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Veterans Administration Hospitals
810
EDITORIALS
usual interest. There were reports of en sions. There was a most enjoyable watercouraging progress from many of the coun sports show at the outdoor swimming pool tries of the Western Hemisphere, given by of the hotel, after a barbecue dinner in the the chairmen or members of committees garden; also a cocktail party at the beautiful and other individuals. There were reports on Indian Creek Country Club. None of us will new or improved techniques, new drugs, new ever forget either of these enjoyable evenings. diets, new problems and their possible solu In addition, the Mexican government sent tions, and so forth. It is impossible to men two delightful movies of Mexico and many tion each contributor by name in a short interesting posters, advertising their coun editorial; and it is not fair to mention a few try. Also, Dr. Cepero of Havana, Cuba, as giving outstanding reports, because all of brought his beautiful movies with sound ef the papers were so manifestly excellent. fects, showing excerpts of several of his Among the presentations which seemed trips to those attractive countries which lie especially to please our Latin-American col south of us. leagues, as well as our English-speaking The result of this meeting seems to be a members, were the five symposia: one was considerable increase in the interest of oph given mainly by the Latin Americans on thalmologists in their neighbors, even though "Parasitic diseases of the eyes." Another a different language is used. And all of us was on "Retrolental fibroplasia"; a third, resolved not to miss the coming congress "Secondary glaucoma"; a fourth, "Tra in Mexico City, January 6 to 12, 1952. choma" ; and one on the "Effect of sunlight Thomas D. Allen. at high altitudes, the effect of bright light at sea level, and the problems of supersonic VETERANS ADMINISTRATION speeds." HOSPITALS There were four papers on "Military oph thalmology"; several symposia on "Indus All physicians should be interested in the trial and school eye problems"; two on "Sur developments that have been taking place gery of the eye and adnexa"; and a most in the veterans hospitals since the end of interesting illustrated discussion on the sub the second world war. Vast sums of money ject of "Nematodes in children's eyes," given are being spent for veterans' care and in by Helenor Campbell Wilder. A summary the construction of many new hospitals. Yet, of many of these papers was printed in two there are probably few doctors who know languages, in an attractive presessional vol exactly what is being accomplished and ume, copies of which may be had for $1.50 doubtless no one is completely aware of what the future holds. This editorial will be con each. The last day of the meeting was devoted fined to the ophthalmological aspects and to research in ophthalmology. This part of particularly those pertaining to the St. Louis the program was arranged by Dr. James H. Medical Area which comprises the states of Allen, who presided. Nine papers were pre Missouri, Kansas, Arkansas, Louisiana, sented on such subjects as "Average ocular Oklahoma, Texas, Colorado, and New Mexi tension," "Hyaluronidase," "The mechanism co. of foreign-protein therapy," "Microwave Shortly after the war the authorities de therapy," "Esotropia (statistical study)," cided that a division of the United States "Toxoplasma," "Retinal metabolism," and and its territories into 13 regions under the "The treatment of leprous pannus." general control of Washington would con But all was not work or lectures, or mov stitute a serviceable organization for Vet ies, for the members of the local committee erans Administration. In each area a chief outdid themselves in arranging for diver consultant in every division of medicine,
EDITORIALS called the Branch Section Chief, was ap pointed, and over these was a director. These branch section chiefs were to act as advisors in their specialties for the veterans hospitals in their areas. There were appointed also to most hospitals consultants and attending physicians who were in the neighborhood of the hospital and available for frequent visits, it being customary in most places for the con sultant to visit the hospital approximately once a week and for the attending physician twice a week, the frequency of the visits varying with the needs of the hospital. These physicians were in addition to a group who were not on a visit basis, but were either full- or part-time, or on a fee basis, by which is meant that they were paid for the indi vidual examinations of patients. At least one meeting of the branch section chiefs with other full-time medical officers of the veterans organization was held. Reports were given by those who had already visited the hospitals in their areas and general plans were outlined. The smaller area to which the writer was assigned at that time included Missouri, Kansas, Oklahoma, Arkansas, and the "panhandle" of Texas. By the time of the first round of visits the post-war plans for veterans hospitals were already in ef fect and in many places the ophthalmological staffs were adequate and functioning satis factorily. After about two years it was decided to appoint dean's committees from medical schools in the vicinities of veterans hospitals to serve as advisory bodies to the hospitals. This change virtually excluded the branch section chiefs from their direct advisory ca pacity in about two thirds of the hospitals. Since the most interest from the specialty standpoint, particularly in a small specialty such as ophthalmology, was centered in hos pitals with close affiliations to medical schools and this left only the more isolated hospitals in which very little ophthalmology was practiced, the major part of the interest was taken away. In the writer's own case only three hospitals were left and the near
811
est was 300 miles from his home. At none of these three were there definite assign ments of beds for ophthalmological patients and in one of them the ophthalmological treatment rooms were being used for desk space. It is not to be gathered from this that the appointment of dean's committees was a mis take. In fact, it was a very sensible move and has been responsible for a closer affilia tion between the schools and the hospitals and has resulted in better service to the pa tients and better teaching opportunities for medical students. It did, however, make the branch section chief's position one of little interest. The directing group in Washington was undoubtedly aware of the dissatisfaction of this group and recently has taken steps to reinstate to a considerable extent the ad visory position of the branch section chiefs. About this time it was deemed best to con solidate many of the areas, reducing the number to six. Because of the change in policy and the willingness of dean's commit tees to welcome the branch section chiefs, now called Area Consultants, the situation has again become one that makes these con sultants feel that they are serving a real purpose and they will be more willing to make sacrifices to visit these hospitals and be of such service as they can. In the St. Louis Medical Area there are 24 active veterans hospitals and 12 in process of construction, five to be opened this year. Obviously in as large a territory as the St. Louis Medical Area, which covers between one fifth and one fourth of the United States, it is not feasible for a physician who is not on a full-time basis with the Veterans Administration to make the rounds of all these hospitals frequently. Fully appreciating this, the veterans organization has permitted the appointment of sub-area consultants and this is being rapidly done throughout the country. Obviously, this will save much time and travel by the chief area consultant. The writer has just returned from a visit to 12 of these hospitals which required 14
812
EDITORIALS
days. Some remarks resulting from these visits may give a picture of the present situa tion of ophthalmology in this division of medical care of veterans. These 12 hospitals were all in the states of Missouri, Oklahoma, Arkansas, Texas, and Louisiana, but are not all of the veterans hospitals in these states. Of the group visited, six have dean's com mittees as advisors and six do not. Those with dean's committees are in or near large cities and medical schools, hence have more ophthalmic activity. In every instance the consultants representing the medical schools were most cooperative and showed great in terest in their duties in the veterans hospi tals. In places where residents were in train ing, it was evident that the young men were having good opportunities for learning and were availing themselves of them. The num ber of residents in these hospitals varied from none to three. The services where resi dents were present were from one to three years in duration. The beds devoted to oph thalmology in the entire group varied from none to about 15, though there was always flexibility and more beds could be found if the need arose. The warmth of welcome was no less in the hospitals where there was no medical school affiliation than in the others. Oph thalmology in the former varied from almost none in hospitals designated for tuberculosis and almost as little in the neuropsychiatric group, to the general hospitals where, in most cases, there was an active eye, ear, nose, and throat full-time physician. One ob tained the impression that these units tended to be a little too self-sufficient and were less eager to welcome local consultants. Dean's committees seem to be important in prevent ing a self-sufficient family attitude in the hospital. The hospitals themselves are well equipped and for the most part of modern construc tion, comparing favorably with private hos pitals throughout the country. Administra tive officers, managers, and directors of the medical service are in general of fine caliber and seem well qualified in their respective
fields. Americans should be proud of the work that is being done for their diseased and disabled veterans. Most of the hospitals are adequately staffed and reasonably full. But some read justment within the services might permit sufficient space for the immediate future. A different viewpoint, however, is apparent ly held by the government because a great number of new hospitals, and very beautiful ones with everything modern and usually no less than 500 beds, are being built through out the country. The Journal of the Ameri can Medical Association for March 18, 1950, states: "Twenty-six new Veterans Admin istration hospitals are scheduled for com pletion during the calendar year 1950. These projects will contain about 11,710 new hos pital beds. . . ." In the St. Louis Medical Area there are completed (but as yet un occupied), or building, or projected 12 new hospitals. Most of these are nearing com pletion. They stand as immense monuments along the highways of these states. In view ing all the new hospitals the question of staffing them becomes as baffling as from what source the patients are to be drawn. There may be implications back of all of this that we shall not be too happy to face in the years to come. One other question comes to the mind of a visiting consultant and that is the accept ance of veterans for hospitalization who are not truly entitled to this care under the existing laws which state in effect that a pa tient to be eligible for hospitalization in a veterans hospital must either be suffering from a service-connected disability or have insufficient means for hospitalization. One cannot help but question the fidelity with which this government dictum is followed. It is true that veterans who do not claim serv ice connection in their disabilities are re quired to sign a statement with regard to their financial status. But the impression is received that the veteran does not consider too seriously the implications of affixing his signature to this statement. No matter how good the intentions of hospital managers,
OBITUARY
813
about four years later from the Saint Louis Medical College. After a three-year preceptorship in ophthalmology, under Dr. M. Hayward Post, he studied for 22 months in the clinics and medical schools of Europe and London. The impressions of this ex perience remained with him throughout the rest of his life. He would relate that return ing from this trip, he had only one dollar and four cents in his pocket, and owed 1,800 dollars. Shortly after this he started the practice of ophthalmology in Saint Louis and rapidly established himself as one of the outstanding ophthalmologists in the middlewest. Dr. Charles was scrupulously honest and maintained the highest standards of social and medical ethics. During his long life, he held many positions of responsibility and honor. He was affiliated with both the medi cal schools of Washington and Saint Louis Universities. For eight years he was ophthal mic consultant on the Board of the Missouri School for the Blind. He was also on the staff of a number of the leading hospitals of the city, being especially active in St. Luke's Hospital and the Missouri Baptist Sani tarium, as it was then known. Although never a prolific writer, there are some very excellent articles from his pen. Most of these were presented either before the old St. Louis Ophthalmological Society, OBITUARY or its successor, the Saint Louis Ophthalmic J O S E P H WILLIAM CHARLES Society, or the American Ophthalmological (1868-1950) Society. He served on the council of this lat Joseph William Charles was born Febru ter organization from 1926 until 1930. Dr. ary 9, 1868, in Boonville, Missouri. He died Charles was also a member of the American in Barnes Hospital, Saint Louis, February Medical Association, the American College 10, 1950. He was the second son of the Rev. of Surgeons, the American Academy of Benjamin Hines Charles, president of the Ophthalmology and Otolaryngology, and old Presbyterian Synodical College of Boon the Association for Research in Ophthalmol ville. His mother was Achsia Holmes. His ogygreat-great-grandfather, Shadrach Bond, He spent most of his leisure at the Bellewas the first governor of Illinois. His rive Country Club and at the University brother, Benjamin Hines Charles, became an Club, where he lived for many years. He eminent attorney in Saint Louis. was a member of the Presbyterian Church. At the age of 18 years, Dr. Charles re In 1905, he was married to Laura Merrill, ceived his A.B. degree from Westminster who died a few years later. On October 22, College. His M.D. degree was acquired 1930, he was married to Elizabeth Dorothy
there may be much pressure brought to bear by local veterans organizations if the ad mission of a veteran for any reason is ques tioned. And veterans organizations, being as powerful as they are politically, are very hard to resist when they take a determined stand. The observer cannot help but question the need of all of these new hospitals while the Army and Navy are closing hospitals be cause of lack of patients. This is probably due to several factors, primarily perhaps a lack of strategic position of the hospitals that are being closed. One wonders, how ever, whether the lack of complete integra tion of services might not be a factor. A good example of what can be done is the beautiful Navy hospital at Houston which is now occupied by the veterans and, under an able manager who understands cooperation with a local medical school, is making a fine use of this handsome group of buildings. In conclusion, the thoughtful observer who has made careful examination of the facilities and conduct of the veterans hos pitals, if the St. Louis Medical Area is any criterion, may well be pleased with what is being done for our war casualties. Lawrence T. Post.
EDITORIALS
usual interest. There were reports of en sions. There was a most enjoyable watercouraging progress from many of the coun sports show at the outdoor swimming pool tries of the Western Hemisphere, given by of the hotel, after a barbecue dinner in the the chairmen or members of committees garden; also a cocktail party at the beautiful and other individuals. There were reports on Indian Creek Country Club. None of us will new or improved techniques, new drugs, new ever forget either of these enjoyable evenings. diets, new problems and their possible solu In addition, the Mexican government sent tions, and so forth. It is impossible to men two delightful movies of Mexico and many tion each contributor by name in a short interesting posters, advertising their coun editorial; and it is not fair to mention a few try. Also, Dr. Cepero of Havana, Cuba, as giving outstanding reports, because all of brought his beautiful movies with sound ef the papers were so manifestly excellent. fects, showing excerpts of several of his Among the presentations which seemed trips to those attractive countries which lie especially to please our Latin-American col south of us. leagues, as well as our English-speaking The result of this meeting seems to be a members, were the five symposia: one was considerable increase in the interest of oph given mainly by the Latin Americans on thalmologists in their neighbors, even though "Parasitic diseases of the eyes." Another a different language is used. And all of us was on "Retrolental fibroplasia"; a third, resolved not to miss the coming congress "Secondary glaucoma"; a fourth, "Tra in Mexico City, January 6 to 12, 1952. choma" ; and one on the "Effect of sunlight Thomas D. Allen. at high altitudes, the effect of bright light at sea level, and the problems of supersonic VETERANS ADMINISTRATION speeds." HOSPITALS There were four papers on "Military oph thalmology"; several symposia on "Indus All physicians should be interested in the trial and school eye problems"; two on "Sur developments that have been taking place gery of the eye and adnexa"; and a most in the veterans hospitals since the end of interesting illustrated discussion on the sub the second world war. Vast sums of money ject of "Nematodes in children's eyes," given are being spent for veterans' care and in by Helenor Campbell Wilder. A summary the construction of many new hospitals. Yet, of many of these papers was printed in two there are probably few doctors who know languages, in an attractive presessional vol exactly what is being accomplished and ume, copies of which may be had for $1.50 doubtless no one is completely aware of what the future holds. This editorial will be con each. The last day of the meeting was devoted fined to the ophthalmological aspects and to research in ophthalmology. This part of particularly those pertaining to the St. Louis the program was arranged by Dr. James H. Medical Area which comprises the states of Allen, who presided. Nine papers were pre Missouri, Kansas, Arkansas, Louisiana, sented on such subjects as "Average ocular Oklahoma, Texas, Colorado, and New Mexi tension," "Hyaluronidase," "The mechanism co. of foreign-protein therapy," "Microwave Shortly after the war the authorities de therapy," "Esotropia (statistical study)," cided that a division of the United States "Toxoplasma," "Retinal metabolism," and and its territories into 13 regions under the "The treatment of leprous pannus." general control of Washington would con But all was not work or lectures, or mov stitute a serviceable organization for Vet ies, for the members of the local committee erans Administration. In each area a chief outdid themselves in arranging for diver consultant in every division of medicine,
EDITORIALS called the Branch Section Chief, was ap pointed, and over these was a director. These branch section chiefs were to act as advisors in their specialties for the veterans hospitals in their areas. There were appointed also to most hospitals consultants and attending physicians who were in the neighborhood of the hospital and available for frequent visits, it being customary in most places for the con sultant to visit the hospital approximately once a week and for the attending physician twice a week, the frequency of the visits varying with the needs of the hospital. These physicians were in addition to a group who were not on a visit basis, but were either full- or part-time, or on a fee basis, by which is meant that they were paid for the indi vidual examinations of patients. At least one meeting of the branch section chiefs with other full-time medical officers of the veterans organization was held. Reports were given by those who had already visited the hospitals in their areas and general plans were outlined. The smaller area to which the writer was assigned at that time included Missouri, Kansas, Oklahoma, Arkansas, and the "panhandle" of Texas. By the time of the first round of visits the post-war plans for veterans hospitals were already in ef fect and in many places the ophthalmological staffs were adequate and functioning satis factorily. After about two years it was decided to appoint dean's committees from medical schools in the vicinities of veterans hospitals to serve as advisory bodies to the hospitals. This change virtually excluded the branch section chiefs from their direct advisory ca pacity in about two thirds of the hospitals. Since the most interest from the specialty standpoint, particularly in a small specialty such as ophthalmology, was centered in hos pitals with close affiliations to medical schools and this left only the more isolated hospitals in which very little ophthalmology was practiced, the major part of the interest was taken away. In the writer's own case only three hospitals were left and the near
811
est was 300 miles from his home. At none of these three were there definite assign ments of beds for ophthalmological patients and in one of them the ophthalmological treatment rooms were being used for desk space. It is not to be gathered from this that the appointment of dean's committees was a mis take. In fact, it was a very sensible move and has been responsible for a closer affilia tion between the schools and the hospitals and has resulted in better service to the pa tients and better teaching opportunities for medical students. It did, however, make the branch section chief's position one of little interest. The directing group in Washington was undoubtedly aware of the dissatisfaction of this group and recently has taken steps to reinstate to a considerable extent the ad visory position of the branch section chiefs. About this time it was deemed best to con solidate many of the areas, reducing the number to six. Because of the change in policy and the willingness of dean's commit tees to welcome the branch section chiefs, now called Area Consultants, the situation has again become one that makes these con sultants feel that they are serving a real purpose and they will be more willing to make sacrifices to visit these hospitals and be of such service as they can. In the St. Louis Medical Area there are 24 active veterans hospitals and 12 in process of construction, five to be opened this year. Obviously in as large a territory as the St. Louis Medical Area, which covers between one fifth and one fourth of the United States, it is not feasible for a physician who is not on a full-time basis with the Veterans Administration to make the rounds of all these hospitals frequently. Fully appreciating this, the veterans organization has permitted the appointment of sub-area consultants and this is being rapidly done throughout the country. Obviously, this will save much time and travel by the chief area consultant. The writer has just returned from a visit to 12 of these hospitals which required 14
812
EDITORIALS
days. Some remarks resulting from these visits may give a picture of the present situa tion of ophthalmology in this division of medical care of veterans. These 12 hospitals were all in the states of Missouri, Oklahoma, Arkansas, Texas, and Louisiana, but are not all of the veterans hospitals in these states. Of the group visited, six have dean's com mittees as advisors and six do not. Those with dean's committees are in or near large cities and medical schools, hence have more ophthalmic activity. In every instance the consultants representing the medical schools were most cooperative and showed great in terest in their duties in the veterans hospi tals. In places where residents were in train ing, it was evident that the young men were having good opportunities for learning and were availing themselves of them. The num ber of residents in these hospitals varied from none to three. The services where resi dents were present were from one to three years in duration. The beds devoted to oph thalmology in the entire group varied from none to about 15, though there was always flexibility and more beds could be found if the need arose. The warmth of welcome was no less in the hospitals where there was no medical school affiliation than in the others. Oph thalmology in the former varied from almost none in hospitals designated for tuberculosis and almost as little in the neuropsychiatric group, to the general hospitals where, in most cases, there was an active eye, ear, nose, and throat full-time physician. One ob tained the impression that these units tended to be a little too self-sufficient and were less eager to welcome local consultants. Dean's committees seem to be important in prevent ing a self-sufficient family attitude in the hospital. The hospitals themselves are well equipped and for the most part of modern construc tion, comparing favorably with private hos pitals throughout the country. Administra tive officers, managers, and directors of the medical service are in general of fine caliber and seem well qualified in their respective
fields. Americans should be proud of the work that is being done for their diseased and disabled veterans. Most of the hospitals are adequately staffed and reasonably full. But some read justment within the services might permit sufficient space for the immediate future. A different viewpoint, however, is apparent ly held by the government because a great number of new hospitals, and very beautiful ones with everything modern and usually no less than 500 beds, are being built through out the country. The Journal of the Ameri can Medical Association for March 18, 1950, states: "Twenty-six new Veterans Admin istration hospitals are scheduled for com pletion during the calendar year 1950. These projects will contain about 11,710 new hos pital beds. . . ." In the St. Louis Medical Area there are completed (but as yet un occupied), or building, or projected 12 new hospitals. Most of these are nearing com pletion. They stand as immense monuments along the highways of these states. In view ing all the new hospitals the question of staffing them becomes as baffling as from what source the patients are to be drawn. There may be implications back of all of this that we shall not be too happy to face in the years to come. One other question comes to the mind of a visiting consultant and that is the accept ance of veterans for hospitalization who are not truly entitled to this care under the existing laws which state in effect that a pa tient to be eligible for hospitalization in a veterans hospital must either be suffering from a service-connected disability or have insufficient means for hospitalization. One cannot help but question the fidelity with which this government dictum is followed. It is true that veterans who do not claim serv ice connection in their disabilities are re quired to sign a statement with regard to their financial status. But the impression is received that the veteran does not consider too seriously the implications of affixing his signature to this statement. No matter how good the intentions of hospital managers,
OBITUARY
813
about four years later from the Saint Louis Medical College. After a three-year preceptorship in ophthalmology, under Dr. M. Hayward Post, he studied for 22 months in the clinics and medical schools of Europe and London. The impressions of this ex perience remained with him throughout the rest of his life. He would relate that return ing from this trip, he had only one dollar and four cents in his pocket, and owed 1,800 dollars. Shortly after this he started the practice of ophthalmology in Saint Louis and rapidly established himself as one of the outstanding ophthalmologists in the middlewest. Dr. Charles was scrupulously honest and maintained the highest standards of social and medical ethics. During his long life, he held many positions of responsibility and honor. He was affiliated with both the medi cal schools of Washington and Saint Louis Universities. For eight years he was ophthal mic consultant on the Board of the Missouri School for the Blind. He was also on the staff of a number of the leading hospitals of the city, being especially active in St. Luke's Hospital and the Missouri Baptist Sani tarium, as it was then known. Although never a prolific writer, there are some very excellent articles from his pen. Most of these were presented either before the old St. Louis Ophthalmological Society, OBITUARY or its successor, the Saint Louis Ophthalmic J O S E P H WILLIAM CHARLES Society, or the American Ophthalmological (1868-1950) Society. He served on the council of this lat Joseph William Charles was born Febru ter organization from 1926 until 1930. Dr. ary 9, 1868, in Boonville, Missouri. He died Charles was also a member of the American in Barnes Hospital, Saint Louis, February Medical Association, the American College 10, 1950. He was the second son of the Rev. of Surgeons, the American Academy of Benjamin Hines Charles, president of the Ophthalmology and Otolaryngology, and old Presbyterian Synodical College of Boon the Association for Research in Ophthalmol ville. His mother was Achsia Holmes. His ogygreat-great-grandfather, Shadrach Bond, He spent most of his leisure at the Bellewas the first governor of Illinois. His rive Country Club and at the University brother, Benjamin Hines Charles, became an Club, where he lived for many years. He eminent attorney in Saint Louis. was a member of the Presbyterian Church. At the age of 18 years, Dr. Charles re In 1905, he was married to Laura Merrill, ceived his A.B. degree from Westminster who died a few years later. On October 22, College. His M.D. degree was acquired 1930, he was married to Elizabeth Dorothy
there may be much pressure brought to bear by local veterans organizations if the ad mission of a veteran for any reason is ques tioned. And veterans organizations, being as powerful as they are politically, are very hard to resist when they take a determined stand. The observer cannot help but question the need of all of these new hospitals while the Army and Navy are closing hospitals be cause of lack of patients. This is probably due to several factors, primarily perhaps a lack of strategic position of the hospitals that are being closed. One wonders, how ever, whether the lack of complete integra tion of services might not be a factor. A good example of what can be done is the beautiful Navy hospital at Houston which is now occupied by the veterans and, under an able manager who understands cooperation with a local medical school, is making a fine use of this handsome group of buildings. In conclusion, the thoughtful observer who has made careful examination of the facilities and conduct of the veterans hos pitals, if the St. Louis Medical Area is any criterion, may well be pleased with what is being done for our war casualties. Lawrence T. Post.