SECTION VI
NONMILITARY GOVERNMENTAL DEPARTMENTS CONCERNED WITH CONTINUING THE REHABILITATION OF DISABLED SOLDIERS
The history of reconstruction as carried out by the Medical Department of the Army would be incomplete without some account of the continuation of the program after the disabled soldiers were released from military control, even though the functions of the Federal Board for Vocational Education, the Bureau of War Risk Insurance, and Veterans' Bureau (formerly the Bureau of War Risk Insurance) were entirely outside the jurisdiction of the Army and contacted with Army reconstruction at only a few points.
BUREAU OF WAR RISK INSURANCE
This bureau was first established in 1914 under the Treasury Department to insure vessels against the hazards of war.1 Its functions were extended in June, 1917, to include the insurance of certain maritime personnel,2 and in October, 1917, were so radically extended that the insurance of the lives and physical ability of soldiers and sailors became its main function.3 Provision was also made for courses of rehabilitation, reeducation, and vocational training for those who became permanently disabled through injuries, but the act did not specify whether such courses were to be provided through an existing Government agency, by civil institutions, or otherwise.3 No records are discoverable which show that such courses were ever given by this bureau, the Federal Board for Vocational Education eventually assuming the function. The provision for these courses was repealed in June, 1918.4
By an amendment in December, 1919, the bureau was authorized to furnish to soldiers and sailors disabled by injuries "reasonable governmental medical,surgical, and hospital service and such supplies, including wheel chairs, artificial limbs, trusses and similar appliances as may be useful and reasonably necessary." 5 It was very desirable that the temporary artificial limbs to be supplied by the Army to amputation cases should conform in general action to the permanent limb which would be furnished later by the Bureau of War Risk Insurance. The Army, therefore, supplied provisional artificial limbs fulfilling these requirements, made of fiber, and thus enabled the disabled soldier to acquire a limb when it was needed and to have the use of it during the interim prior to his discharge.6
The United States Public Health Service was given charge of the medical aspect of the work of the Bureau of War Risk Insurance, and this subject will therefore be covered under that service, although this section of the work remained under the nominal jurisdiction of the Bureau of War Risk Insurance.
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UNITED STATES PUBLIC HEALTH SERVICE
ACTIVITIES SUBORDINATE TO THE BUREAU OF WAR RISK INSURANCE
The medical officer in charge of the medical division of the Bureau of WarRisk Insurance was originally a civilian, but regulations governing the bureauwhich were issued in May, 1918, required that an officer of the United StatesPublic Health Service hold that position.7 Congressional action in March,1919, assigned all the medical activities of the Bureau of War Risk Insurance to the United States Public Health Service, including authority to buy, lease, or transfer to that service hospitals, hospital sites, hospital service, and hospital equipment for the purpose of treating beneficiaries of the Bureau of War Risk Insurance and those classes of individuals which had theretofore been entitled to treatment by the United States Public Health Service.8
COOPERATION WITH THE ARMY
Cooperative relationships were informally established between the Bureau of War Risk Insurance and various divisions in the Surgeon General's Office in the effort to correlate reconstruction before and after discharge from the Army.9 The first definite Army instructions to this end were issued in December, 1918,10 and provided that an officer should be assigned, wherever disabled soldiers were being treated, held, or discharged, to handle all matters relating to the work of the Bureau of War Risk Insurance and of the Federal Board for Vocational Education. It also authorized representatives of these two organizations to enter all hospitals, posts, camps, and stations for the purpose of interviewing disabled men who had been recommended for discharge, and to examine their records.
ORGANIZATION
In the spring of 1918 the medical division of the Bureau of War Risk Insurance consisted of three sections-medical and surgical relief, compensation, and medical inspection.7 An expansion was necessary with the demobilization of the military forces and reorganization into the following sections was made in April, 1919: General and military surgery; general medicine; tuberculosis; eye, ear, nose, throat, and dental; neuropsychiatric; miscellaneous.' The addition of the following sections was made by June, 1919: Prosthetics; statistical; medical accounts; dental; complaint.7
FUNCTIONS
The functions of the medical division are summarized as follows: 7
1. To determine the nature, extent, and probable duration of the disabilities of claimants, and to render opinions relative thereto to the compensation and insurance claims division as a basis for awards of compensation or insurance. Opinions as to.disabilities of claimants are formed by (a) reviewing the medical evidence on file in the case, and if that is insufficient, by (b) securing a record from the Army or Navy of the claimant's medical record while in the service, and by (c) securing additional physical examinations of claimants by medical officers of the United States (usually United States Public Health Service officers) or by physicians designated by the director.
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2. To adopt and apply a schedule of ratings and reductions in earning capacity from specific injuries or combination of injuries of a permanent nature, based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupation, and from time to time to readjust the schedule or ratings according to actual experience.
3. To see that claimants of the Bureau of War Risk Insurance are furnished with such reasonable governmental surgical, medical, and hospital service and with appliances as the director may determine to be useful and reasonably necessary.
4. To issue certificates of injury, after medical examinations have been made, to the effect that the injured person at the time of discharge or resignation was suffering from an injury likely to result in death or disability.
5. To secure a physical examination and to render an opinion as to the physical condition of applicants for reinstatement of insurance that has lapsed.
6. To review and render an opinion as to the medical evidence of death.
7. To maintain an active, sympathetic, and harmonious liaison with the several divisions of the Bureau of War Risk Insurance and with correlated intra- and extra-governmental agency.
EXPECTED CASES REQUIRING TREATMENT
A survey of the probable number of men who would require treatment by the Bureau of War Risk Insurance resulted as follows:7
It was carefully estimated from all available sources of data that the maximum number of men and women discharged with some disability would approximate 640,000. It was not presumed that this entire group would prove compensable, or would even make claim, since many of the disabilities would be of a minor nature; furthermore, more than 100,000 men were accepted into the service with certain disabilities already existing and noted (Group C men).
Included in this large estimated number of potential claimants were certain groups or classes of diseases and injuries which could definitely be stated to be compensable, and, in the main, permanently so. Such classes were (a) nervous and mental disorders; (b) tuberculosis; (c) major amputations; (d) certain injuries and conditions of the special senses. There was also the uncertain though undoubtedly large problem of the thousands of cases of circulatory diseases, digestive diseases, respiratory diseases other than tuberculosis, and conditions and diseases of the bones and joints and of organs of locomotion.
There were 1,700 beneficiaries of the Bureau of War Risk Insurance under treatment at the beginning of the year 1919, but by the end of the year 24,500 men had been discharged from the military services because of tuberculosis and 50,000 on account of nervous and mental disorders.11To meet the requirements of the expected flood of patients it was considered that approximately 12,000 hospital beds would have to be available at all times and that eventually 30,000 beds would be necessary.7 All Army hospitals were opened for the admission of beneficiaries of the Bureau of War Risk Insurance in February, 1919,12 and congressional action of March, 1919, provided the means for furnishing the remainder of the required beds-transfers of Army cantonment hospitals to the United States Public Health Service and the utilization of beds in civil hospitals supplying those required for immediate use.11
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HOSPITALS IN OPERATION, 1919
The United States Public Health Service was operating 20 marine hospitals, a tuberculosis sanatorium at Fort Stanton, N. Mex., and the following United States Public Health Service hospitals on June 30, 1919: 13 Palo Alto, Calif. (formerly United States Army Base Hospital, Camp Fremont), capacity 1,000; Greenville, S. C. (formerly United States Army Base Hospital, Camp Sevier), capacity 1,235; Alexandria, La. (formerly United States Army Base Hospital, Camp Beauregard), capacity 1,000; Dansville, N. Y. (formerly United States Army General Hospital No. 13), capacity 250; Norfolk, Va. (Sewells Point) (United States Army Quartermaster Terminal), capacity 213; Chicago, Ill. (formerly United States Army General Hospital No. 32), capacity 550; Corpus Christi, Tex. (formerly United States Army General Hospital No. 15), capacity 235; Washington, D. C., leased, capacity 80; Jacksonville, Fla. (formerly United States Army Base Hospital, Camp Joseph E. Johnston), capacity 830; East Norfolk, Mass. (formerly United States Army General Hospital No. 34), capacity 300.
REORGANIZATION
Decentralization became necessary with the increase in the work, and the country was divided into 14 districts, with a district supervisor from the United States Public Health Service in charge of each.7 This officer had a dual responsibility to the Director of the Bureau of War Risk Insurance and to the Surgeon General of the United States Public Health Service. Civilian physicians throughout the districts were appointed as "designated examiners.”7
IMPROVED CARE OF INSANE
Closer cooperation was found to be necessary in the handling of insane cases in the spring of 1919 in order that there would be no interval between the time of discharge from the Army and the commencement of continued care in an institution near the patient's home.14 To this end, instructions were issued that the discharge of an insane patient would be accomplished only after his arrival at the civil institution designated by the chief medical advisor, Bureau of War Risk Insurance.
RECONSTRUCTION SECTION ESTABLISHED
The reconstruction section of the United States Public Health Service was organized in July, 1919, to establish, supervise, and direct the work of the several branches of physiotherapy and occupational therapy, including amusements and recreations.15 The American Red Cross and other auxiliary agencies lent their assistance, as they had in Army hospitals. The actual work of reconstruction was started in the various hospitals in September, 1919, and had been extended to 42 stations by the end of that fiscal year, with 102 reconstruction aides on duty in hospitals.15 The total reconstruction personnel at the end of the year was 299, and the demand for personnel to carry on the work of physiotherapy and occupational therapy always exceeded the available supply.
A conference between representatives of the Surgeons General of the United States Public Health Service and of the Army was held in July, 1919, to arrange for the transfer to the United States Public Health Service of such supplies and occupational personnel as the Army no longer required.16
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SECTION OF NEUROPSYCHIATRY
The duties of the section of neuropsychiatry related to the development of temporary and permanent special-service hospitals, the establishment of special wards in general hospitals, the development of out-patient treatment and care, examinations, and reports, the use of contract hospitals and their inspections and the development of a nursing and special-service corps in connection with the care and treatment of that class.15 On June 30, 1920, the United States Public Health Service had 230 beds for epileptics, 367 for psychoneurotics, and 1,415 for insane cases; 4,128 nervous and mental cases had been treated in United States Public Health Service hospitals and 5,641 in contract institutions.
SECTION OF TUBERCULOSIS
The tuberculosis section had 4,274 beds on June 30, 1920, and was proposing to admit tuberculous cases to all general hospitals.15 A morale officer was detailed to each institution in turn to assist in instructing patients in matters requiring their cooperation in treatment.
NURSING CORPS
The nursing corps on June 30, 1920, consisted of approximately 1,100.15 Difficulty in recruiting a sufficient number of nurses was experienced, especially those trained to care for neuropsychiatric cases.
FEDERAL BOARD FOR VOCATIONAL EDUCATION
For many years prior to the World War the Federal Government had allotted various amounts of money to be used by the individual States for vocational educational purposes, but largely without control.17 Systematic cooperation and control on the part of the Federal Government was first introduced by the Smith-Hughes Act, approved February 23, 1917, which created the Federal Board for Vocational Education, to consist of the Secretaries of Agriculture, Commerce, and Labor, the United States Commissioner of Education, and three citizens of the United States to be appointed by the President, one of the latter to be a representative of manufacturing and commercial interests, one a representative of agriculture, and a third a representative of labor.18
The members of the board were formerly appointed July 17, 1917, by the President. The board held conferences with State representatives for the formulation of plans of action, a great deal of their attention being directed toward efforts that would be of assistance to the military forces in the war.17 These efforts assumed in October, 1917, the form of vocational training of drafted men for specialists' positions prior to reporting at the cantonments. Another activity was the study of rehabilitation for disabled soldiers and sailors, and the Federal Board for Vocational Education participated in many conferences on the subject with various governmental departments which were interested.17
Thousands of disabled men returned to civil life with scant or no knowledge of the rehabilitation law, due to two main reasons: 17 (1) The lack of facilities for rehabilitation in the early months of the war and the desire of the military authorities to avoid suggestions which would cause discontent among men
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who had been rehabilitated and retained in the service; (2) the impossibility at times of providing the personnel necessary, owing to the great number of discharge points, and the fact that many men denied a disability in order to insure their early discharge.
The feature of the law which made the Federal Board for Vocational Education the educational agents in the training, and the Bureau of War Risk Insurance responsible for the payment of men while in training and for the selection of cases to be trained, was responsible for a great deal of the above mentioned ignorance of the law.17 This situation was corrected by the passage of an amendment to the rehabilitation act in June, 1919, which placed the entire responsibility for selection, training, and payment with the Federal Board for Vocational Education.21
EDUCATIONAL POLICIES
The Federal Board for Vocational Education utilized existing institutions in training its students in preference to operating schools of its own.17 The patronage strengthened the schools, and assistance here and there in the matter of educational equipment enabled them to furnish the necessary amount and variety of training facilities.
In the early development of the work men were placed in educational institutions rather than in training on the job, for these principal reasons:17 Such institutions could expand with sufficient rapidity to meet the requirements; in the days of greatest pressure it was much easier to place men in educational institutions than to find suitable places in job training; placement training for the first year was practically impossible because of the wage situation. The small wage which many employers gave, in addition to the job training, led to interminable difficulties with the Bureau of War Risk Insurance in regard to the reduction in compensation. After the amendment of July 11, 1918, the board decided that it would be advisable to disregard any wage paid to a student in training.17
The blind, the deaf, the tuberculous, and the mental cases were trained along the same general lines as those employed in the Army hospitals, the blind receiving courses in the Red Cross Institute for the Blind, Baltimore, Md.
The function of the Federal Board for Vocational Education was determined to be the governing of rehabilitation rather than the actual teaching, this latter function being delegated to civil educational institutions, commercial schools, shops, factories, etc.17 Labor associations, employers, and educational institutions cooperated in the training and placement in a substantial way.17
Patients in hospitals of the United States Public Health Service were an exception to the above rule.17 There the Federal Bureau for Vocational Education undertook the educational, occupational, and vocational training,15 the United States Public Health Service then furnishing the professional care as it had for beneficiaries of the Bureau of War Risk Insurance.17 There were about 250 training courses offered and the same number of placement trainings.17
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A CONVALESCENT FARM HOSPITAL
An interesting experiment in rehabilitation was Convalescent Hospital No. 1, Lawrenceville, N. J.17 Originally established by the Army with the idea of furnishing a place where convalescence and practical instruction in farming would be coincident, it was found that the number of men who desired to take such a course was too small to justify the maintenance expense. The Federal Board for Vocational Education therefore took over the 500-acre farm and buildings April 1, 1919, and conducted it as a receiving station and school of practical farming until August 5, 1919, just prior to the time when the land-grant colleges were ready to admit the students of the Federal Board for Vocational Education."'
The instruction was organized on the short-course, shop, laboratory, and field plan. The unit courses given were as follows:
1. Agriculture, horticulture, and dairying: 2. Farm mechanics-Continued.
Care of plants in greenhouse. Farm implements.
Care of horses and hogs. Farm tractors.
Dairying: Repair of farm machinery.
Feed. Farm-lighting system.
Milk. 3. Poultry:
Breeds and breeding. Breeds.
Calves. Brooding.
Judging. Care of poultry.
Diseases. Marketing.
Farm crops. Incubator.
General agriculture. Housing.
Trucking: Diseases.
Truck crops. 4. Academic:
Plant enemies. English.
Harvest. Arithmetic for mechanics.
Soil. Arithmetic.
Production of crops. Reading.
Marketing. Americanization.
2. Farm mechanics: Letter writing.
Farm carpentry. Arithmetic for truckmen.
Gas-engine operation. Geography.
Farm management. Spelling.
Automobile repair.
While the total enrollment was less than 200, this farm-hospital school would undoubtedly have been an efficient agency in caring for the convalescent farm-minded men had the war continued longer. It returned men to the farm better fitted for farm activities and bridged the gap between hospital discharge and the opening of established educational institutions.22
UNITED STATES VETERANS' BUREAU
The medical care and rehabilitation of soldiers and sailors of the World War were originally accessory functions of the Bureau of War Risk Insurance, the United States Public Health Service, and the Federal Board for Vocational Education, but had become the predominant activities of the latter two organizations by the year 1919.23 The resultant great expansions of the divisions handling the veteran relief work overshadowed the parent organizations and
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were cumbersome and unwieldy.23 A plan for decentralization and consolidation in districts of all the activities concerned was completed in February, 1921, but the contemplated action was prevented by the discovery that such actionwould not be legal.23 To prepare for anticipated amendatory legislation, 50 medical officers from the districts were called to duty in Washington and nearly all pending claims requiring medical action were completed by July 22, 1921.23
The functions of these three organizations which were concerned in the compensation, medical care, and vocational education of veterans were invested in a new organization August 9, 1921, when Public Act No. 47, Sixty-seventh Congress, established the United States Veterans' Bureau. Decentralization was effected in order to expedite the work, and 14 district and 126 subdistrict offices were established within a few months.23 The authority to award insurance claims, compensation insurance, and vocational training was retained in the central office. These conferences led to a general conference in January, 1918,a when a tentative bill was drawn up which later became the vocational rehabilitation act of June 27, 1918.19
REHABILITATION RESPONSIBILITY
This act transferred all rehabilitation duties for disabled soldiers and sailors, after discharge from the military or naval service, from the Bureau of War Risk Insurance to the Federal Board for Vocational Education. The latter had apparently expected, before the passage of the act, that the reconstruction program would be committed to its care, for it sent 15 individuals to Canada for training in that line of work in order to secure a trained nucleus for its inauguration.17 Arrangements were made, very shortly after the passage of the act referred to above, to utilize the existing facilities of the country in the training of disabled men along professional, agricultural, industrial, and trade lines, to secure the cooperation of various agencies in their proper care and placement, and to secure the welfare of their families while they were in training.17
ARMY COOPERATION
Application was made to the Surgeon General of the Army late in June, 1918, for permission to send representatives of the Federal Board for Vocational Education into Army hospitals to explain to disabled men the benefits of the new law.17 This permission was not given until after the armistice began, on the grounds that the rehabilitated men would be needed in the Army for limited service and should not be brought into contact with civilians seeking their ultimate restoration to industrial life.17 Three representatives were sent to France, however, in August, 1918, and brought the benefits to the attention of nearly all patients in the overseas hospitals, largely through the assistance of the American Red Cross and with the approval of the chief surgeon, American Expeditionary Forces.20
aSee Chapter 1.
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REFERENCES
(1) Act September 2, 1914 (38 Statutes 711).
(2) Act June 12, 1917 (40 Statutes 102).
(3) Act October 6, 1917 (40 Statutes 398).
(4) Act June 27, 1918 (40 Statutes 617).
(5) Act December 24, 1919 (41 Statutes 371).
(6) Osgood, R. B.: A survey of the orthopedic services in the United States Army hospitals, general, base, and debarkation. Journal of Orthopedic Surgery, Boston, 1919, i, 359.
(7) Medico-military activities during the World War to July, 1920, by Treasury Department, Bureau of War Risk Insurance. On file, Historical Division, S. G. O.
(8) Act March 3, 1919 (40 Statutes 1302).
(9) Letter from division of military orthopedic surgery to the Acting Surgeon General United States Army, October 4, 1918, and attached documents. Subject: Weekly report. On file, Historical Division, S. G. O.
(10) Circular No. 132, War Department, December 11, 1918. Subject: Cooperation with the War Risk Insurance Bureau and Federal Board for Vocational Education.
(11) Public Health Reports, xxxiv, No. 23, June 6, 1919.
(12) Circular Letter No. 98, Surgeon General's Office, February 20, 1919.
(13) Treasury annual reports, 1919, United States Public Health Service, 220.
(14) Circular No. 225, War Department, April 30, 1919.
(15) Treasury annual reports, 1920, United States Public Health Service, 252, 260.
(16) Letter from the Surgeon General, United States Public Health Service, to the Surgeon General, United States Army, War Department, Washington, D. C., July 17, 1919, and attached papers. On file, Record Room, S. G. O., 353.91-1.
(17) Annual reports, Federal Board for Vocational Training, 1917, 1918, 1920.
(18) Act February 23, 1917 (39 Statutes 929).
(19) Act June 27, 1918 (40 Statutes 617).
(20) Letter from chief surgeon, American Expeditionary Forces, to Lieut. Col. F. T. Murphy, M. C., director medical and surgical department, Army Red Cross, Hotel Regina, Paris, October 18, 1918, and attached documents. Subject: Proposed work in France of the Federal Board for Vocational Education. On file, Record Room, S. G. O., 704.6.
(21) Act July 11, 1919 (41 Statutes 158).
(22) Final report of physical reconstruction, by Maj. A. G. Crane, S. C., 328.
(23) Annual reports of the director, United States Veterans' Bureau, for the fiscal years ending June 30, 1922, and June 30, 1923.
