Chapter VII: Part 7

Between the dates above mentioned there have been in and admitted to these 97 hospitals, 44,318 patients. Of this number, 474, or a trifle over 1%, have been discharged for disciplinary reasons; 732 or 2% have left against Medical Advice, and 1804 or 4% have been absent without leave for a period of 7 days or over, and have so been dropped from the rolls of the hospital. This is a total of 3010 or 7%.

In the 67 Public Health Service hospitals there have been 33,028 patients, of this number 336, or 1% have been discharged for disciplinary reasons, 520 or 1.5% have left against Medical Advice, and 1233 or 3.5% have been dropped as over 7 days A.W.O.L. This is a total of 2089 or 6%.

In the 14 Naval hospitals, there have been 2571 patients. Of this number, 44, or 1.7% have been discharged for disciplinary reasons, 49 or 1.5% have left against Medical Advice, and 44 or 1.7% have been dropped as AWOL. This is a total of 107 or 4%.

In the 9 soldiers homes there have been 4721 patients. Of this number 56 or 1.2% have been discharged for disciplinary reasons, 111 or 2.3% have left against Medical Advice, and 437 or 9.2% have been dropped as A.W.O.L. This is a total of 604 or 12.7%.

In the six Army hospitals, there have been 3076 patients. Of this number 44 or 1.4% have been discharged for disciplinary reasons, 50, or 1.6% have been discharged against medical advice, and 65 or 2% have been dropped as AWOL. This is a total of 159 or 5%.

St. Elizabeth’s hospital has had 922 patients and our records show that none have been discharged for disciplinary reasons, none left against advice and none have been dropped as A.W.O.L.

In a general way, the large tubercular hospitals show the greatest number and percentage of discharges under this order. One or two hospitals show over 30% discharges, these being mostly against advice and absent without leave.

Since the issuance of the September General Order #27 a great deal of adverse criticism of it has been received from many sources.

With this in mind and with the knowledge that penalties were prescribed in the original order which did not conform exactly to the wording of the Sweet Bill General Order #27 has been rescinded and General Order #27–A issued in its place.

The essential features and changes in General Order #27–A are as follows:

1. There are four classifications:

(a) Patients leaving institutions against medical advice.

(b) Patients leaving institutions without permission.

(c) Patients discharged from institutions for disciplinary reasons.

(d) Patients disciplined by forfeiture of compensation without
discharge.

2. Under Paragraph (a) patients leaving institutions against advice,
there is a definition of when treatment is completed.

Patients leaving the hospital against Medical Advice the first time
receive transportation and expenses to their homes. They may be
readmitted to hospitals.

3. Under (b), Patients A. W. O. L.

Patients AWOL for a period of 7 days may be readmitted to hospital
but only to the hospital from which they are absent. After 7 days,
absence, they are dropped from the rolls of the hospital, and
further hospitalization can be authorized only by the Director.

4. Under (c) Patients discharged for Disciplinary Reasons, there are
three limitations

1. No patient who is mentally irresponsible shall be discharged for
disciplinary reasons.

2. No patient shall be discharged for disciplinary reasons, if his
physical condition is such as to endanger his life by reason of
such discharge.

3. No patient shall be discharged for disciplinary reasons, except
on the recommendations of a Board of Officers approved by the
Medical Officer in Charge of the institution.

Provision is made for minor punishments.

The Board of Officers above referred to is to be composed of two medical officers on the staff of the hospital and a representative of the U. S. Veterans’ Bureau appointed by the District Manager. When it is impracticable for the District Manager to appoint a representative he will request the Medical Officer in Charge of the hospital to appoint a member of his staff to represent the Veterans’ Bureau.

Patients discharged for the first time for disciplinary reasons receive transportation home. They are not readmitted to hospital except by the authority of the Director.

On the second or subsequent discharge for disciplinary reasons or for being AWOL, the board may recommend a forfeiture of compensation up to a maximum of 75% each month for a period of three months time.

Patients discharged under any of the above classes who are, following their first discharge, readmitted to hospital and after this 2nd admission are discharged for completion of treatment revert to their former status with a clean record.

5. Under (d) patients disciplined by forfeiture of compensation without discharge. Provision is made whereby patients who have committed an offense when it is not deemed necessary or advisable to recommend their discharge because of the nature and gravity of the offense, or because of the patient’s physical condition, forfeiture of their compensation up to a maximum of 75% each month for three months may be made effective.

Provision is made for the proper recording of all patients discharged in all districts, for the making of all forfeitures effective and here after all admission cards will bear a notation indicating whether or not the patient has been previously discharged under this order Section II of General Order 27–A is as follows:

Patients discharged for disciplinary reasons will not be readmitted to the hospital from which discharged. So far, of the patients discharged for disciplinary reasons, 71 have been readmitted to hospitals.

The principal complaint received from patients discharged has been that they knew nothing of General Order #27.”

ADMIRAL STITT: stated that it had been the rule to have all the papers read before opening the discussions.

SURGEON P. S. RAWLS, U. S. P. H. S. (R): read the next paper, “Relation of District Managers to Hospitals”, as follows:

“The District Manager and his District Medical Officer need no introduction to you. You are all familiar with their responsibilities. They are the representatives of the Veterans’ Bureau with whom you come in contact most frequently.

The office of District Manager was created by the Director, Colonel Forbes, when he assumed direct control of District organizations. The District Manager is charged with the responsibility for all phases of the work of the Veterans’ Bureau in his district. The Director also appointed a District Medical Officer who, through the District Manager, is responsible for all phases of medical work of the District—the examination, treatment, hospitalization, dispensary, convalescent and follow-up care—in fact the entire physical rehabilitation of patients of the Veterans’ Bureau. And only recently the additional responsibility of the determination and rating of disability has been added.

The medical organization of the District Office has been developed primarily for the purpose of establishing claimants of the Veterans’ Bureau as patients entitled to treatment, and the furnishing of proper treatment, under regulations, orders and instructions issued by the Central Office. The District Manager and his District Medical Officer are charged execution of these instructions. They are charged with hospitalization of patients in your hospitals and during such hospitalization, they must look to you to assume the burden of responsibility. In order to prevent misunderstanding and to define the relation of the Veterans’ Bureau and its District Manager to the Service hospitals and their Commanding Officers, Field Order #23 was issued which states in Paragraph #2 and #3 as follows:

You will note that one of the duties of the District Manager is to keep you informed of the general aims and policies of the Bureau. This means contact—close personal contact, if possible, with the Commanding Officers of the hospital, working together, keeping informed—the District Manager with the work and problems of the Commanding Officers informed of instructions through the official channels of the Service to which he belongs.

When the District Manager hospitalizes patients in your hospital, he must, necessarily, have certain reports, as he is still responsible to the Director for these patients. The reports of physical examination, on the proper Bureau forms are obviously essential. Important, too, is the prompt and accurate report of admission to and discharge from hospital of patients of this Bureau. Mention has been made of the multiplicity of reports asked for and the Bureau and its District Offices are making definite effort to relieve you of this burden. With the extensive decentralization of the work of the Bureau to the District Offices and the closer cooperation of those offices with your hospitals the request for reports made upon you in the past will be reduced. I feel confident that this result is already evident if comparison is made with conditions of a year ago. During the recent conference in Washington of District Managers, District Medical Officers and Vocational Officers, the question of reduction of reports and forms was urged resulting in a careful revision and some elimination which should indirectly affect you.

The most direct method of improving this condition will be placing a representative of the District Manager in your hospital. He will be able to act with the authority of the District Manager on many matters now causing difficulty and delay.

I should like to take this opportunity to call your attention to certain phases of treatment which the Veterans’ Bureau and the District Manager expect you to give to patients, namely, to disease or disability developing for which the patient was not admitted to hospital and to conditions which are not apparently of service origin. In this connection, I would remind you that the Director is charged with providing treatment to beneficiaries taking Vocational Training for disease or disability not due to misconduct, although not related to any service disability. This is embodied in Regulation #12 recently issued and from which I quote:—

The relation between the District Manager and the Commanding Officer of Service hospitals should be one of mutual cooperation. The success of the hospitalization program of the Bureau depends on this. The intelligent and sympathetic support of every Commanding Officer is essential and the Central Office firmly believes that every District Manager will give you his unqualified support in your work in hospitalization of patients of the Veterans’ Bureau. The one thing that I would impress on you above all others and which will do more than all the instructions that could be issued, is get together with the District Manager.”

COLONEL H. M. EVANS, of the U.S. Veterans’ Bureau: discussed the subject “Physiotherapy and Occupational Therapy in Hospitals” as follows:

Mr. Chairman, Ladies, and Gentlemen:

The subjects of Occupational Therapy and Physiotherapy constitute what has been designated as the Section of Physical Reconstruction in hospitals. Early after the United States entered the War the Surgeon General of the Army realized that it was necessary to utilize all the agencies that would aid in the recovery of men disabled in the War. He, therefore, established a Section in the Hospital Division of Physical Reconstruction, to include Occupational Therapy, curative work-shop instruction, and Physiotherapy which includes Electrotherapy, Hydrotherapy, Mechanotherapy, Thermotherapy, massage, and directed exercise. Col. Frank Billings, of Chicago, was made Chief of the Section, and the Work was developed until there were 48 hospitals with more or less perfect equipment in Physiotherapy and Occupational Therapy, 2000 Occupational Aides and curative work-shop instructors, and 1200 Physiotherapy Aides and Medical Officers. There were as many as 34,000 men engaged in some form of Occupational Therapy in one month, and 20,000 different men treated by Physiotherapy.

Upon the retirement of Col. Billings I was made Chief of the Section, and the work continued to develop until 69 per cent. of all hospital patients were doing some form of work in Occupational Therapy or Prevocational Training. There were many hospitals that maintained an average of 5000 Physiotherapy treatments a week for a number of months. As the men were discharged from Army Hospitals the burden of the Public Health Hospitals became greater, and many of the individuals who had been active in the Army work became associated with the Public Health and established as a part of their hospital program the Section of Physical Reconstruction, to include Occupational Therapy and Physiotherapy. This work has developed throughout the past year and a half. It was not thought within the province of the Public Health to develop Prevocational Training.

The speaker, having resigned from the Army, accepted a commission in the Public Health Service and was detailed to the Federal Board for Vocational Education as Medical Officer in Vocational Training. For a year and a half in this capacity he assisted in developing 181 centers, most of which were in connection with hospitals, in which the Prevocational Training was the major part of the work. Under this management there were about 800 teachers employed, and about 14,00 men engaged in some form of work. Unfortunately, the necessity of calling this Prevocational Training, in order to have it come under the Federal Board law, gave a wrong impression of the work as done in hospitals. When the Veterans’ Bureau came into existence, it took over the activities of the Federal Board and the Bureau of War Risk Insurance and correlated these with the Public Health Service, the Veterans’ Bureau having, under the law, power to do anything that was necessary in the rehabilitation of the ex-service men.

The Centers that had been operated under the Federal Board were divided, and all those attached to hospitals were put under the Medical Division and the work was considered as Occupational or Prevocational; all Centers that were for Section 2 trainees were designated as Vocational Schools, and on November 17, 1921 a program for Physical Reconstruction in Veterans’ Bureau Hospitals was approved by the Director, as outlined in _Exhibit A_.

In accordance with this approved plan, which had previously been approved by the Federal Board of Hospitalization, it became necessary to have a procedure; as all other personnel in hospitals were responsible to the Commanding Officer and controlled from the headquarters in Washington, it was deemed advisable and consistent to have all Veterans’ Bureau personnel that were detailed to a hospital placed on Central Office Payroll and directed by Central Office. In accordance with this, on January 18, 1922, a procedure was approved, to be issued as a General Order, as shown in _Exhibit B_.

This makes it very plain as to the attitude of the Federal Board of Hospitalization and the attitude of the Director of the Veterans’ Bureau toward Physical Reconstruction.

In addition to the agencies described, which are usually a part of Physical Reconstruction, there have been placed for administrative purposes the Follow-Up Nurses of the Veterans’ Bureau, which includes 265 graduate nurses, distributed throughout the various districts, and acting in the capacity of Follow-Up Nurses under the direction of the Medical Officers, performing duties in accordance with regulations as outlined in Field Order #18, _Exhibit C_.

During the past month the Follow-up Nurses performed the duties as shown in _Exhibit D_.

Upon the division of the so-called Training Centers, as outlined, the number of teachers and the number of trainees which were strictly in hospitals were reduced, so that the Report for December, 1921, shows a summary, as given in _Exhibit E_.

The greatest difficulties in the way of proper establishment of physical reconstruction have been, First, Adequate space for hospitals. Up to the present time this has been considered an extraneous service and it has only been possible to secure suitable quarters in a relatively small number of hospitals; but upon the approval of the Federal Board of Hospitalization and the Director of the Veterans’ Bureau, it now becomes an integral part of the hospital program, and little difficulty should be experienced in the future. Second, It has also been difficult to secure proper personnel, particularly for Occupational Therapy for mental cases, and in order to have this work efficiently done it is my opinion that school of training should be established at St. Elizabeth’s Hospital, whereby a sufficient number of Occupational Aides, who have had experience with other types of patients, may have the opportunity to receive special training in handling mental cases. When you remember that in the Army there were only 48 special officers in Physiotherapy and that we now have 100 hospitals, and most of these would need a special officer for this work and are contemplating establishing a number of clinics in each district, it is absolutely necessary to make some provision for training medical officers in Physiotherapy.

We have had authority for some months to employ 100 Physiotherapy Aides and have utilized every aide that has been made available by Civil service, and have but 7. If we are to meet the requirements in Physiotherapy it will be necessary to establish a training center for Physiotherapy Aides, and it is suggested that the facilities for this work at Walter Reed Hospital and the various Bureau Clinics, and the Hydrotherapy department at St. Elizabeth’s be utilized for the training, and that a regular program be utilized and course of study provided to meet the requirements of this service.

Another one of the difficulties that is not only applicable to hospitals, but to all centers of Vocational Training, is the method of disposing of fabricated articles. The amount of paper work necessary incident to this and the fact that the money does not revert to the service but to the general treasury makes it a very unsatisfactory and cumbersome procedure, and some legislative should be asked for to enable the Veterans’ Bureau to proceed as the Indian Service proceeds in disposing of fabricated articles, or articles that are the result of the work of the trainees. Under the new procedure all personnel of the veterans’ Bureau detailed to a hospital are directly under the Medical Officer in Charge. The special work is directed by the Educational Director, who should be considered as one of the staff of the hospital. The greatest criticism that has been partially sustained in regard to Occupational Therapy has been that men who are physically able to do more purposeful things have been kept making trivial things, First, because it was relatively easy to amuse them, Second, Because of some of the articles the patient has derived considerable revenue from the sale thereof. The whole scheme should have in mind, First, The Therapeutic value of the activity, Second, The Prevocational Training of the activity, with the hope that you could shorten the time of hospitalisation and also shorten the time of Vocational Training by the amount of Prevocational work done in a hospital.

Prior to the work in Army Hospitals much individual work had been in Physiotherapy and Occupational Therapy, but this was not correlated. One man emphasized the static machine, another man built up his institution upon the basis of Hydrotherapy, another upon the physical exercise, but it remains for the work in the Army Hospitals to coordinate these agencies and present a solid front for Physiotherapy. One of the things that remains yet to be accomplished is a proper coordination between Physiotherapy and Occupational Therapy. It is waste of energy and money to have a Physiotherapy Aide spending hours of time in massaging a stiffened joint when, if her work could be supplemented by properly directed physical exercise in a shop or upon the farm, the same member could be so used as to assist in restoration quite as readily as from massage. It is expressly understood that all the work in Occupational Therapy should be upon prescription of the Medical Officer in Charge of the Hospital or his designated agent, and a proper cooperation between the Medical staff and the staff of the Reconstruction Section will insure most satisfactory results, and that this cooperation of the work will be very necessary in order to secure proper efficiency.

In the General Order referred to the ratio of teachers to patients per teacher must be considered as a general guide only, as it is quite well known that in mental hospitals the number of men that can be cared for by a single aide or teacher will be less than in other hospitals, and it must also be understood that the character of treatment in Physiotherapy will also modify the number of treatments that may be given by each individual.

I am particularly grateful for this opportunity to present the matter of Physical Reconstruction to the men who are caring for the disabled veterans, and who can do so much to make this phase of the hospital program a success.

EXHIBIT A

November 17, 1921.

Assistant Director, Medical Division, The Director, U. S. Veterans’ Bureau. Physical Reconstruction Section.

1. Modern hospital treatment requires that Physical Reconstruction be established as a part of the hospital program. It is our duty under the Sweet Bill to render this service to the beneficiaries of the Bureau while in hospitals and in dispensaries. Such service includes.

(a) Occupational therapy and Pre-Vocational Training.

(b) Physiotherapy, which comprehends directed physical exercise,
Mechanotherapy, Massage, Electrotherapy, Hydrotherapy, etc.

(c) Follow-Up Nursing.

_OCCUPATIONAL THERAPY AND PRE-VOCATIONAL TRAINING_

In order to carry out the work in hospitals of Occupational
Therapy and pre-vocational training it is necessary to have

(a) Personnel.
(b) Equipment.
(c) Expendable material.
(d) Suitable space for work.

(a) It is estimated that it will require 50 additional trade and
industrial teachers, 50 additional commercial or academic
teachers, and 100 occupational aides, making a total of 200,
salaries ranging from $1600 to $2400.

(b) As the new hospitals opened will be receiving men from
smaller hospitals, the equipment that has been used in the small
hospitals may be transferred to the larger ones. It is not
possible to make an accurate estimate as to what additional
material may be needed, as we do not know how much of this can
be secured from other branches of the Government, but in
hospitals numbering less than 200 patients the amount to be
expended for equipment would be relatively small. In the new
hospitals, however, numbering over 200 patients, where
pre-vocational training is desired, a reasonable equipment would
have to be furnished.

(c) As to expendable materials for Occupational Therapy the past
experience has shown that it will amount to $2.00 per month per
man actually at work, and possibly 25 per cent of the entire
hospital population will be doing some work of this character.

I would recommend the approval of the plan in operation in the
Public Health Hospitals for disposing of salable materials made
in Occupational Therapy or trade work, which is that the patient
may make two articles, giving one to the Government to be sold,
and the other retained by himself. The price for which the
articles to be sold should be established by a Board of
Appraisal, appointed by the Medical Officer in Charge, or
Superintendent, the proceeds to be used as a revolving fund for
purchasing supplies for this work, if it is legal—if not, the
proceeds to revert to the Treasury of the United States.

_PHYSIOTHERAPY_

The personnel for this work has been previously authorized to
the extent of 100 physiotherapy aides and 10 Medical Officers in
Physiotherapy. It will be necessary, of course, to have suitable
equipment. This will be recommended by the District Managers and
approved by the Medical Division before a requisition is filled.

There is a small expense for expendable material in
Physiotherapy, which will not amount to more than 50¢ per month
per man for treatments.

_FOLLOW-UP NURSING_

The plan for Follow-Up Nursing has been approved and 300 nurses
have been authorized. These are practically all assigned, and we
are requesting authority for an additional 50 as they may be
needed.

_NATIONAL SOLDIERS’ HOMES_

It is the desire of the Board of Governors of the National
Soldiers’ Homes that the personnel and equipment for the
reconstruction work, including Occupational Therapy,
pre-vocational training, and Physio-Therapy, be furnished by
this Bureau.

_NAVY_

It is desired that the personnel, equipment, and material for
reconstruction service, covering all phases of the work, be
furnished to the Naval Hospitals and detailed there to work
under the direction of the Medical Officer in command.

_ARMY_

It is the desire of the Army Hospitals serving the Veterans’
Bureau patients that they be permitted to operate the entire
reconstruction program for these men, and to submit monthly
statements prorating to the Bureau its proportional part of the
expense incurred in serving the patients, the entire personnel,
supplies, and equipment for these hospitals to be furnished by
the Army, and compensated on the pro rata basis.

_CONTRACT HOSPITALS STATE AND COUNTY INSTITUTIONS_

The Bureau has been furnishing all personnel and equipment for
the work in these hospitals, and this work should be established
in the hospitals where there are 50 or more War Risk patients,
and continued in the smaller hospitals where it is now
established until the number available for this work is reduced
to 20. In all contract hospitals where contracts are to be made
in the future suitable supplies should be required of the
hospital for this work as a part of the minimum standard for
hospital requirements.

_PUBLIC HEALTH HOSPITALS_

Formerly the Public Health Service furnished all personnel and
equipment utilized in Physiotherapy. The personnel utilized in
Occupational Therapy was also furnished by the Public Health
Service but the workers engaged in Pre-Vocational Training were
furnished by the Federal Board.

In view of the consolidation of all three agencies for the care
of the World War Veterans in the U. S. Veterans’ Bureau, the
following relation is recommended between the Public Health
Service and the U. S. Veterans’ Bureau. Physiotherapy Aides, and
Reconstruction Aides used in Occupational Therapy, will be
furnished by the Public Health Service and will be paid by them
from appropriations made from time to time by this Bureau. The
workers and teachers utilized in Pre-Vocational Training in
Public Health Hospitals will be furnished and paid by the U. S.
Veterans’ Bureau. The Aides will work directly under the medical
officers in direct contact with the patient under the general
supervision of the Medical Officer in Charge of the hospital.
The teachers and workers in Pre-Vocational Training will operate
directly under the Educational Director of the hospital, who in
turn will be directly responsible to the Commanding Officer or
Medical Officer in Charge of the Hospital.

_SUPPLIES_

Supplies and equipment for the work in Physiotherapy and
Occupational Therapy and Pre-Vocational Training will be
furnished by the Public Health Service or upon request of the
Public Health Service by the U. S. Veterans’ Bureau.

_SUITABLE SPACE FOR WORK_

It is necessary, in order to carry on the work in Occupational
Therapy and pre-vocational training to have well lighted space,
properly ventilated and heated, suitable situated, and
approximately, ten per cent of the bed space in a hospital.
This, however, does not have to be in a ward, but may be
provided in a separate building.

3. The general outline of the policy is that to serve the men in Occupational Therapy and pro-vocational training it will require one teacher for every 20 men at work, or for every 40 men in a hospital, exclusive of the administrative force, as it is estimated that only 50 per cent will be available for this work. Experience has taught us that, where there are 50 beds there will be 20 or more men available for this work, and that in such small groups trade work should not be undertaken, but in hospitals of 200 beds or more the work should be organized on the following lines—Occupational Therapy for ward work and pre-vocational training, to include academic, commercial, agricultural and trade work, as the survey of the hospital indicates and as the Medical Officer in charge may approve.

4. In organizing the work in new hospitals a survey of the needs and facilities shall be made to the Medical Division for approval before the work is established. When the hospital population has been so reduced in any unit that it is deemed impracticable by the Medical Division to continue this work, it may be closed at their direction.

5. It will be necessary to have specially qualified and experienced individuals in Central Office to be detailed to the Inspection Section from the Reconstruction Section to make inspections of the work in the hospitals, and approval for travel authorization and expenses incurred by this personnel is requested.

Robt. U. Patterson,
Assistant Director,
Medical Division.

Approved: _C. R. Forbes_
Director.

EXHIBIT B

U.S. VETERANS’ BUREAU January 18, 1922.

_GENERAL ORDER NO. 68_

Subject: ORGANIZATION AND ADMINISTRATION OF THE SECTION OF PHYSICAL
RECONSTRUCTION, MEDICAL DIVISION, U.S. VETERANS’ BUREAU.

The following General Order is hereby promulgated, effective this date, for observance by all officials and employees of the U.S. Veterans’ Bureau.

1. The Section of Physical Reconstruction is under the Medical Division, and includes Occupational Therapy, Pre-Vocational Training, and Physiotherapy in hospitals and dispensaries, and Follow-Up Nursing outside of hospitals.

2. The internal management of hospitals of the Army, Navy, Public Health, National Soldiers’ Homes, St. Elizabeth’s Hospital, and Contract Hospitals falls under the jurisdiction of the several services mentioned, or in private and State institutions under the superintendent.

3. Occupational Therapy, Pre-Vocational Training, and Physiotherapy are a part of the hospital care and treatment, and fall under the management of the Medical Officer in charge of each institution, and do not come under the jurisdiction of the District manager or the District Medical Officer.

4. Institutions formerly known as Training Centers have been divided into two groups:

(a) All centers called Vocational Schools are under the
Rehabilitation Division.

(b) All centers in hospitals will be called Reconstruction Centers
and are under the Medical Division.

_ARMY_

In all Army Hospitals serving the U.S. Veterans’ Bureau beneficiaries reconstruction work will be established, and personnel, equipment, and expendable materials for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished through the Surgeon General of the Army and paid for by the U.S. Veterans’ Bureau on a pro rata basis for such service to its beneficiaries.

_NAVY_

In all Naval Hospitals serving U.S. Veterans’ Bureau Beneficiaries Physical Reconstruction will be established and the personnel, equipment, and supplies for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by the U.S. Veterans’ Bureau for its beneficiaries in such hospitals.

_PUBLIC HEALTH SERVICE HOSPITALS_

The Occupational Aides and Physiotherapy Aides in Public Health Service Hospitals will be furnished by that service. The teachers in Pre-Vocational Training will be furnished by the Veterans’ Bureau. The Physiotherapy Aides will be directly under the Medical Officer in Charge of Physiotherapy, or, if no such officer is assigned, under the ward surgeons. The Occupational Aides will work directly under the Reconstruction Officer, if there is one assigned; if not, under the ward surgeons. Teachers and workers in Pre-Vocational Training will be directly under the Educational Director. The entire personnel of the hospital will be under the direction of the Medical Officer in Charge.

Supplies and equipment for Occupational Therapy and Physiotherapy will be furnished by the Public Health Service. Supplies and equipment for Pre-Vocational Training will be furnished direct by the Veterans’ Bureau.

_NATIONAL SOLDIERS’ HOMES_

In all National Soldiers’ Homes Reconstruction service will be established, and personnel, equipment, and supplies for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by the U.S. Veterans’ Bureau. The Aides in Physiotherapy are to work under the direction of the Medical Officer (Physiotherapist) assigned, or, if there is not such an officer, directly under the ward surgeons. The Occupational Aides and teachers in Pre-Vocational Training will be under the direction of the Educational Director. The personnel detailed to the Homes are under the direction of the Medical Officer in Charge.

_ST. ELIZABETH’S HOSPITAL_

Physical Reconstruction has been established as a part of the work in St. Elizabeth’s Hospital. The personnel, equipment, and supplies for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by the U. S. Veterans’ Bureau. The Physiotherapy Aides will be under the direct supervision of the Medical Officer assigned to the Physiotherapy Section, or, if no such officer is assigned, under the Medical Officers in charge of the patients being treated. The Occupational Aides and teachers in Pre-Vocational Training will be directly under the Educational Director. All personnel will be under the general direction of the Medical Officer in Charge.

_CONTRACT HOSPITALS_

In all Contract Hospitals, where the number of beneficiaries justifies, the Reconstruction Service will be established. All Personnel and equipment will be furnished by the U. S. Veterans’ Bureau. The Occupational Aides and teachers in Pre-Vocational Training will be directly under the Educational director. Physiotherapy Aides will be directly under the ward surgeons. The personnel assigned will be under the general direction of the Medical Officer in Charge.

_PROPERTY ACCOUNTABILITY_

The Educational Director in a center at a hospital will designate an employee under his jurisdiction as a Property Custodian, which Property Custodian will make the same semi-annual reports to Central Office as are required of District Property Custodians by General Order #52.

The accounting for physiotherapy supplies and equipment will be in accordance with General Order No. 52.

_SUPPLIES_

Supplies and equipment for Physical Reconstruction in hospitals other than Army and Public Health Service will be requisitioned from Central Office. Requisitions must be prepared in accordance with Field Order No. 43.

_SECURING PERSONNEL_

The personnel in the Reconstruction service is obtained through Central Office from Civil Service register. When the Educational Director at a hospital desires additional personnel he will make request through the commanding officer of the hospital to Central Office direct, stating the qualifications of individual required. Central Office will then make the most advantageous assignment possible and order the individual to report for duty at the designated station. In securing personnel for dispensaries and for follow-up nursing, the request will come from the officer in charge through the District Medical Officer and District Manager to Central Office, stating the qualifications of individual required. The Reconstruction Section will secure the name or names of individuals and request the District Medical Service Section to secure the appointment of the same through Personnel Division, and notify the District Office of the date the same shall go on their payroll and the amount of salary they shall receive. All personnel in the Reconstruction service, except the Occupational Aides and Physiotherapy Aides in Public Health Hospitals and Army Hospitals, will be on Central Office payroll. This will include teachers and occupational aides.

_TRANSFERS_

Transfers of personnel in hospitals will be made by Central Office upon the recommendation of the Commanding Officer and the Educational Director. Transfers of personnel on the District Office payroll in dispensaries and the follow-up nurses may be made within the District by the District Manager. If it is an interdistrict transfer, the same must be made by Central Office. All surplus personnel, either in hospitals, National Soldiers’ Homes, or in District Office, or in Sub-District Office, should be reported promptly to Central Office.

_COMMUNICATIONS_

All communications from Central Office to personnel in a hospital will be routed through the Medical Officer in Charge of hospital. All communications from personnel in a hospital will be sent through the Commanding Officer to proper destination. All communications to personnel in Reconstruction Section outside of hospitals will be sent through the District Manager to its destination. All communications from personnel outside of hospitals within a District shall be sent through the District Manager to its destination.

_SUPERVISION OF OCCUPATIONAL THERAPY AND PRE-VOCATIONAL TRAINING_

There shall be a sufficient number of supervisors of Occupational Therapy and Pre-Vocational Training employed and placed on Central Office payroll to properly supervise the work in all districts. Their duties shall be to supervise the work under the direction of Central Office, to keep Central Office fully advised as to the condition of the work and the needs of each reconstruction center they visit, and to recommend any changes in personnel, giving reasons for recommendations.

_PHYSIOTHERAPY_

There shall be a medical officer skilled in Physiotherapy designated as Chief of Physiotherapy for each district. He may be a part-time or a full-time man, as the necessity requires. His duty shall be to supervise and direct the installation of the equipment in the District and Sub-District Offices, and, upon request from Central Office, to visit and report upon the work in any hospital in his district. His line of communication will be through the District Medical Officer and the District Manager to Central Office; and Central Office’s line of communication will be to the District Manager—Attention, Chief of Physiotherapy.

_FOLLOW-UP NURSING_

Field Order No. 18 covers the entire matter of Follow-Up Nursing.

C. R. Forbes.
Director, U. S. Veterans’ Bureau.
]

EXHIBIT C

File No.

U.S. VETERANS’ BUREAU October 19, 1921.

_FIELD ORDER NO. 18_

Subject: STATUS AND DUTIES OF NURSES WORKING IN THE PHYSICAL
RECONSTRUCTION SECTION OF THE MEDICAL DIVISION, U. S.
VETERANS’ BUREAU.

The following Field Order is hereby promulgated, effective this date, for observance by all officers and employees in the District Offices of the United States Veterans’ Bureau:

1. Appointment of Nurses.

All appointments will be made by the U. S. Veterans’ Bureau on the recommendation of the District Medical Officer with the approval of the District Manager under the regulations of the U. S. Civil Service Commission. Preference will be given to nurses who have had at least three years’ general nursing experience outside of an institution, particularly to those who have had experience in tuberculosis, neuropsychiatric and Public Health Welfare nursing.

2. Administration.

Nurses on duty in the districts will be carried on the District pay-rolls and will be responsible to the Chief Nurse of the District, who in turn will be responsible to the District Medical Officer under the District Manager. The work of all nurses in the various districts not on duty in hospitals will be directly supervised by the District Medical Officer who will be responsible through the District manager to the Medical Division; U. S. Veterans’ Bureau (Physical Reconstruction Section), to whom communications on matters in connection with their work should be addressed.

3. Chief Nurse.

In each district a Chief Nurse will be appointed by the Central Office of the U. S. Veterans’ Bureau through the Assistant Director in Charge of Medical Division upon the recommendation of the District Medical Officer and with the approval of the District Manager. The duties of the Chief Nurses in the districts will be to superintend the activities of the nurses in their respective districts, to visit the local offices when directed by the District Medical Officer, to inspect the work of the nurses, to co-ordinate the work of the nurses in the districts, sub-districts, and local offices and to check up the nurses’ reports. It will also be the duty of each Chief Nurse, through the District Medical Officer and the District Manager, to keep the Superintendent of Nurses in the Physical Reconstruction Section of the Medical Division, U. S. Veterans’ Bureau, informed of the quality of the work performed by the individual nurses under her direction. Reports of especially good work, or unsatisfactory work, should be sent in detail to the Superintendent of Nurses through the District Medical Officer and the District Manager. The Chief Nurse in each district will instruct nurses under her charge as to the proper form for conducting correspondence and of the channels through which the same will be sent.

4. Duties of Nurses.

_General Duties._

(a) To assist Medical Officers of the Districts, whenever there is one at their station, in the care of beneficiaries who may require medical supervision and care.

(b) To keep contact with claimants and refer possible claimants to the proper authorities for the adjustment of their needs.

(c) To conduct medical follow-up work under the immediate direction of the local or sub-district authority where there is no medical officer on duty.

(d) At station where there is a social service worker to refer proper cases to them. If no co-operating social service agency is available the nurses will perform such social service duties as time will permit in addition to their regular duties.

(e) Whenever the address of a beneficiary is found to be incorrect, nurses will report correct addresses to the nearest Bureau Office immediately.

(f) Nurses, when visiting claimants, will give their residence address for emergency calls to each claimant under their care and supervision.

_Special Duties._

These may be grouped under three heads:

1. For Tuberculosis Claimants:

(a) Ascertain state of health from time to time. Record pulse, temperature, etc., to detect evidence of tuberculous toxemia. Note gain or loss of weight; presence of cough. Amount and character of sputum, etc.

(b) Ascertain their state of morale and that of their families.

(c) Give simple instructions regarding health and appropriate advice from time to time.

(d) Furnish literature of appropriate character when same is available.

(e) Emphasize the value of hospital care for those who become sick from other causes or whose pulmonary condition becomes active.

(f) Report promptly to the nearest medical officer beneficiaries whose condition seems to indicate that hospitalization is necessary.

2. For Neuro-Psychiatric Claimants:

(a) Health instruction and definite advice with regard to home conditions.

(b) Advice and supervision to prevent intemperance, excessive use of tobacco, drugs, etc.

(c) Advice regarding habits, whether married or single.

(d) Note general behavior and mental state, such as stream of talk, mental activity, characteristics of same, such as incoherence, inattention, distractibility, etc.

(e) Note mood of beneficiaries, such as preoccupations, hallucinations, illusions, etc.

(f) Endeavor to obtain insight as to how much the patient realizes the nature of his present condition or of previous illnesses.

(g) Interpret claimant’s condition to his family and instruct them in the necessity for tolerance of claimant’s peculiarities.

3. For Claimants with General Disabilities.

(a) Make visits to beneficiaries pending hospitalisation, or after being discharged from hospital, while in training, particularly those said to be absent from training on account of illness, reporting results of investigations to the local medical officer. If an emergency arises the claimant should be sent immediately to a designated physician, if too ill to report to a physician, a physician in the employ of the Bureau will be notified of the name and address of the patient and requested call. A report on each case will be made to the nearest local office, together with recommendations and a statement of any action that has been taken. If Claimant’s absence from training was not due to illness that fact will be communicated to the local Bureau authority.

(b) Report on every case assigned to her and render subsequent reports on such cases as may be required from time to time; to make supplemental reports from time to time as may be necessary. Such reports will be made on Medical E, or other designated form, and will have for their object the discovery of present results of service disabilities, intercurrent ailments, or physical conditions which are preventing the physical rehabilitation of the man. The attention of the District or local medical officer will be called to any seemingly improper conditions, and recommendations will be made looking to their correction. Subsequent reports will show whether or not these conditions have been remedied. For the purpose of reducing the number of visits that are required the claimant will be induced to call at the office if practicable.

(c) When calling at the home of a patient the nurse will notice the sanitary conditions of the home, particular attention being given to plumbing, adequacy of rooms, air space per capita, light, heat, bathing facilities, number of flights of stairs necessary to reach quarters, etc. Information as to how long claimant has lived there and if he has made frequent changes of residence. Recommendations will be made for improvement of conditions which appear to be prejudicial to the health of the men and his _family_ and an earnest endeavor will be made to have them corrected. In case the _family_ of a beneficiary needs medical treatment or other attention the social worker or in her absence the Red Cross or other Co-operating agency will be notified.

(d) Reports on Medical G, or other designated form, will be made on cases that break down in training, indicating when possible the cause of the interruption of training, whether the same is actually due to a reactivation of the original disability, to an intercurrent condition, or to extrinsic causes connected with training, work, or living conditions. Medical Form G, or other designated form, will be forwarded through proper channels to the District Medical Officer or his nearest representative.

(e) To visit at stated intervals all cases in localities in which there are not county nurses, and to endeavor to obtain contact occasionally with county nurses, where such are on duty, with a view of keeping them informed of conditions for the best interest of the ex-service man.

(f) Field notes on all of the above duties will be conveniently kept on Assignment Memorandum Form 701, or other form that may be designated hereafter.

5. It is not the function of the nurses to supervise Vocational Training. She is not to intimate to the beneficiary any doubt as to whether he is assigned to the proper course, or whether institutional or job training is best suited to his needs, but any suggestions she can give to the Training Officer in regard to the man’s attitude towards his training, will be helpful in his rehabilitation. Nurses will not call men away from their work for the purpose of interviewing them, unless by special arrangement, suggested by the Training Officer.

6. In territory where a nurse and a Social Service worker are both on duty, the nurse is not to attempt to investigate social conditions or make recommendations for rectifying them, if unsatisfactory conditions are found. _Per contra_ the Social Service worker is not to assume the work of the nurse in investigating conditions affecting the health of the beneficiaries. Emergency cases will arise where it will be obviously advantageous to the interests of the beneficiaries for whether a nurse or a Social Service worker to take immediate action on a matter not strictly within her province, but when this has to be done the other should be at once notified of the circumstances.

7. Nurses will not be expected to assist in special nursing except in training centers, or in temporary emergencies when it is impossible to hospitalize claimants, or where there is no person available to give instruction in home nursing.

C. R. FORBES,
Director, U. S. Veterans’ Bureau.

EXHIBIT D

NURSES’ CONSOLIDATED REPORT
for
NOVEMBER, 1921.

_SUMMARY_

Superintendent of Nurses 1 Neuropsychiatric Chief Nurse 1 Chief Nurses 14 Follow-up Nurses 246 TOTAL NUMBER NURSES ON DUTY ——— November 30,—1921— 262

───────────────────────────────────────────────────────────────────────

No. Cases treated at Dispensaries & Relief 610 Stat’ns No. Visited at Homes 6907 No. Needing Medical Care 12938 No. Medical E’s made out 15279 No. Medical O’s made out 339 No. Needing Social Adjustment 1316 —————— TOTAL MEDICAL ACTIVITIES 37,389

No. Neuropsychiatric Cases under supervision 7,329

Total No. Interviews—(Home, Placement) 45,487
(School, Office)

No. Appointments approved during November, 1921 27

No. Reported for duty (Oaths rec’d Central Office 20
to date)

No. Resignations submitted 5

No. Declinations Appointment 1

TOTAL NO. CLAIMANTS UNDER SUPERVISION
NOVEMBER 30, 1921— 63,397

(MRS.) K. C. HOUGH,
SUPERINTENDENT OF NURSES.

EXHIBIT E

RECONSTRUCTION TRAINING

SUMMARY BY DISTRICTS

January 1, 1922.

───────────────────────────────────────────────────────────────────────
Assigned Enrolled Percentage
Dist. Number of Number War Risk to in of Avail.
Institutions of Staff Patients Classes Classes Patients
Enrolled
───────────────────────────────────────────────────────────────────────
1 7 30 1443 652 429 66

2 11 50 2282 926 782 84

3 7 16 819 344 257 75

4 9 61 2538 1228 846 68

5 8 66 3846 2053 1394 68

6 4 18 1185 563 452 80

7 19 49 2309 916 753 82

8 15 52 1631 914 711 78

9 5 12 303 260 239 92

10 11 33 1432 707 521 74

11 2 19 1577 617 341 35

12 15 55 2646 1117 725 65

13 3 9 649 172 138 81

14 1 13 942 442 300 70
───────────────────────────────────────────────────────────────────────
Grand 117 483 23602 10911 7888 72
Total:

ADMIRAL STITT: reminded the men that at the meeting yesterday afternoon a motion was made to discuss the paper on the “The Social Service Worker” this morning, and there were about 25 minutes for the discussion of each of the four subjects—the social service worker, disciplinary regulations, relation of district managers, and physiotherapy and occupational therapy in hospitals.

CAPT. BLACKWOOD: said it was his opinion that the social service worker has done more to aid the Commanding Officer and to follow up the work on the ex-service man, as well as the service man, than anything else he knew of that has been introduced into the hospitals. The social service work in the Navy is all done by the Red Cross, one of the most wonderful organizations in the United States for doing good.

SURGEON CHRONQUEST emphasized the point that diversion and recreation should be distinguished from the social service, with which it is so often linked.

SURGEON LASCHE: stated that at first he was sceptical about the introduction of people under extraneous control into the hospital, but that he incorporated the Red Cross into the official organization of the hospital and made the director a member of the staff. He believed in keeping a fairly close supervision over the activities until he knew the individual, and made a rule that the social worker should send a carbon of every letter written about the patients to the officer in charge. It was found that at the beginning there was no possible reason for about 30% of the letters written, but only one-half of one percent of the letters produced harmful results. He said he was inclined to think that owing to the fact that the Red Cross has the benefit of a nation-wide organization that for the present it is very much better to utilize their services than to establish government employees to do the same work.

COL. BRATTON: said that experience had shown him that the Red Cross is a great aid in carrying on relation to the outside world. He told of the situation in Atlanta. When the hospital was established he found it would be necessary to satisfy the people of Atlanta that the wounded boys were being properly taken care of, and was fortunate to secure the services of a first-class man from the Red Cross. The result was that the people became very interested in the work and sent committees with food, also provided pictures two or three times a week and all kinds of entertainment.

SURGEON PAYNE stated that one of the greatest difficulties he had experienced had been in sidetracking the people who, though kindly disposed, brought food and all kinds of entertainment which were injurious to the patients. He said he did not believe in any kind of athletics in a hospital, unless under the Physiotherapy Department, neither did he believe in dances in a hospital. He said people would bring in all kinds of food and the patients would eat it before going to mess, and then of course would complain of the hospital food furnished. The greatest benefit from the Red Cross had been the coordination of those activities.

COL. BRATTON asked that some of the men who served in General Hospital #6 speak on this subject.

SURGEON WILLHITE: stated he had served under Colonel Bratton, and agreed heartily with all he had said. He stated also that in his work in the hospital in Philadelphia the Red Cross had done the finest kind of social service work, coordinating all the agencies that Dr. Payne spoke of as so detrimental to him, and he believed had been a very great benefit rather than a hindrance.

Dr. Dedman took up the work of the Red Cross in taking care of relatives of patients who come to the hospital. Often these people spend all their money for railroad fare, and have none left when they reach the hospital, and the hospital has to take care of them. He said he had arranged that four or five rooms be fixed up for such people as this and believed some definite authority should be had from the Veterans’ Bureau to house these people and furnish their meals. He stated that some boys will ask for things and others will not. He referred to an instance in which a patient had told a lady that he needed a shirt, and two days later when she brought him one she gave it to him before the whole ward and the boy was ridiculed for a long time afterward. He had had trouble in getting the work done through the social welfare workers in the hospital, as the public wants the individual glory of handing something to the boys themselves. The Red Cross has also been a great aid in investigating home conditions of the patients, especially of tubercular patients who want to go home to die. Also, in the case of a man who asks for a long furlough because his mother or sister is dying, the Red Cross will investigate and get an immediate report, and many times it will be found that the mother or sister is not sick at all.

SURGEON PAYNE: stated that he did not want to be misunderstood, that he did not mean to take credit away from the Red Cross.