trainees, were furnished appliances for service-connected disabilities, or as adjunct treatment for service-connected disabilities during the fiscal year.

Prosthetic appliances furnished by district offices and hospitals

Prosthetic appliances furnished by district offices and United States Veterans'

hospitals

PHYSIOTHERAPY AND OCCUPATIONAL THERAPY

During the fiscal year 1924 no marked changes have been made in the policies governing occupational therapy and physiotherapy. Rather, efforts have been bent toward the further standardization and coordination of these activities. To this end a small but carefully selected list of occupations has been approved for tuberculous patients; other lists have been approved for psychotics and psycho

neurotics.

For the tuberculosis hospitals the occupations range from those which are suitable for patients in the active stage of the disease to

those which are utilized to give indicated exercise to convalescent patients prior to discharge. The approved occupations for psychotics are largely manual, as it is considered that the study of academic and commercial subjects has a very limited application in the treatment of these patients. Out-of-door occupations of various degrees of complexity consistent with the mental condition of the patient are preferred.

The matter of utilizing waste and salvaged material has been emphasized, a special circular covering this subject having been issued in November. An increased amount of clinical data has been furnished to the field services.

Assembled examinations for the position of physiotherapy aid have been substituted for nonassembled. This makes it possible to determine more accurately the qualifications of applicants, and to make assignments more intelligently.

The expenditure for occupational therapy supplies and equipment has been kept at the minimum consistent with efficient service, and shows a reduction from the amount expended in 1923. The return to the Government from the sale of by-products made in the course of occupational therapy amounted to approximately $50,000 for the fiscal year 1924.

Prior to this year appointments to the position of aid have been confined to females, but it has seemed advisable no longer to exclude males from these positions. Many of the reconstruction assistants have qualified with the civil service for the position of aid, and have received appointments under this designation.

There was some reduction in personnel during the year, and the fact that the occupied hours and number of treatments have not shown a corresponding decrease bespeaks increased efficiency on the part of field employees.

Physio and occupational therapy personnel on duty June 30, 1924

Since

This compares with a grand total of 649 on June 30, 1923. the last report, however, the personnel on duty at St. Elizabeths Hospital, Washington, D. C., have been transferred to the pay roll of the Interior Department; therefore the net reduction in United States veterans' hospitals, contract hospitals, and dispensaries is 52.

The expense of physiotherapy in bureau hospitals and dispensaries based on the salaries of personnel and the cost of equipment and supplies, but not including rental and overhead, is approximately 20 cents per treatment, whereas under contract $1 to $3 per treatment is allowed.

Statistical reports for the last six months of the year (January to June, inclusive) are included in Tables 19 to 21 (see pp. 86 to 87).

NURSING

The work of the nursing section is carried on by one superintendent of nurses and one assistant superintendent. Its administration covers the nursing service both in the hospitals and the dispensaries of the bureau.

Nurses making application for duty with the bureau are required to be citizens of the United States, graduates of accredited schools of nursing, and duly registered. The diversity of the work requires the selection of specially trained personnel for duty in the dispensaries from which stations they work out to contact the beneficiaries in their homes. Nurses selected for this service, in addition to the requirements for hospital duty, are required to have had a four months' course in public health or visiting nursing, or, in lieu thereof, one to two years' experience in public health nursing under a nurse supervisor. The follow up work includes the preparation of patients for hospitalization or treatment and the observation of convalescents after discharge from hospital so that relapse may be prevented. During the past two years the nursing service of the bureau has become favorably known to nurses throughout the country. This has been brought about by the maintenance of high standards, which has also resulted in an increasing loyalty, efficiency, and stability in this group of professional women. Several papers have been prepared during the year and published, among them one prepared for the purpose of interesting the nurses throughout the country in the bureau's nursing service.

The superintendent of nurses has visited, for the purpose of supervising and reporting on the nursing service, district No. 8, and Edward Hines jr. Hospital, Maywood, Ill,. during the past year; and on the same tour of duty has represented the service at the convention of the American Nurses' Association in Detroit, Mich., June 16-21. At that convention there was an exhibit of the activities of the nursing service of the bureau, which attracted considerable attention. The superintendent of nurses, by virtue of her position in the United States Veterans' Bureau, was made a member of the executive committee of the American Nurses' Association. She is also a member of the national committee of the American Red Cross Nursing Service.

On November 5, 1923, the chief nurses from the bureau hospitals and the 14 district offices met in a five-day session with the medical director and the superintendent of nurses, at the central office, Washington. The problems of nursing administration in bureau. hospitals and the district offices were discussed, and many valuable suggestions made which have been put into practice.

During the year 439 nurses were separated from the service. This large number was brought about partially by the discontinuance

of the routine follow-up on trainees in all districts. It is felt that, although there has been no increase in the number of nurses on duty in the district medical service, much progress has been made in strengthening and improving the district service to beneficiaries. It is especially noticeable that nurses are making a greater effort to secure more adequate care for beneficiaries with service connected disabilities who are being cared for in their homes.

The following table is a tabulation of the activities of the nursing service in the 14 regional districts. This tabulation was made for a period of six months, since the present report has been in effect only since January 1, 1924.

Number of beneficiaries under supervision each month in the 14 districts

Total number home visits, 87,181. Dispensary treatments, 194,792. Interviews, 155,900.

The following is a tabulation of the total number of nurses on duty in the United States Veterans' Bureau nursing service, June 30, 1924:

The duties of the dietetic section comprise the general supervision of hospital mess administration, including the purchase of supplies, general equipment for kitchens and mess halls; review and criticism of hospital dietaries; authorization of cooked rations; appointment, assignment, and transfer of dietitians.

Dietitians are assigned according to their special qualifications. While they are all college or technical school graduates, meeting certain civil service requirements, some are best fitted for adminis trative work and others especially trained for dietotherapy work. During the fiscal year 1924, practically no changes were made in policy governing the operation of the dietetic section.

As this service has become more stabilized, it has become possible to secure better qualified and more experienced personnel. Closer

cooperation has been established between ward surgeons and dietitians, and in this way the dietitians have been better able to obtain reports on individual cases and render more efficient service.

The dietaries submitted from the hospitals show well balanced meals, carefully planned with regard to the particular needs of the patients. Monthly reports show a large amount of dietotherapy work being done, especially in general and tuberculosis hospitals.

No effort has been made to reduce food cost, except in the matter of judicious and careful buying and keeping a close check on waste. The food service has been improved as more adequate equipment has been furnished.

The following personnel were on duty June 30, 1924:

During the fiscal year the gross expenditures at veterans' hospitals amounted to $22,500,455.10, which represents a decrease of approximately $3,250,000 over the preceding fiscal year. This reduction was entirely in the operation of general hospitals, as both the tuberculosis and neuropsychiatric types reported an increase in expendiComparing these expenditures by type of hospital, it is found that in the instance of tuberculosis hospitals there was an increase of approximately $314,000, and for neuropsychiatric hospitals $409,000. With reference to general hospitals, the expenditures decreased by some $4,000,000, which reduction was primarily due to the operation of fewer hospitals of this type during 1924. In considering the several items of expenditure, it is found that about $566,000 less was expended for salaries than for 1924, while the amount paid for rentals decreased $346,760.

The operating expense, from which is eliminated expenditures for major repairs and alterations to buildings and nonexpendable equipment, of veterans' hospitals for this period was also considerably below that of 1923, amounting to a decrease of approximately $1,800,000. This reduction was likewise in general hospitals, as both other types reported an increase in the cost of operation. The per diem cost per patient for all hospitals decreased from $4.91 to $4.62, a drop of 29 cents, while a comparison as to types shows a reduction of 31 cents in general hospitals, and 37 cents in neuropsychiatric hospitals, with an advance of 11 cents in the rate of tuberculosis hospitals. In connection with this material reduction in the cost of operation of all hospitals, it is to be borne in mind that during this year a daily average of 290 less patients was hospitalized, although the hospitalization of this number for the entire year at the average rate of $4.62 per day would absorb only 27 per cent of the $1,800,000 reduction in the operating expense of hospitals over the fiscal year 1923.

Tables commencing page 68 show these data for individual hospitals by department and object of expenditure,