permanent results from sanitarium treatment. I don’t believe
we have solved the problem completely, and I believe other agencies will
have to be called in.
In this connection the question of dispensary work and social and
nursing follow-up work is going to be extremely important. The man who
leaves an institution ought to be followed up very carefully, and effort
should be made to bring him back to some medical unit for re-examination
at least every two months in order to see if there is any relapse of the
former activity.
SENIOR SURGEON R. H. STANLEY, USPHS (R): It is always interesting of course,
to be told what we ought to do and how to do it, but it seems to me it
would be a great deal more interesting to take the little time we have
this afternoon and discuss some of our real problems, and I mean by that
problems that we as commanding officers of the hospitals have to contend
with every day. I know and you know there are thousands of little things
come up upon which we would like to have advice. There are many problems
I might be able to solve readily; there are others you would be able to
solve. I believe it would be worth more to tell how to get rid of some
of these problems.
I believe that the success of running a hospital rests entirely upon the
confidence that your patients have in you. If you are sincere they know
it, and when they know that they will do anything for you. If you are
not sincere they are going to know it mighty quick and you are going to
have trouble. If you tell the men you are with them, that you are going
to be 50–50 with them, if you call them in and talk to them as you would
to a son, and if you let them see you are not doing it because of a
matter of necessity, you can get by without writing petitions into
Washington.
I found the other day a petition had gone to Washington from my
hospital. It was necessary to discharge two men for drinking. It was
their first offense. They came to me and said, “You have not treated us
fair because it is our first offense.” Just before I left my station I
received a letter which was addressed to these men by Colonel Forbes. In
that letter he said “I have received your petition signed by 27 patients
and asking that the hospital be investigated on account of a few
patients being discharged for drinking. I wish to state for your benefit
that I have given the matter consideration and I am standing right
behind the medical officer in charge.” Leaving out the names, I had
copies made of those letters and placed one of them on the bulletin
board of the hospital.
When I went out to Whipple Barracks there had been some little
disturbance there among the men. They were dissatisfied in various ways
and it seemed like a big problem how to handle these men. When I once
had their confidence I handled them.
I have found this in my experience, that I have never been able to have
a satisfied personnel unless I give them the best I can. So long as you
feed them well you will not have much trouble, because that will keep up
the morale better than any other one thing I know. If you will feed
them, be honest with them, be fair, you will have very little trouble in
running the hospital.
SURGEON J. F. WALLACE, USPHS (R): The subject of entertainment probably
would cover the subject of recreation at hospitals. It is rather hard
for me to describe what recreation should be given at a tuberculous
hospital because it depends on the location of the hospital. At the
hospital at Fort Stanton where I am located we do not have any
entertainment. If any social workers come down there I will be glad to
entertain them, because we have only three visitors a year down there.
That is one of the things in which I would compare our institution with
some of these other institutions.
For many years I have been connected with a large sanitorium where we
had strict discipline and little entertainment. The patients were
satisfied. Our average stay of patients is six months. In looking over
your sanitoriums you don’t find many patients staying six months.
When I was in the Army I was in one of the largest t.b. sanitoriums of
the country. They sent back hundreds of men to this hospital and people
came out and entertained them. They were entertained every night by the
Red Cross with moving pictures, they were entertained in the afternoons
by a local organization; they were entertained to death. These men
afterwards got out and were not satisfied unless they were placed in an
institution which was a social center. After I went out I was Chief of
the Eleventh t. b. district of Denver. I noticed that the men who were
treated at Fort Lyon were a better class to handle because they were not
so much entertained. Once in a while I would talk to some of these men
and ask them if they wanted to get well, as I could tell them a place to
go and frequently I used to send them to Fort Stanton where they could
not be entertained and they could get well.
If you have ever lived in an isolated place, you can appreciate it. My
wife and I had pioneered this sanitorium together for quite a while.
Once in a while we used to go to Denver and we could enjoy any show they
had in Denver, even the 10–cent and 20–cent ones. I have heard men
criticize entertainments at Fitzsimmons; they would swear and walk out
while Madame Schumann-Heinck was singing, because they were
dissatisfied; they were saturated with entertainment. I am against
entertainment for tuberculous patients only in a very mild degree. We
have one picture show a week and they enjoy that picture show. We have
only Sunday School Sunday morning. The minister will bring in a few
amateur singers and the boys think they are wonderful; they are
wonderful; and they will all sing.
I have some fifty War Risk patients at my Sanitorium. I have known them
for three years. I know them all by name. They were kicked out from
Sanitorium to Sanitorium. They came down to Stanton. I went there on the
first of July and no man has asked for his transfer or discharge. I
suppose there is less turn-over of t.b. patients at any place than at
Fort Stanton, where there is no entertainment. These men can go
anywhere. We have a 30,000 or 40,000 acre farm. We try to get these men
interested in the different things in the Sanitorium. On Christmas we
let the men arrange the Christmas trees. They amuse themselves down
there. The men trap quite a number of wild animals, bob cats, etc. and
they are interested in the place we have, which is close to nature. You
would be surprised how little amusement you need for entertainment if
you get away from it. You have got to control these men and direct them
every minute in the day. You have got to give them a task. Have their
hours for rest; their hours for exercise. It is up to you who are
running Sanitoriums to entertain your men. You might lecture to them;
that is entertainment; but don’t have them twice a week or three times a
week. Once in a great while the men are interested in the study of their
disease. Don’t speak to them in scientific terms, let them understand
the disease. They say in the curing of tuberculosis it depends more upon
what a man has from his neck up than what he has from the neck down.
Impress upon them that they have got to live a careful life. Keep people
out who want to entertain them. Your men will be just as well and better
satisfied with little entertainment if you keep them busy all day long.
DR. SMITH, U.S.P.H.S.: I wanted to discuss this afternoon a matter which is
of great concern to all branches of the service, and that is Order 59 as
applied to transfers from hospital to hospital. Order 59 is going to be
watched rather carefully by the Veterans’ Bureau. Order 59 lists
hospitals and gives a certain number of hospitals to each district. A
district manager in New York may take a tuberculous patient and send him
to a local hospital or he may send him away to a certain designated
hospital to which he has blanket authority to send him, Oteen or
Fitzsimmons; but according to Order 59, once they send a man to a local
hospital, the district manager may not remove the man from that hospital
and send the man to Fitzsimmons Hospital in Denver. In other words, it
is worth watching to see whether Order 59 will not rather tempt the
district managers to make a snap diagnosis on the ground and send away
to the hospital to which he has blanket authorization to make transfers,
on the one hand, a man whose disease is so far advanced, that it might
be unwise to send him; or, on the other hand, men with questionable
diagnosis. It will be worth watching. I am sure the Veterans’ Bureau
will desire information on the subject as to whether you who are out in
the tuberculous hospitals will receive classes of patients who are
unsuitable in the usual sense of the word for transfer.
Here is another thing we shall all need to watch and concerning which
the Veterans’ Bureau will I know desire information. Will the practice
of sending patients to the local general hospitals result in a piling up
of patients who need to be transferred and whose transfers will be
delayed. We all know that a transfer is indicated not only for the
purpose of providing a climatic change and we all know that in certain
sections of the country there are provided beds for tuberculous patients
and it is necessary to keep these beds filled.
According to the present practice and strict interpretation of order 59,
if the medical officer in charge of the Naval Hospital in New York has a
tuberculous patient and wants to effect his discharge to Fitzsimmons, he
first asks the district manager for permission to transfer the patient.
The district manager in turn asks the Director of the Veterans’ Bureau;
the Director of the Veterans’ Bureau advises the district manager, who
in turn advises the officer in charge of the Navy Hospital. Now it will
be necessary to watch and see whether this effects an undesirable delay
in making the transfers. The Veterans’ Bureau will desire to be informed
if such is the case.
There is another thing. A patient under treatment at Fort Bayard, New
Mexico, and fit for discharge cannot, according to a strict
interpretation of Order 59 be discharged without invoking the same
authorities who sent him there. In other words, he must take it up with
the district manager, who then advises the man in charge of the
hospital.
Order 59 is magnificent in this, if it works out: that no man will be
transferred from one hospital to another except upon the recommendation
of the medical officer in charge, and you who have had experience in
this matter will know what that means. It means that it is not the man
with the longest and strongest pull who will be transferred but the man
whose transfer is recommended by the officer in charge of the hospital.
We are prepared to assist in every possible way in carrying out that
order but it is necessary for us to watch the effect from the field and
get advices from all hospitals concerned, as to whether this order will
not need modification.
SURGEON F. H. MCKEON, USPHS: Some have stated that they were in ignorance of
the existence of G. O. 27. At Hospital # 64, upon the receipt of that
order we immediately had about one hundred copies made and the entire
hospital personnel was supplied therewith. After that every man upon
admission was furnished with a copy, together with a copy of the rules
of the hospital, for which he signed a receipt. I offer that as a
suggestion.
On Tuesday the statement was made here that a man who is able to take
five or six hours prevocational training at a hospital has no place in a
hospital and should be in training. I think that statement should be
qualified somewhat. It may easily happen that a man who can safely take
five or six hours prevocational training in a hospital would soon break
down under vocational training, for the reason that while he is in
hospital his entire life is supervised; he must take a rest hour; he
must turn in at a given time at night; he is assured of three or
possibly more proper meals a day. Those conditions do not obtain when
that man becomes a trainee and I sincerely hope that the follow-up
nursing system which the Veterans’ Bureau is putting into effect now
will result in a more careful supervision of the trainee’s life, so that
when it is found he is living not wisely but too well he may be given
proper advice and be returned to the hospital before the breakdown
occurs.
This afternoon the subject of hospitalizing the tuberculous veteran in
n. p. hospitals was discussed. I rather think it a somewhat sweeping
assertion to say that every tuberculous individual with mental symptoms
should be hospitalized in a t. b. sanitorium. We will all grant that men
with signs and symptoms of an active tuberculosis disease should be
hospitalized in an institution for the treatment of tuberculous. But to
my mind that does not hold where the disability is clearly a mental
disorder; that man is ambulant. The other man gives no trouble whatever
because he is bed-ridden. I have no doubt that every t. b. hospital
commander here today has had such cases. Your ambulant case, with few if
any indications of active tuberculosis but who notwithstanding is
tubercular, when he develops mental symptoms is not only a source of
annoyance in the tuberculosis hospital but is destructive of morale. His
place is clearly in a hospital for the treatment of mental cases.
DR. M. C. GUTHRIE, U. S. VETERANS’ BUREAU: This matter affects us
administratively from a different angle. Many of the general hospitals
have wards for the cure of tuberculosis. We presume that the turn-over
must be fairly rapid. When men have accumulated in sufficient number and
their disposition is determined as to whether they should go to a
tuberculous institution, and they refuse to go, shall we turn them out
or shall we let them stay?
SURGEON L. M. WILBUR, USPHS: If the transfer is suggested in the interest of
the physical welfare of the patient and he refuses to accept that
transfer, he is interfering with treatment. The regulations provide for
that.
SENIOR SURGEON T. R. PAYNE, USPHS: I don’t agree with some of the t. b. men.
I think a man can make a fight if he is dissatisfied and does not want
to go and I think you will do harm in transferring him. If a man is
home-sick and will not improve, I think he will do very much better to
stay just where he is and you ought not force that man to go somewhere
where he will not be satisfied. A sanatorium is a school to teach men
how to live. In a general hospital you will have trouble in enforcing a
rest hour because there are a great many other men in the institution
who are not compelled to do so. The pass privilege is another thing.
Some patients have but one pass a week and other patients get passes
frequently. It serves to dissatisfy the t. b. men as they felt they were
not on an equal footing. That is the only objection I can see.
SENIOR SURGEON J. E. DEDMAN, USPHS (R): There are several things that occur
to me. In the first place there is the question of food. Of course that
is the vital thing in every hospital. In our hospital, as I said before,
we have a large number of negroes and what you give to the white boys in
the north is not satisfactory to the colored patient. I think it is an
important thing to try to give the men what they want in the way of
food.
When I went to Greenville it was the custom to give the men breakfast at
about seven o’clock; luncheon at 10:30; noon meal at 12 o’clock; at noon
the men were not hungry and were generally dissatisfied with the food;
at 3 o’clock, after the rest hour, they would have another nourishment;
supper was served at five o’clock and as a rule they did not care much
for that. Then we would send over to the wards large quantities of milk
and eggs and bread and butter. They did not need any base balls. They
played ball with apples.
It occurred to me that that was a bad system. We omitted the morning
nourishment and the afternoon nourishment and I substituted an evening
cafeteria luncheon thinking that it was a long gap from the supper at
five o’clock to breakfast at 7. We thereby saved a great deal of money
and since we did that we find the patients think the food is fine. We
also find that they sleep better by taking this light luncheon just
before they retire. I mention that for what it is worth.
The rest hour is important in tuberculosis. That is why hospitalization
is so essential, because men will not take proper rest. We have a
morning rest from 9 to 10, afternoon rest from 1 to 3 and evening rest
from 6 to 6:45. The last period is not universal, and we wonder how you
can get an accurate record of a man’s condition when you do not get his
evening temperature. We find that it has been a great help to us. When I
instituted this rest period from 6 to 6:45 I told the men it was for
their good and although they objected at first, it appealed to their
reason, after they were told why it was done, and we have had no
trouble.
Another thing we have inaugurated along this line. I talked with Dr.
Smith last spring. He agreed to send to our hospital a school for
chiefs. I think this was a most helpful thing, because we had chiefs of
medical staffs come to us and take a course that would tend to make for
uniformity in administrative medical work in our tuberculous hospitals.
I have talked since that time with several of the men who came down to
take that course and I believe every one of them expressed the opinion
that it was very helpful to him to have an opportunity to exchange ideas
and to have the same methods for carrying of medical staff work which
required tact and executive ability.
There is one thing I could not pass by because it is of such great
importance to the Federal Employees Compensation Commission. We have
sometimes employees engaged along various lines, and shortly after I
arrived at the station I found one or two who said they had
tuberculosis. I think it is most essential to see that not only one man
but a board of medical officers examine every employee when he comes
into a tuberculous hospital to make sure that he does not show activity
in tuberculosis so that later he will not have a claim against the
Federal Employees Compensation Commission by saying that he was working
in a tuberculosis hospital and contracted tuberculosis while in the
hospital.
There are many things I would like to speak of. I was very much
impressed with what the doctor said about entertainment. I believe it
helps the morale and is the most wonderful thing in the world. We can
spend sleepless nights building up morale in a hospital and one man can
disturb the entire morale.
In closing I want to say, after all is said and done, the big thing with
us is the backing we get from the heads of our department and from the
Surgeon General. I have known times I felt like throwing up the sponge.
All of us have gone through these moments. The main and only thing that
keeps us up is the encouragement we get from the heads of the department
and I want to take this opportunity to express my appreciation.
GEN. SAWYER: This meeting was called for the week of the 20th, with the
understanding of the Budget Director, General Dawes, that on tomorrow
the Chiefs of the various Departments of the Government were to hold
their semi-annual session and we thought that you would enjoy that
occasion. It has been found impossible in the compilation of the facts
and figures necessary to hold that meeting tomorrow. Therefore it
becomes necessary for us to change our program and I am happy to
announce to you that I feel sure you will have quite as interesting a
program as you would have otherwise, for tomorrow we will have as the
first speaker of the morning, Congressman Madden, the head of the
Appropriations Committee. If you have not heard him I am sure you will
be very much interested both in what he has to say and in the way he
says it. We are then to have as the next speaker of the morning, General
Dawes. General Dawes is remaining over tomorrow that he may have the
pleasure of meeting you personally, and I predict that you will agree,
after you have heard General Dawes, that if you have had no other excuse
or no other compensation in coming to this meeting, you will have it in
hearing General Dawes. For the balance of the program of tomorrow
forenoon, it comes to my mind that possibly it would be most interesting
to you all if we were to take up some of the questions that come to your
mind that have not been presented in this program. This was suggested to
me by one of the gentlemen here who I noticed does not talk much but who
evidently thinks a lot, that it would be to the interest of a good many
if they might bring up some subject that they are particularly
interested in. So we are going to have in the morning a question box,
and if any of you have questions in which you are particularly
interested and will present them at the desk of the Secretary, we shall
try to have them taken up for discussion at this round-table hour
tomorrow forenoon.
President Harding will not be here in the morning. When I spoke to
President Harding to come over and address this meeting, he said to me,
“General, you know Mrs. Harding and I are to receive this body tomorrow
evening.” I am sure that you are going to have in that reception, in the
personal contact with the President and Mrs. Harding, a joy such as you
have not contemplated.
_Seventh Session_ Friday, January 20, 1922.
GENERAL SAWYER: Fellows of the conference, as I told you yesterday we had
expected this morning to be here with the Chiefs of the Bureaus. I
explained to you why that program was changed. I told you also that you
would not be disappointed in today’s program, and now I am going to
prove it.
America produces many things. It is wonderful in agriculture, in
industry, in commerce, but one of the greatest products of America is
its men, and, strange as it may seem if you will stop to study it from
that aspect, you will find that each State of the Union has its record
for producing certain kinds of men. For instance, from Wyoming we get
our stock men; from Iowa, our farmers; from Indiana, our authors,
particularly our fiction writers; from Ohio, of course, we get our
presidents; from Illinois, a thousand miles from Wall Street, we get the
greatest of financiers. It is true that Illinois has produced more
financiers than any other State, and men who have been at the head of
the greatest banking institutions of the United States have come from
this great corn-raising, middle-western State.
I should like to remind you, before I introduce this speaker, that this
Federal Board of Hospitalization represented last year an expenditure,
in all of their various lines of work, of $750,000,000.00. We have in
our employ this morning something like 42,000 individuals, for which it
is costing us something like $42,000,000. Today we are providing 132,000
meals for the people in the government hospitals and the employees that
are necessary to take care of them. Tonight, if this northern blizzard
continues, it will require 132,000 blankets to cover them; and in the
most economical way in which we can provide for the needs of these sick
men it will cost us—it does cost us—in round numbers, a hundred thousand
dollars each day, with institutions operated as economically as they can
be.
I only relate this that all of you may know and may carry this message
to the country—that Uncle Sam is certainly not stingy; that Uncle Sam is
really putting forth every energy he possibly can to carry out the idea
of the best treatment of the World War Veteran.
This is my story in brief.
I have pleasure now in introducing to you Congressman Madden, Chairman
of the Appropriations Committee of the House.