TABLE 6.—Results of treatment of 2,643 patients with pulmonary tuberculosis by type of tuberculosis on admission

Of the 474 incipient cases admitted for hospitalization, 218, or 45.9 percent, underwent complete hospitalization; 256, or 54.1 percent, were discharged following incomplete hospitalization; 152 left without permission, or were discharged against medical advice or for disclipinary reasons; of this number, 101 were improved following incomplete hospitalization, and 51 were unimproved. Of the 218 cases who underwent complete hospitalization, 77 were discharged as arrested; 18 were apparently arrested; 96 were improved; 15 were unimproved; and 12 died.

One thousand one hundred and sixty-nine moderately advanced cases were admitted for hospitalization, and of this number, 477, or 40.9 percent, were discharged after undergoing complete hospitalization; 692, or 59.1 percent, were discharged following incomplete hospitalization; and, of this latter number, 398 left without permission, were discharged against medical advice or for disciplinary reasons; of this number, 179 were improved following incomplete hospitalization and 219 were unimproved.

Of 477 patients with moderately advanced tuberculosis who had undergone complete hospitalization, 74 were discharged as arrested; 101 as apparently arrested; 126 as improved; 66 as unimproved; and 110 died.

Of 1,000 cases of pulmonary tuberculosis in the far-advanced stage admitted for hospital treatment in the U. S. Veterans Bureau, 462, or 46.2 percent underwent complete hospitalization; 538, or 53.8 percent, were discharged following incomplete hospitalization; and, of this latter number, 293 left without permission, or were discharged against medical advice or for disciplinary reasons.

Of 462 cases who underwent complete hospitalization, 2 were discharged as arrested, 2 as apparently arrested, 27 as improved, 78 as unimproved, and 353 died.

EFFECT OF NUMEROUS INCOMPLETE HOSPITALIZATIONS ON THE TREATMENT OF

TUBERCULOSIS

Regulations of the Bureau relative to hospitalization are quite lenient, so that it is possible for tuberculosis patients to leave the hospital while undergoing treatment, and return subsequently for further treatment. Such promiscuous

hospital discharges and admissions interfere with the proper treatment and rehabiliation of the tuberculous beneficiaries. To what extent this practice exists may be learned by reviewing tables 7, 8, and 9.

Table 7 shows that in 474 incipient cases of pulmonary tuberculosis treated in Bureau hospitals the average length of stay was 355.7 days. Of this number, 60.13 percent underwent 1 or 2 hospitalizations, 19.62 percent 3 or 4 hospitalizations, 15.40 percent 5 to 7 hospitalizations, 3.80 percent 8 to 10 hospitalizations, and 1.05 percent 11 to 15 hospitalizations.

TABLE 7.-Showing the results of treatment, the average periods of hospitalization and the number of hospital episodes of 474 beneficiaries admitted to U. Š. Veterans' Bureau hospitals with incipient tuberculosis

Table 8 indicates that of 1,169 moderately advanced cases of pulmonary tuberculosis, the average hospital stay was 625.9 days. Twenty-two and twentyfour one hundredths percent underwent 1 or 2 hospitalizations, 35.42 percent 3 or 4 hospitalizations, 29.17 percent 5 to 7 hospitalizations, 8.81 percent 8 to 10 hospitalizations, 3.68 percent 11 to 15 hospitalizations, and 0.68 percent 16 to 24 hospitalizations.

TABLE 8.-Showing the results of treatment, the average periods of hospitalization. and the number of hospital episodes of 1,169 beneficiaries admitted to U. S, Veterans' Bureau hospitals with moderately advanced tuberculosis

Table 9 shows that of 1,000 far-advanced cases of pulmonary tuberculosis, the average length of hospital stay was 539.0 days. Fifty and six-tenths percent underwent 1 or 2 hospitalizations, 25.5 percent 3 or 4 hospitalizations, 16.7 percent 5 to 7 hospitalizations, 4.8 percent 8 to 10 hospitalizations, 1.9 percent 11 to 15 hospitalizations, and 0.5 percent 16 to 24 hospitalizations.

TABLE 9.-Showing the results of treatment, the average periods of hospitalization, and the number of hospital episodes of 1,000 beneficiaries admitted to U. S. Veterans' Bureau hospitals with far-advanced tuberculosis

These data indicate that a large number of tuberculous ex-service men in need of continuous hospital care were certainly not taking advantage of the Bureau's effort to properly and effectively treat the tuberculouse disease and rehabilitate them so that they might attain maximum benefit from the same. It would appear that such action on the part of the tuberculosis patients tends to hamper the excellent hospital regimen prescribed by the Medical Service in the treatment of this disease, and offsets a large amount of good which the Bureau might otherwise have accomplished.

How best to overcome this practice is not known. It is not believed that anything good can come from legislation which requires compulsory hospitalization, nor would it seem practicable to prohibit such patients reentering hospitals after having been discharged, inasmuch as such action might be to their detriment and might interfere with the final arrest of the tuberculous disease. It is thought that a good deal can be accomplished by a system of education of the patient and his family, as well as by measures of moral persuasion.

The Bureau has introduced a system of lectures by physicians to the patient body. These lectures are given in the various wards by the ward surgeons and an attempt is made to teach the patients the nature of tuberculosis and how best to combat it.

The Bureau, through the instrumentality of its social workers, attempts to educate the families of tuberculosis patients in the principles of hygiene and sanitation and how best to prevent the tuberculous disease from spreading to other members of the patient's family.

COMPENSATION FOR TUBERCULOSIS

The rating of disabilities resulting from disease based on the degree of occupational handicap, in order to estimate the amount of compensation to be paid United States Veterans' Bureau claimants in compliance with section 202 (4) of the World War Veterans Act, is based on a schedule (4) prepared by the Medical Service. This schedule, as finally drawn up, consists of a combination of two extended tables. One table lists over 1,000 selected occupations. Opposite each occupation appear 17 variants, representing various

parts of the body, indicating estimates of the relative functional importance of the bodily part concerned with respect to the occupation in question. The other table, developed by a medical expert, evaluates approximately 1,600 disabilities with 9 separate ratings on each, depending on the occupational importance of the bodily parts as evaluated in the first table.

The principle upon which the schedule is based is that compensation is payable, not on account of disease or injury, but in accordance with the extent of the occupational handicap resulting from such disease or injury. Consideration is also given to the general reduction in employability resulting from the disease and the fact that a change of occupation, together with the disability compensation, would equal or even exceed the average preenlistment earnings of the occupational group to which the claimant belongs.

In carrying out the provisions of the new rating schedule, it was found that, in the case of a large number of claimants whose compensation status had been terminated and who were reexamined and rerated, almost 25 percent were replaced on a compensation status.

A study of the statistics shows that there has been an increase in the average monthly compensation for tuberculosis. This increase, it is believed, is due to the rating in accordance with the revised schedule of payments. There has also been an increase in the number of awards made. This is due to the more generous provisions of the new rating schedule, as well as to the liberalizing features of the amendment of the World War Veterans' Act providing for an extension of the time for the filing of claims as well as for an extension of time for submitting new evidence.

Furthermore, the increase in the number of compensable beenficiaries suffering from tuberculosis as well as the increase in the average monthly compensation paid all tuberculous beneficiaries is, in part, due to the provisions of the rating schodule allowing cases of arrested pulmonary tuberculosis a monthly compensation of $50. A great many tuberculous beneficiaries, who had previously been rated at less than 10 percent, have been placed on an active status in accordance with the revised regulations of the United States Veterans' Bureau.

It is interesting to note that, on account of the newly established policy of the Bureau, placing as many beneficiaries on a permanent compensation status as is possible, there has resulted a decrease in the number of temporarypartial and temporary-total cases. This has, in turn, yielded an increase in the number of cases rated as permanent-partial and permanent-total.

The number of active compensable cases for tuberculosis as of March 31, 1928, is 60,386. The total number of active compensable cases for all diseases is 253,297. The tuberculous beneficiaries, therefore, constitute approximately 23 percent of the total compensable load.

The total amount of monthly compensation paid by the Bureau to these tuberculous beneficiaries is $3,923,063, or an average compensation of $64.97 per month. The total annual outlay of the Government for the compensation of tuberculous ex-service men and women approximates $47,076.756. Of the total number of 60,386 beneficiaries on an active compensable status, 4,595 are on a temporary-partial status, and the average monthly compensation of this class of beneficiaries is $62.06.

Thirty-seven thousand, five hundred and forty-three beneficiaries are on a permanent-partial status, the total compensation paid these claimants being $1,842.286 per month. The average monthly compensation is $49.07. Seven thousand, one hundred and fifty-eight beneficiaries are on a temporary-total status. The total monthly outlay for the compensation of these beneficiaries is $651,456, or an average monthly compensation of $91.01.

The number of tuberculos beneficiaries on a permanent-total status is 11,080. The total monthly outlay for compensation is $1,141,839 or an average monthly compensation of $103,05.

There were 10 beneficiaries on a double permanent-total compensation status at a total monthly cost of $2,300, or an average monthly compensation of $230.

It is interesting to note that the total number of active compensable tuberculous cases has increased since 1922, during which year there were 36,600 cases on the compensation rolls. The number of active compensable tuberculous beneficiaries has increased to 60,386 as of March 31, 1928.

SUMMARY AND CONCLUSIONS

1. It has been estimated by the Medical Service that, of a total living exservice population of 4,380,000, the approximate mortality from tuberculosis is 5,580 per annum. It has also been estimated that the ratio of tuberculosis mortality to tuberculosis morbidity is 1:9.5. Accordingly, there are at the present time approximately 53,010 cases of tuberculosis of all forms among the ex-service population, which means a morbidity ratio of 1.21 per 100.

2. In view of the fact that all tuberculous ex-service men are eligible to hospitalization by the United States Veterans' Bureau, it would seem that the large number of ex-service men with active tuberculosis, together with the number having arrested tuberculosis who are likely to become active, constitute potential hospital material. It is therefore believed by the Medical Service that the problem of the hospitalization of tuberculous ex-service men will continue to play an important part in the activities of the Medical Service of the United States Veterans' Bureau for a number of years to come.

3. Inasmuch as the results of treatment depend to a considerable extent upon the stage of disease at the time of admission to the hospital, the small percentage of incipient cases and the large percentage of moderately advanced and far-advanced cases admitted to the Bureau institutions would explain in part the differences in the results obtained in the hospitalization of tuberculosis patients of the Bureau as compared with those of civilian institutions. There is another reason, particularly for the larger mortality rate in Bureau hospitals as compared with civil sanatoria: this is that the Bureau is obliged to hospitalize any tuberculous ex-service man who applies for, and is in need of hospitalization. A great many of the patients admitted for treatment in the Bureau institutions are terminal cases, and die soon after entrance. These cases are in a large measure responsible for the high mortality rate from tuberculosis in the Bureau hospitals.

4. It has been the observation and experience of the Medical Service that, at the particular stage of tuberculous disease when rest is most essential, many of the patients become noncooperative, are prone to abuse rest hours, resort to excessive activity while absent on leave, or curtail their hospital residence. These, it is believed, are additional reasons why the results of treatment of tuberculous disease in the United States Veterans' Bureau are not quite as favorable as those in civil sanatoria.

5. The Bureau statistics indicate that 20 percent of the tuberculous beneficiaries, discharged from hospitalization as apparently arrested or arrested, gave evidence of reactivation; 75 percent of this number showed evidence of activity within 1 year after discharge. This accounts in part for the large number of readmissions to United States Veterans' hospitals, as shown in the 1927 statistics of the Bureau. The latter indicate that there were twice as many readmissions as there were first admissions for pulmonary tuberculosis.

6 A study of Bureau statistics shows that while the hospital load of tuberculosis patients has decreased since 1922, the compensation load has nevertheless materially improved.

7. It is noted that the type of tuberculosis patients now being admitted to the Bureau hospitals is changing; by this it is meant that at the present time more far-advanced cases are being admitted than were admitted in previous years, some of these being in the terminal stages. If this continues, the hospital facilities for infirmary beds will have to be increased.

8. A study of the relationship of the period of hospitalization to the stage of tuberculosis disease shows that the more advanced the stage the longer was the hospitalization period, except in cases in which there was unimprovement during the hospital stay, in which patients were transferred to their homes for treatment, or in which death took place during the hospital residence.

9. A study was made of a large group of Bureau patients for the purpose of ascertaining the effect on the tuberculosis condition of incomplete and numerous hospitalizations. This study showed that frequent and incomplete hospitalizations offset, to a considerable extent, the large amount of good which usually follows continuous hospital residence. It is difficult to determine how best to overcome the tendency of patients to curtail their hospital residence and resort to frequent and short periods of treatment. The Bureau is endeavoring to impress upon the tuberculous beneficiaries and their families the importance of continuous hospitalization, of the good results from such a regimen, and of the ill effects resulting from the numerous incomplete and short hospital residences.