Part 15

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in the original order which did not conform exactly to the wording of the Sweet Bill General Order #27 has been rescinded and General Order #27–A issued in its place.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_