Fifth SessionThursday, January 19, 1922.

GEN. SAWYER: “I would like to ask if either of our committees are ready to report or whether they have any inquiries to make”. He asked Captain Blackwood for a report.

CAPT. BLACKWOOD reported that the Committee on Forms met yesterday noon and felt they had a task that was going to take months. As they had no copies of the forms in use two of the members of the committee were to get them by noon today.

GEN. SAWYER: urged that the matter be pushed in order that some little understanding at least might be had before the end of the meetings, that perhaps some suggestions could be made that could be carried out after the meetings adjourned. “I am requested to state for the Committee on Resolutions that there is no special report that they have to make now.” He introduced Admiral Stitt, to preside.

ADMIRAL STITT: “The first paper is “Discussion of Disciplinary Regulations of Veterans’ Bureau as they affect the beneficiaries and hospitals,” which someone will read for Colonel Patterson, who is still ill.”

MAJOR R. W. BLISS, U. S. Veterans’ Bureau, took up “Discussion of Disciplinary Regulations of Veterans’ Bureau as they affect the beneficiaries and hospitals”, as follows:

“In a discussion of U. S. Veterans’ Bureau General Orders 27, dated September 9, 1921 and 27–A dated January 14, 1922, covering the Disciplinary regulations governing beneficiaries of the Veterans’ Bureau who are patients in hospital, it is assumed that even before September 1921, all present recognized the advisability and necessity of some lawful method by which the small lawless element, often present in hospitals, as it is in any other community might be effectively dealt with.

It is further assumed that the provisions of the September General Order #27 are generally well known to this audience.

Therefore, this present paper will be limited to a brief statement of fact of the numbers of patients discharged under this order, and to a statement of the essential differences in the September G. O. #27 and the G. O. 27–A, issued yesterday, leaving any comment to the general discussion.

I have here a chart showing the name, location and type of every Government hospital receiving Veterans’ Bureau patients, and giving the total number of patients in each, and the total number of patients discharged from each one, under the provisions of General Order #27, between the dates of the issuance of this order, on September 9, 1921 and January 14, 1922.

This represents 67 Public Health Service Hospitals, 14 Naval Hospitals, 9 hospitals connected with the National Homes for Disabled Volunteer Soldiers, 6 Army hospitals and St. Elizabeths’ Hospital, under the Interior Department, a total of 97 Government hospitals.

The total number of patients, to which I shall refer hereafter, mean Veterans’ Bureau Patients.

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:

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 arepresentative 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 urgedresulting 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 inExhibit 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 inExhibit 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 inExhibit 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 inExhibit 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.

November 17, 1921.

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

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.

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) Personnel.

(b) Equipment.

(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 receivingmen 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.

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.

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

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.

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.

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.

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.

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 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.

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 shouldbe 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.

Robt. U. Patterson,

Assistant Director,

Medical Division.

Approved:C. R. ForbesDirector.

Approved:C. R. Forbes

Director.

EXHIBIT B

U.S. VETERANS’ BUREAUJanuary 18, 1922.

GENERAL ORDER NO.68

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:

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 theArmy and paid for by the U.S. Veterans’ Bureau on a pro rata basis for such service to its beneficiaries.

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.

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.

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.

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.

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 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 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.

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.

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