of the infestation in accordance with the best medical practice with very definite improvement in some of the nervous cases. Some have been relieved entirely of their nervousness upon ridding them of these parasites.

Competent clinical laboratory facilities are quite necessary for complete and efficient study of these cases, and the bureau has maintained such assistance in each of its neuropsychiatric hospitals. Reports of these institutions show that these facilities have been utilized to the utmost and that they have proven their value in every instance. One of the smaller institutions of 176 beds reports an active clinic for the treatment of neurosyphilis in accordance with modern methods and accepted practices. The clinical director in commenting on the value of the laboratory service states: "Failure to have a lumbar puncture in such cases often clouds the diagnosis and prevents the institution of proper treatment." This physician cites his record of 621 such diagnostic and therapeutic punctures, and states: "There has never been any paralysis or seizures resulting in a single instance. A number of patients have had temporary headaches, a few vomited, and in one or two instances a slight rise in temperature has been noted." This record is indicative of the high type of work done in keeping with the best medical practices of the day, and which is available to Veterans' Bureau patients in even the smaller hospitals. X-ray services available in this type of institution have been of equal aid and have been made frequent use of.

While it is appreciated that the majority of insane beneficiaries will require hospital care for an indefinite number of years, the fact has not been lost sight of that remissions occur permitting patients to return to their communities from time to time, and in some instances even to resume their former activities in society. To this end every effort has been exerted to prevent and attempt to delay regression and ultimate deterioration in the insane. Occupational therapy has been an integral part of each institution. Cooperation and interest of the patient have been sought in various manual pursuits in which his interest can be aroused. Such diversions as basketry, weaving, leather work, toy making, gardening, chicken raising and bee culture, farming, etc., have been utilized. More and more effort along this line is constantly being made, and it has come to the notice of this department that benefit has even been derived in those cases already deteriorated. Instances in which spontaneous interest has been aroused have been followed by notable improvement in deportment, tidiness, and cooperation in patients whose intellectual level approaches the vegetative stage.

In addition to those procedures largely in the domain of occupational therapy, reports show that each and every institution has had the able assistance of the American Red Cross, the Knights of Columbus, and other organizations, in organizing and carrying out diversional entertainments for the benefit of the patient. What has been stated elsewhere of the value of diversional occupation in general applies with particular force to patients suffering from nervous and mental diseases.

Other well recognized aids in the treatment of these cases, as hydrotherapy, electrotherapy, and physiotherapy, have been made use of in selected cases as indicated.

In so far as practicable all bureau hospitals have had the advantages of local consulting specialists to whom problem cases have been presented. One institution reports 59 neurological operations of a highly technical nature performed during the year. These embrace operative procedures upon the thyroid, brain, peripheral nerves, and spinal cord. The value of this consulting service is twofold: It benefits the patient requiring it and the resident staff, who derive stimulation and counsel from these eminent specialists.

The hospital at Waukesha, Wis. (No. 37) for psychoneurotics, borderline types, and for purposes of diagnosis, has been maintained at a high standard as heretofore. This institution, in addition to those general features already referred to, is equipped with electrocardiographic apparatus for the investigation of obscure heart and circulatory diseases.

Reports from the neuropsychiatric hospitals indicate a fortunate minimum of serious epidemic diseases among either patients or personnel during the fiscal year ending June 30, 1924. This is gratifying when it is recalled that the insane in hospitals live in fairly close contact, and that there is frequently added to their number patients coming from the outside communities where infectious diseases are more or less in evidence at all times. One case of typhoid fever occurred at United States veterans' hospital No. 49, Philadelphia, Pa. The situation was promptly met by prophylactic inoculation, and no further cases occurred. A small epidemic of scarlet fever occurred at hospital No. 44, West Roxbury, Mass. This was brought into the institution by a patient who had been home on pass. Six other cases developed. Prompt measures prevented further spread, and all patients recovered without sequel.

It is generally recognized among those conversant with the care of the insane that by reason of their false beliefs and false sensory perceptions, ideas of suicide are frequently encountered, and not infrequently persisted in until carried out. The constant vigilance necessary to prevent it is often circumvented by the cunning and persistence of these unfortunates. It is therefore much to the credit of those having charge of this large number of bureau patients that reports covering the fiscal year show only one such regrettable occurrence, in a parole patient who exhibited every indication that he was well on the road to recovery.

Out-patient treatment and supervision of patients who have returned to the community have been instituted and extended during the past year. These clinics have been maintained in Veterans Bureau hospitals where they are sufficiently accessible to make this practicable, and at other points where not so practicable. They have proven of inestimable value, particularly those in association with hospitals. A check is maintained on the patient's adjustment in the community; sympathetic advice is given; symptoms of recurrences noted in their incipiency; and much valuable additional information in the case accumulated. Recognized as of great value to the patient, these clinics will serve to acquaint the bureau with all factors concerned in preventing its beneficiaries outside of hospitals from making an adequate social and economic adjustment. Recommendations and observations on the first 1,000 cases treated in the out-patient clinic of hospital No. 44, West Roxbury, Mass., justified the policy of further extending these activities.

It has been gratifying to note the kindly feeling exhibited and cooperation extended by the citizens of the communities in which these neuropsychiatric hospitals are situated. This has been particularly commented upon in the yearly reports from hospital No. 86, Sheridan, Wyo., and also at the time of the opening at hospital No.95, Northampton, Mass.

There have been transferred to Veterans' Bureau hospitals during the year from State and contract hospitals 912 patients suffering from neuropsychiatric diseases. The vast majority of these represent chronic institutional cases.

At the end of the fiscal year 1923 there were in contract hospitals, including State hospitals for the insane, 3,718 patients, which number has been reduced during this fiscal year to 2,785. The greater part of this reduction took place toward the end of the year, as new construction became available. During the fiscal year accommodations were completed for 1,055 psychotic (insane) patients and 255 psychoneurotic nervous) patients. There have also been completed 958 additional beds for insane patients which will be equipped for occupancy in a very short time. The facilities offered by the Department of the Interior, through St. Elizabeths Hospital, Washington, D. C., have been utilized as heretofore. Between 850 and 900 Veterans' Bureau cases have been maintained at this institution during the present year.

Besides facilities for caring for colored beneficiaries in neuropsychiatric hospitals already mentioned, the bureau had at the close of the fiscal year 187 colored insane claimants hospitalized in the psychopathic department of hospital No. 91, Tuskegee, Ala.

That some thought to the future needs is being given should be remembered by recalling that the bureau has under construction at the present time accommodations for 1,425 additional insane patients. A study of the situation at this time would seem to indicate that further expansion for the care of the mentally afflicted beneficiaries of this bureau will from time to time be necessary. Insanities in the ex-service men are the insanities of everyday life, in no way distinguishable from those suffered by nonservice members of the civil communities. The history of State insane hospitals has been one of steady growth; and inasmuch as beneficiaries entitled to treatment in the bureau's neuropsychiatric hospitals go back to ex-service men since the Spanish-American War, a steady increase in hospital beds for these cases will be necessary, in direct proportion to the normal ratio of insanity resulting from the stress and strain of their daily pursuits and the exigencies of modern civilization.

INSULAR ANd foreign SUBDIVISION

In consonance with the act of Congress approved December 24, 1919, the insular and foreign subdivision was organized in the early part of 1920 as a section of the medical division, primarily to care for those service men of countries allied with the United States in the World War who were residing in American territory, and who were entitled to such services. Authority for extension of the facilities of the United States Veterans' Bureau was in each instance obtained from the Government under whose flag the foreign applicant had served.

Pending the accomplishment of a reciprocal agreement between Canada and the United States, an understanding of good faith was established whereby service was exchanged until clearly defined rules and principles of procedure could be formulated and approved by the director of this bureau and the Minister of the Department of Soldiers' Civil Reestablishment, Ottawa, Canada. Through this provisional arrangement emergency, medical, surgical, hospital, and prosthetic service was furnished on authority in each case until in September, 1921, the definite reciprocal agreement referred to was approved by the two Governments, with certain extensions to include all men resident in this country who had served under the British flag. A surprisingly large number of Canadian ex-service men were Americans who enlisted in the Canadian forces prior to the declaration of war by this Government. This bureau's records show that over 45,000 such men crossed the line into Canada and joined up with the Canadian colors, the greater number of whom have since returned to their homes in the United States.

Medical examinations of allied ex-service men made by full time salaried medical officers of this bureau are without charge, unless X-ray or laboratory tests are furnished, and in such cases the actual expense for this added service is reimbursed by the Government concerned, provided prior authority for the service is obtained. A maintenance or hospital charge is made covering actual expenses incurred in each case.

While no formal reciprocal agreement is in effect with any other of the allied Governments, arrangements have been made between this bureau and the French, Belgian, and Italian Embassies; and the Czechoslovakian, Polish, Greek, and Serbian Legations, whereby, upon request, service will be extended to beneficiaries of these Governments on the basis of the actual expense. Reimbursement is made to the bureau by the Governments concerned, usually within 30 days after the presentation of the vouchers covering the service.

Immediately following the close of the World War it was found that many of the prospective bureau beneficiaries had either been discharged from the American military service abroad, or returned to their former homes in foreign countries. As time lengthened, the problem of taking care of these men, as provided for by the war risk insurance act and the amendatory acts thereto, became manifest, and efforts were made to extend the service in a proper way. The furnishing of various kinds of medical care and treatment, including hospitalization, to those who are entitled to this service and are resident in foreign countries, is one of the most far-reaching and beneficial activities of the bureau's numerous efforts to provide service. In no case is service furnished to a man in a foreign country except over the signature of the director.

In caring for beneficiaries in foreign countries, this bureau is largely dependent upon the good offices of the Department of State, largely through its Consular Service, to whom requests are made for medical examinations, and all necessary service which may be in order. Medical examinations made in foreign countries are conducted by physicians who are designated by the American consul located nearest the claimant. When available, medical officers of the United States Army, Navy, or Public Health Service are designated as examining physicians, and to whom no fee is payable. However, when such

physicians are not available, suitable medical personnel are selected by the consul, who pays a reasonable fee for the examination, which amount is reimbursed to the State Department by the bureau. In a similar manner other necessary services are furnished when such are in order.

When it is found necessary to expedite service in an emergency case the bureau resorts to the use of cable and radio. So close is the cooperation between the bureau and the Department of State that immediately upon receipt of a cable or radiogram from one of its representatives in a foreign country in which request is made for expedited action, the Department of State promptly advises this bureau by telephone, the message being subsequently confirmed by letter. It is of record that the return authority has been received for the service in a foreign country within the same day of its request. The Department of State has instructed its representatives abroad that when a United States ex-service man properly identifies himself as such, and applies for medical, surgical, or hospital service, it is to be furnished pending further instructions from the bureau, if it is the opinion of the medical officer making the examination that the claimant requires emergency treatment for what is believed to be a war disability.

At this time the bureau is caring for beneficiaries in about 100 different countries. In addition to United States ex-service men resident in foreign countries, there were drafted into the service from insular possessions approximately 45,000 persons. To take care of these claimants in insular possessions it was deemed advisable to establish subdistrict offices in the Philippine Islands with headquarters at Manila, in the Territory of Hawaii with headquarters at Honolulu, and in Porto Rico with headquarters at San Juan. The office in Porto Rico is under the immediate charge of a medical officer of the United States Public Health Service, to whom an allotment of funds is made. There is also a training officer attached to the office in Porto Rico. The insular and foreign subdivision acts as a district office in cooperation with these island subdistrict offices. Practically all accounts covering expenditures in connection with examinations, treatment, and hospitalization of bureau beneficiaries in foreign countries and in the insular possessions, whether authorized or unauthorized, are audited and prepared for settlement in this subdivision. The preparation of these accounts requires much detailed work and correspondence, the rates of exchange entering largely as a factor in the account. All investigations which are necessary regarding United States ex-service men and their dependents in foreign countries and in insular possessions are accomplished through this subdivision. Repatriation and deportation cases are also cared for in cooperation with the Departments of State and Labor. All training for beneficiaries in our insular possessions and in foreign countries falls under the supervision of this subdivision. The preliminary arrangements for training in the insular possessions are made in the subdistrict offices. The director of vocational training of the Department of Soldiers' Civil Reestablishment makes the necessary contact with bureau beneficiaries residing in Canada. Foreign training is granted only in special, meritorious cases, and then only by the approval of the director. While the foreign training cases have been few, the results have been encouraging, the reports show