(6) Neurosurgery.

(7) Paraplegia.

(8) Thoracic surgery.

(9) Cardiovascular surgery.

(10) Tumors.

It has been our experience that in view of the general scarcity of specialists in these fields and the need for special facilities and equipment, the center plan has provided patients with a high quality of service which otherwise would not generally have been available to them. Furthermore, this assembling of patients with chronic disorders provides opportunity for research and the training of personnel. 7. Specially adapted physical facilities

In certain hospital sections of centers with a domiciliary role, where there is a comparatively high proportion of older aging patients with chronic diseases, specially adapted facilities are being planned. As stated before, in the domiciliaries the Veterans' Administration has already embarked on the rehabilitation of physical plants and equipment to provide a homelike, rather than the typical institutional, environment. In addition, many of the programs in our hospitals, such as those for the paraplegic patients, have specially adapted equipment to meet the specific needs of the respective category of patients.

Newly constructed predominantly psychiatric hospitals now include buildings designed especially for infirm patients. They contain 100 beds on 1 story at a ground-floor level with adjoining gardens and interiors designed to meet the medical, nursing, and social needs of the patients. Units presently being planned and constructed are in hospitals at Topeka, Kans.; Čleveland, Ohio; and Palo Alto, Calif.

Modernization of the physical plant at Veterans' Administration hospital, Downey, Ill., will contain a 300-bed infirmary building, selfcontained from the viewpoint of dining, recreational, and treatment facilities.

F. MAJOR DISEASES OF VETERANS BY AGE GROUPS

Of the 114,876 veterans hospitalized in Veterans' Administration hospitals on December 30, 1955, 15,392 were 65 years of age and over; 11,336 patients 45 to 56 years; 24,516 patients 35 to 44 years; 24,244 patients 25 to 34 years; 4,508 under 25 years of age. The following table shows the number of patients by major diagnostic category broken down into age groups. In the past 10 years, there has been a significant increase in the number of veterans with cancer, disease of the cardiovascular, muscular skeletal, digestive, and genitourinary systems.

The increasing age of veterans is the most important single factor accounting for the increase in the number of patients with these medical and surgical conditions.

G. WHAT THE VETERANS' ADMINISTRATION IS DOING IN THE FIELD OF OLDER VETERANS, INCLUDING EXPERIENCE, EXAMPLES, AND NAMES OF ANY VETERANS' FACILITIES DOING SPECIAL WORK IN THIS AREA

1. Expanded physical medicine and rehabilitation

(a) Physical medicine, up until 1946, both in civilian life and the Veterans Administration, was composed of a limited program of physical therapy and occupational therapy activities. To meet the need for the patient with chronic disabling conditions and the increasing age of our veteran population, the field of physical medicine was expanded to include rehabilitation with an augmented and dynamic program of physical therapy and occupational therapy, and the institution of three other essential components of rehabilitation, namely, corrective therapy, manual arts therapy, educational therapy, and special programs for blind and the hard of hearing. A description of the practice of these components in the Veterans' Administration in relation to the aging follows:

(b) Physical therapy has special values in the care of the aging particularly in relation to the relief of pain so commonly associated with the aging process. Physical therapy on medical prescription is concerned with the prevention of deformity, the treatment of disease, injury, and disability, and functional rehabilitation, by means of the use of therapeutic exercise, scientific massage, self-care activities, heat, cold, light, water, electricity (except roentgen rays, radium, and electrosurgery) and certain accredited methods of manual or electrical diagnostic and prognostic tests and measurements. In a broad sense, physical therapy may also be considered to include therapeutic teaching, as it is usually necessary to instruct aging patients, members, and their families in the use of prosthetic and orthopedic appliances, in therapeutic exercise, and in other home-treatment methods.

(c) Occupational therapy has particular significance in the treatment of aging patients and members. It involves treatment of those who have disease, disorder, or injury, by the professional use of therapeutic activities to carry out the medical prescription. Occupational therapy provides for aging patients and members, purposeful activities to promote their recovery when possible and to assist in restoring them to the fullest mental and physical capacities compatible with their abilities and disabilities. Treatment in occupational therapy is adjusted to the nature of their disease, illness, or impairment. This involves planning, developing, and administering the treatment in relation to the treatment objectives, the nature of the veteran's illness or impairment. Treatment objectives are usually classified under four major types. (See appendix B for a study of occupational therapy for geriatric patients in the Veterans' Administration hospital, Gulfport, Miss.)

(d) Corrective therapy contributes to the overall rehabilitation effort of the physically and mentally sick and handicapped aging veteran through application, for therapeutic purposes, of medically prescribed activity of an exercise and self-care nature. (For a discussion of the role of corrective therapy by the Chief of Corrective Therapy, Veterans' Administration, see appendix C.)

See appendix B for a description of the program of physical medicine and rehabilitation in the Veterans' Administration.

(e) Manual arts therapy aids in the treatment of aging patients through the professional use of actual and simulated work situations of an industrial and agricultural nature which have vocational significance, in order to observe patients in those situations and to report by means of progress notes to the prescribing physician concerning their treatment reactions in connection with planning and establishing medical rehabilitation goals for patients. For a discussion of the role of manual arts therapy programs in vocational educational and vocational guidance by the Chief of Manual Arts Therapy, Veterans' Administration, see appendix D.)

(f) Educational therapy provides an encouraging psychological factor of vocational significance to measure and develop mental and physical capacities associated with a rehabilitation goal, and to assist in restoring aging patients to the fullest mental and physical capacity compatible with their abilities and disabilities. (For a discussion of this program by the Chief of Educational Therapy, Veterans' Administration, see appendix E.)

(g) The objectives of the blind rehabilitation program are: (1) To detect in blind veterans early signs of pathological factors which militate against medical and vocational rehabilitation, and provide strong supportive aid in finding the causes of these tendencies and removing them whenever possible; (2) to reclaim those blinded individuals who underestimate their remaining potentialities and need to be shown they can still be relatively active members of the community outside the hospital; (3) to raise the level of physical activity and social participation in the life about them on the part of those blinded veterans whose age and personal histories indicate very little hope that they can leave the domiciliaries at any time. The average age of blind patients who are domiciliary members was 58.2 years. (For a discussion of this program by the Chief, Blind Rehabilitation, Veterans' Administration, see appendix F.)

(h) The function of audiology and speech correction is involved in the rehabilitation of patients having hearing or speech disorders, or both, by providing one or more of the following areas of service: testing of hearing acuity, interpreting results of hearing examinations in terms of audiometric measurements, evaluating electronic hearing aids in terms of patients' increased hearing acuity, and selecting the fitting hearing aids; auditory training-training in the utilization of hearing aids; speech reading (lip reading)—training in the comprehension of speech through observation of accompanying facial and other bodily movements; speech correction and conservationtraining patients with speech defects resulting from hearing disorders and from articulatory and phonatory ailments, in speech correction, conserving or helping them regain intelligible speech.

(i) Medical rehabilitation boards: Early in 1946, it became evident that there must be an integrated team approach by the various hospital services concerned with the various phases of rehabilitation, to the problems presented by patients whose disabilities posed formidable obstacles in terms of in-hospital and anticipated post-hospital adjustment. Through joint effort in collaboration with the patient, this board endeavors to help him clarify his own objectives, become aware of his own potentialities, and uses every available hospital service to achieve the best medical, social, emotional, and vocational rehabilita

tion plan for the individual patient. The method followed is group consideration of the patient as a person in relation to his total health and rehabilitation problem, involving joint planning on the part of individual members of the board for a consistent, interrelated, integrated service. Types of patients with problems referred to the board are:

(1) Those with chronic, severely disabling conditions, as a consequence of which rehabilitation is expected to be a long, difficult process, requiring extended hospital treatment.

(2) Those for whom normal staff relationships have not resulted in the establishment of satisfactory rehabilitation treatment objectives because of the complicated nature of the problem. (3) Patients who appear to be making uncertain progress toward established rehabilitation goals.

(4) Those who present problems that are obstacles to in-hospital and post-hospital progress in line with their potential capacities. (j) Physical medicine and rehabilitation service beds: One of the first means of meeting the threat of an increasing proportion of longterm, chronic patients was assignment of beds or sections of beds to the physical medicine and rehabilitation service. This measure afforded the opportunity for intensive rehabilitation and preventive measures resulting in maximum restoration of function compatible with the disabilities which could not have been possible if the patients were scattered on the medical and surgical wards of the hospital and rehabilitation instituted on an itinerant basis. At the present time there are approximately 1,950 beds on the physical medicine and rehabilitation services in 54 Veterans' Administration hospitals.

A VA film entitled "Journey Back" shows the rehabilitation of some patients with the same sort of severe handicaps which many aging patients face.

(For an illustration of the physical medicine and rehabilitation program in relation to geriatrics, Los Angeles Center, see appendix G.)

2. Prosthetic and sensory aids

As veterans become older, the probability becomes greater that they will require some type of prosthetic or sensory aid if they are to continue near-normal existence. As the eyesight dims, eyeglasses are a necessity; hearing is often impaired, generally requiring the use of a hearing aid; circulatory problems become more acute, often necessitating amputation of an arm or leg and, where feasible, the substitution of an artificial limb; and the general infirmities of old age often require the use of a wheelchair, crutches, canes, and similar items.

Any or all of these prosthetic and sensory aids, and many other similar items, are furnished to aged veterans through the established prosthetic and sensory aids program of the Veterans' Administration. In order to be eligible for issuance of such items, of course, the veteran must either be service-connected for the disability requiring the appliance; the appliance must be required for completion of treatment of a condition for which he was hospitalized in Veterans' Ad

For a directive on the establishment of such boards see Veterans' Administration, Technical Bulletin (TB 10A-333) (Washington, D. C., May 21, 1953), 6 pages