Part 9

The first of these agencies, perhaps, is the application of the general principles of medicine and surgery to the treatment of the sick individual. In other words, the patient’s general health becomes a problem for inquiry and appropriate consideration, irrespective of his mental state, on the general theory that physical health is at least the best condition precedent for undertaking a restoration to mental equilibrium.

The second of these agencies is the complement of the first, and is best designated under the general term of psycho-therapy and consists in the recognition of the mental disease as such irrespective of whether there can be found any physical foundation for it or not, and on the basis of such recognition endeavors to deal with it as a thing in itself. In passing I may say that theoretically the best results would come if these two agencies could work hand in hand each with sufficient understanding of the other.

The third agency, which has been very much broadened in its activities in recent years, I may designate as the social agency. It recognizes implicitly at least, if not consciously, that mental disease at any rate the kind of mental disease included in the second group, the so-called “insane” is a disorder of the individual as a member of the social group and that it manifests itself largely by disturbances of his relation to his fellows, and therefore it becomes a legitimate therapeutic endeavor to attempt a readjustment of these relationships. To this end the social agency has been developed in many directions. In the first place, we have amusements. The simpler amusements may be called, speaking from the point of view of the patient, the passive variety,—the type of amusement that is brought to the patient, such as theatrical performances, moving pictures, and the like, whereas the second type of amusement, which is more advanced and more valuable, is the type in which the patient himself takes part, such for example as theatrical performances in which he is a performer, musical programs, in which he plays or sings. Then there is the group which is not after all very widely separated from the amusement group and yet is somewhat different, and that is the group which we might term athletic activities and which demand upon the part of the patient some initiative. These range all the way from the simplest activities, which are imitative in nature, such as calisthenics under the instruction of the athletic director, to mass games, where a large group of patients are all engaged together in a common purpose, such as push ball, to games of contest requiring not only initiative but a relatively high degree of efficiency, such as the tug-of-war and the various types of races and stunts, boxing and wrestling, and which are from time to time advantageously staged on a field day and receive the added stimulus of an audience. In addition to such activities as the above there are also many minor ones of a similar nature, the principle of which, however, is the same,—the social give-and-take of patient between ward and ward, the instruction in such things as folk-dances, and the like.

The fourth agency, which has been very largely developed recently, but which has always been used, is the agency of work. This has been applied in approximately three ways. The first of these is known as diversional occupation and comprises practically the whole field of what is thought of by many as occupational therapy. The activities in this field consist of such work as basket weaving, leather tooling, bead stringing, rug weaving, and a thousand other similar activities. The object of this activity is to assist in the re-direction of the patient’s interests, to turn them away from infantile and regressive objects, and to project them again into the outer world of reality. Then there is the industrial type of work therapy in which the patient is carried still further along the line of personal initiative and given an opportunity to do creative work which is at the same time useful and which helps him to keep in form pending the time of his ultimate discharge from the hospital. And finally, there is the vocational education work, which undertakes definitely and systematically to give a man training in some specific direction which he can utilize, after he leaves the institution, and which will have a definite economic value. For this latter work of vocational training there is needed such psychological advice and assistance which will at least prevent the wastage of time and effort upon unprofitable or impossible tasks, whereas the vocational psychologist cannot by any rule-of-thumb-tests tell that a man will make a success in this or that direction, he can tell within reasonable limits that a certain patient cannot profitably undertake a certain type of training, that his capacities do not measure up to the minimum requirements that would make success possible. In this way the work of vocational education for the neuropsychiatric case can be narrowed down so that it can be applied more intensively and more effectively to selected groups that can be reasonably assumed to be good risks.

The fifth agency, which can be advantageously brought to bear upon the neuropsychiatric case, is the agency for extra-mural social adjustment, and the personnel consists of the psychiatric social worker. With her help the patient discharged from the hospital can have the maximum amount of assistance for relating him again with the problem of self-support and self-sufficiency. She, through her study of his family situation, his economic status, his industrial placement and social contacts can assist to these ends.

The third group of neuropsychiatry cases is like the second,—a group that has always been with us, but unlike the second it is a group that never before has been systematically hospitalized. It is the group of what might broadly be termed borderland states, comprising all sorts of types of defective, delinquent, psychopathic, neurotic, and mildly psychotic individuals. Whereas they perhaps present no new problems when one is speaking from the platform of neuropsychiatry, they do present a distinctly new group of problems from the standpoint of hospitalization. Here all the agencies which have been described in connection with the second group need to be brought into action, but beyond them there needs to be a definite intensive study of methods for the new hospital problems involved. I mention only one aspect of the problem because it is one which has forced itself repeatedly upon the attention of hospital authorities and that is the need for an intelligent, and I may say, a therapeutic utilization of discipline in dealing with these cases, in this group there very probably are contained a reasonable number of individuals of unusual equipment, who, if our ingenuity and our breadth of vision are great enough, may perhaps be saved for some work of more than ordinary usefulness.

One of the medical agencies which it is contemplated to bring to bear upon this third group of neuropsychiatry cases is the dispensary because it is recognized that there is actual danger in hospitalizing a certain proportion of this group, and therefore it is much better to deal with them as ambulant cases. They can be dealt with in the dispensaries which are equipped not only to take care of them, but for all other medical and surgical conditions, and so will get the very best possible attention. There should, however, be connected with these dispensaries, especially the larger ones in the more densely populated districts, a psychiatrist with psychotherapeutic training who should have a psychiatric social worker to help him. If there are enough patients to warrant it perhaps additional assistance might be needed.

And finally, I would emphasize that in this great scheme, which contemplates the hospitalization of from ten to fifteen thousand neuropsychiatric cases of the general type above referred to there should be included all of the armamentarium for scientific research and all of the opportunity for individual endeavor and initiative which is calculated to bring the brighter professional minds to bear upon the subject and to illuminate it with the light of their genius. In order that such results may be effected as promptly as may be, and with the highest possible efficiency, I believe there should be established a training center for neuro-psychiatrists where our younger men, who are recently graduated from our medical colleges, and who have the inclination to specialize in this branch of medicine, can fit themselves in a minimum period of time to take it up as their life work. And that this result may be accomplished I think it important that in extending an invitation to the younger medical men to enter this branch of the service that it should be possible to give them some assurance of permanency in their respective jobs.”

GENERAL SAWYER: “The subject with which Dr. White has dealt is so important that it will have more consideration later in the program, as you will notice.

It is quite necessary in the operation of all affairs with which Americans or even any of the human family deal, to have somebody who knows something of the legislative procedure that is necessary to the conduct of their affairs.

Honorable Charles H. Burke was added to the Hospitalization Board for two reasons: first, because he does represent in his great family many hospitals, the services of many doctors, likewise of many nurses. He therefore comes to us, being a Congressman of long experience, as a man who can deal with the subject partly from a professional aspect or view of the matter, and again with a thorough and complete understanding of the legal side of the affairs with which we are dealing.

So I have great and special pleasure this morning in presenting to you the Honorable Charles H. Burke, Commissioner of Indian Affairs, who will address you briefly on the statutory regulations affecting the hospitalization of the World War Veteran.”

BURKE: “Mr. Chairman, fellow members, ladies and gentlemen:

I think in the introduction of General Sawyer I learned for the first time how it happened that I was accorded the honor and the privilege of being a member of an organisation made up of such a distinguished membership as is this Board, barring your humble servant.

It would hardly be expected, after listening to these discussions by these eminent experts in their particular lines, that I would undertake to say anything along the scientific side of this proposition, and I am going to be rather general in what I state in the short time I shall talk to you.

Government activities can only exist by reason of the law, and so it will be proper to consider perhaps or discuss briefly the application of the law with reference to the activities that are being conducted, of which you, each of you, are a part.

The responsibility for whatever the Government may do in this or any other matter rests largely upon the Congress. I have hastily gone through the legislation that has been enacted in the last few years with reference to taking care of and providing for the ex-service men, and during the war for their dependents, and for those who might become incapacitated or disabled from any cause. There has been much legislation, demonstrating that the Congress is keenly alive to the importance of the situation. There has been one act after another, and hardly an act but what has been amended within a very short time after its enactment.

The recent law is what is known as the Sweet Bill, the law under which we are now operating. Within the memory of many who are here present the appropriations for all purposes of the Government were under a billion dollars, and there is being and is appropriated at the present time nearly half of that amount for the purpose of caring for the hospitalization, etc. of these ex-service men. Am I correct, Colonel Forbes, in the amount of money that is being appropriated? It is a vast and large sum of money, and it is the duty of those charged with the responsibility of expending that money to see that we get a hundred cents’ value for every dollar that has been appropriated. This requires economy and efficiency, and this gathering and this organization which General Sawyer is the chairman, was created for the purpose of getting better results from the moneys that are appropriated by the Congress; and you, each and every one of you, have been brought here, as I understand, for the purpose of coming in closer contact with those who are charged with the responsibility, in the first instance, of administering the expenditure of this large sum of money; and you owe to this responsibility exactly the same responsibility as does Colonel Forbes or anyone else occupying a higher station than you may occupy.

Therefore, I am confident and I am certain that when this conference shall have concluded, every person that has come here will go back to his respective place where his duty requires him, with a better understanding and with a more determined disposition to try and render better service and get really more for the money that is being expended for the purpose for which it is being expended.

Speaking of legislation, we shall undoubtedly require considerably more legislation because, as I have stated, in the short time since this subject was first taken up by Congress think of the progress that has been made.

As I understand, in 1919 the Public Health Service were hospitalizing something like two thousand persons. General Sawyer stated here today that we are now caring for twenty-two thousand; and I think it has been stated—and it is generally considered—that the maximum will soon be thirty-two thousand. So you see that it is more than likely that we are going to have to have additional legislation and more appropriation; and I may say to you generally that I have that confidence in the American people—I have that confidence in the Congress of the United States—to know that there need be no uncertainty nor hesitation on any one’s part with reference to what may be done to provide for caring properly for these dependents and these ex-service men who are entitled to every consideration.

I believe, as the result possibly of this conference, it may be brought to the attention of this Board that there is some legislation amending the so-called Sweet Bill. I think Colonel Forbes, as the head of the Veterans’ Bureau, has already discovered and suggested some very necessary amendments to the law, and I have no doubt that he will be able to secure those additions to the law. It looks now as if we may have to provide for additional hospitals by the enactment of further appropriations of money. It will not be done unless it is necessary, but I am sure if it is necessary that adequate provision will be made and made promptly by the Congress.

One of the policies of this administration is coordination and cooperation, and endeavor to avoid duplication in administrative matters; and if there is a bureau charged with a certain responsibility and with certain duties to perform, if it may be possible for them to do what may be under the jurisdiction of another bureau, to centralize and have this work done by one rather than two; and so in the work of coordination in the administration of this particular activity there has been a great saving. The Public Health Service, I believe, makes certain provision and takes care of certain persons at the request of the war Veterans’ Bureau and vice versa. I think it has been said,—if it is true it ought to be corrected,—that when the Veterans’ Bureau takes care of patients for the Public Health Service, there has been no provision made for reimbursing the Veterans’ Bureau. That will undoubtedly be taken care of by Congress, either by increasing the appropriation for the Veterans’ Bureau, or providing that when they render service for the Public Health Service, the Public Health will reimburse them for such moneys as they may expend.

Now one of the things that I want to particularly bring to your attention, and to perhaps admonish you, in the two or three minutes I have left, is to remember, as I stated at the outset, that governmental activities exist only by authority of the law, and that we must keep within the law; and remember, if there are some things in connection with your duties that are not operating just as you would have them, that they cannot be changed without changing existing law. The responsibility for the law is upon the Congress of the United States. The responsibility for this great undertaking is upon the Congress of the United States, and if you have not sufficient money to properly take care of these men, the responsibility is not yours; the responsibility is upon the Congress.

It is your duty;—it is our duty to bring to the attention of the Congress the money that is necessary in order to properly handle this subject. Then it is for the Congress to say whether or not that amount will be appropriated. Under this present administration, those of us who are in Bureau positions have been admonished that we must keep our expenditures within the appropriations, and we have had brought to our attention the statutes upon this subject. I am going to read them to you for your information, and I want to say to you who may have charge of an institution and have had a certain allotment of funds for a given period, that it is up to you to see that your expenditures do not exceed that allotment. If you have not sufficient money to do what you feel you ought to do, you must reduce your expenditures for the time being, regardless of its effect upon the service, because under the law you have no right to create a deficiency or incur any liability on the part of the Government in advance of an authorization and an appropriation therefor.

I want to call your attention to the statutes on this subject because they are being brought to our attention not only by the President and the head of the Bureau of the Budget, but by the Congress; and so I want you people to understand that we are expected to follow the law.

Mr. Burke read extracts from: Section 3679

Act of March 3, 1905.