Part 18

5. Classification of all patients with reference to their special needs and their clinical condition, such classification being flexible enough to permit frequent changes.

6. A system of clinical records which permits study and review of the history of cases even after they have been discharged.

7. When possible, the maintenance of a school of nurses under the direction of a supervisor of nurses, who should have, not only the training in general nursing, but special training in nursing patients with mental diseases.

8. The employment of female nurses in all reception and infirmary wards.

9. Liberal use of parole for quiet, chronic patients who can live in farmhouses.

10. Special provision for the tuberculous.

If, after written notice has been given, any institution furnishing medical care and treatment to patients of the United States Veterans’ Bureau fails or refuses to make reasonable effort to meet the foregoing requirements, such institution will be deemed to be rendering unsatisfactory service, and if under contract with the United States Veterans’ Bureau, such contract may be cancelled, and the Director will refuse to make contracts when the care and treatment offered do not substantially meet the requirements specified herein.

LEON FRASER Acting Director, U. S. Veterans’ Bureau. ]

SENIOR SURGEON B. J. LLOYD, (U.S.P.H.S.,(R)): presented the second paper, entitled “Admissions to, Transfers and Discharges from Hospitals of Beneficiaries of the U. S. Veterans’ Bureau,” which is given below:

“I do not often speak in public. Occasionally I attempt to speak extemporaneously, but today I shall claim your indulgence and confine my remarks strictly to what is written in this manuscript, for the reason that if taken in a disconnected sense some of the things I shall say might sound sensational, whereas if taken in a connected sense and in the way I shall say them, I think you will agree with me that there is absolutely nothing sensational in my remarks.

Attendance at this conference is indeed both a privilege and an opportunity. To be asked to address this gathering is a distinction worthy of the best that can be said on the topic assigned.

I take it that you are already familiar with the rights and benefits to which the disabled ex-service man is entitled; that you are familiar with the usual routine of paper work and other procedures in admitting, transferring and discharging, and I shall therefore omit some of the more or less definitely settled, fixed policies in this discussion.

I fully realize that my subject is an extremely important one and that it is in a measure connected with nearly every benefit extended to the ex-service man or woman, and with every service that is rendered in his or her behalf. On the intelligent administration of the functions of admission, transfer and discharge to, or from our hospitals, as the case may be, depends, in great measure, not only the economical and efficient administration of our entire hospital program, but in equal measure the recovery, the health, the happiness, the future usefulness, even the very lives of men and women, many of whom have made great sacrifices and passed through great agonies.

When I make these assertions, do not think for a moment that I am comparing these functions with the actual volume of work that is done in the hospitals, with the relief that is given therein, nor with the benefits which accrue to the patient, but, just as victory in a great battle may depend on the placing of the right troops in the right place at the right time, so victory, in the struggle of the disabled ex-service man for rehabilitation, for health, or for life, may depend on his being sent to the right hospital at the right time. Neither must he be discharged too soon, nor kept too long, and when he is transferred from one hospital to another there should be sound medical reasons therefor, barring those unfortunate cases, where the beneficiary may be transferred to a hospital near his home when it is seen that death is inevitable.

Going back now to the contact which hospitalization makes, or should make, with the other benefits extended to the ex-service man, let me picture to you the state of our past, and to a great extent, our present organization, by recalling to your minds the old story of the six blind men of Hindustan who went to see the elephant, each trying to tell what the elephant was like. The first man got hold of the elephant’s ear and said that the animal was very like a fan; the second got hold of his leg and said, “No, I can’t agree with you; this elephant is like a young tree.” The third man got hold of the elephant’s trunk and said, “The elephant is like a snake.” The fourth man grasped a tusk and said that the elephant was like a spear; the fifth fell against his side and said he was like a wall; and the sixth got hold of his tail and said he was like a rope. Now all were partly right and each was mostly wrong, and a somewhat similar condition exists with regard to our work.

This meeting, gentlemen, is an attempt to further co-ordinate the efforts of all the agencies that are at work for the ex-service man. Ours is a tremendous responsibility, both from the standpoint of our duty to the ex-service man and of our duty to the taxpayer as well.

No man except the man in the field knows better than I do that you have been circularized and regulated and instructed and uninstructed, informed and misinformed, ordered and dis-ordered, until I have no doubt you have been tempted to slam your fist down on your desk and say, “Well, for Heaven’s sake, how many bosses have I, anyway, and which lead had I better follow.” And as for reports, no doubt you have wondered, “Well, what will they want to know next?” And yet there has generally been a fairly good reason for every question you have been asked and a reasonably intelligent, honest, and often an enthusiastic, and sometimes an efficient man or woman behind the interrogation point.

In addition to having all these things done to you, I suspect that you and your colleagues in the hospitals, some of you at least, feel that you have been libelled and slandered by newspapers whose editors thought they were telling the truth, and by newspapers whose editors probably did not stop to consider whether they were telling the truth or not. You probably feel that you have been libelled and slandered, unintentionally of course, by men inside of legislative halls, and also, again perhaps unintentionally, if carelessly, by men and women outside of legislative halls, and by men and women both inside and outside of well-meaning civic organizations. And, I may say that in the Arlington Building in this city there are reams of evidence which might be cited in support of your beliefs, and at “C” Building at 7th and B Streets, there are tri-remes of such evidence, and these reams and tri-remes of evidence have cost the Government of the United States thousands, tens of thousands, yes, hundreds of thousands of dollars for investigations, when, as a matter of fact, the majority of the complaints that have been filed against hospital administration need never have been investigated by the Government at all if the individual who submitted the complaint had taken the trouble to do a little honest investigating on his or her own account.

The fact that these statements have been made with the best intentions in the world does not lessen the injustice contained in many of the charges, nor does it remove the sting which has accompanied these charges, and you, gentlemen, have listened to the soft pedal on the inside and to jazz on the outside until you have probably said, “For the love of justice, is there not some man who has grit enough to get up in public and tell the truth and say what he thinks?”

But, gentlemen, it will not always do to talk back. Actions speak louder than words, even though they do not make as much noise, and Solomon was right when a few centuries ago he remarked that “A soft answer turneth away wrath.” We must always maintain a courteous, gentlemanly, dignified attitude. We must never for a moment allow our sympathies for the deserving unfortunate ex-service man to become in the least weakened, and we must continue to give him the benefit of the doubt in border-line cases, and finally we must maintain our equanimity under the most trying circumstances.

And now that we have you here, we are going to ask you some more questions, and I hope you know the answers, because I don’t know the answers to some of these questions myself, nor do I intend to answer them.

In passing, I might remind you of the fact that in times past we have spent money very freely on our hospital program, and that while we still desire to give our beneficiaries what is perhaps a little more than reasonable medical and surgical care and treatment, at the same time we must be able to show Congress that we are operating economically under present conditions, and certainly, when not in conflict with the patients’ rights or interests, the question of economy of administration must be considered in admitting, transferring and discharging. Are we giving this question of economy of administration the proper consideration in performing these functions, and if not, what are the reasons? We want to know. This I will label “Question No. 1,” and let you think it over for a while. It is perhaps not the most important question I shall ask but it is important.

Now, having delivered myself of this question, and not having answered it, I suppose you are ready for Question No. 2. Well, I am not. I want to talk a little before I spring the next question. Of course we all know that the primary object in placing a man in a hospital is to give him a chance to get well, or as nearly well as possible. This, however, is not the only thing to be accomplished in the hospitalization of patients of the Veterans’ Bureau, and, if I may speak frankly, I may say that, while theoretically, hospitalization, rehabilitation, and the awarding of compensation ought to dovetail into each other without any overlapping or getting in each other’s way, as a matter of fact they won’t do it,—at least they haven’t done it so far; but, nevertheless, we’ve got to make the best possible connection between these functions.

Let us hark back to Regulation No. 57 of the old Bureau of War Risk Insurance, which gave temporary total disability to the beneficiary whose disability showed Service connection, together with compensation at this high rate as soon as the man entered the hospital, and which cut down this compensation anywhere from $80 per month to nothing at all as soon as the beneficiary left the hospital. Although this Regulation has been somewhat modified recently, it is still a very strong incentive for men to seek hospitalization. It takes an unusually patriotic citizen to take $30 to $60 a month or less when he can get $80 a month and board and lodging if he can remain inside of a hospital.

Apropos of this provision, I recall the circumstances of a young man who came to me quite some time ago, having left the hospital at Fort McHenry. He presented himself in a courteous, dignified way, was perfectly serious and absolutely frank. He began the interview by handing me the card of a U. S. Senator. Then he told me his story, and it was a good story. I shall try to recall it as nearly in his own language as possible. “Doctor”, said he, “I have just left your hospital at Fort McHenry. I do not like it. I realize that the Public Health Service is not to blame for conditions which I found there. It is not suited for a hospital. It is badly located. There are odors which it seems impossible to overcome. The walls and floors are dingy, and while they are clean, they cannot be made to look clean.

“I was shot through the stomach by a machine gun. Here are the scars. If I do not work hard I feel fairly comfortable, and yet I am not well, I receive $30 a month when I am outside the hospital, I receive $80 a month and my board and room when I am in the hospital. Personally I would much prefer to remain at home, but when I work hard enough to make a living I break down. I have seen so many men in the hospital who are receiving their board and lodging and their $80 a month who are not as deserving of this as I am that I do not propose to remain at home and work on my present compensation, and I would just like to see you keep me out of a hospital. And furthermore, I demand to be sent to the hospital of my choice. What are you going to do about it?”

I replied, “Young man, you have been unusually frank in what you have said. I shall be equally frank with you. If I had been wounded as you have, and if I had the information which you have gained from your stay in different hospitals, I should probably make the same demands. You can have your transportation whenever you want it.”

I saw this young man later at No. 38 in New York and he told me that he was about to get what he considered a satisfactory rate of compensation, and that as soon as he could get it he would go home.