(b) The facilities at station for unloading coal.

The kind of cars in which shipment should be made.
The rate of delivery.

The number of cars that can be unloaded per day. And all information that will aid the central office to take intelligent action on the annual estimates. If there are no storage facilities at a hospital or other station and coal must be delivered throughout the fiscal year, the estimate shall show clearly the amounts of each kind to be delivered in each month of the fiscal year. 7. Where coal is purchased f. o. b. mines or other point of origin, shipment shall be made from the mines or other point of origin on Government bill of lading. Where coal is procured in this manner, a certificate of a sworn weighmaster will be required, covering the weight of the coal shipped, and if there is no weighmaster at or near such mine or other point of origin, then the certificate of the weighmaster at the nearest railroad track scales will be procured.

8. If coal is purchased delivered in carload lots, to a hospital or other station and facilities are at hand to weigh the coal, it shall be weighed, but no switching charges will be incurred for the weighing of the coal, unless proper authority therefor has been secured in advance. If, however, the medical officer in charge, or other responsible officer, has reason to believe that coal delivered to him by carload lots is short in weight, he may, as an emergency, cause the same to be weighed, and make prompt report to central office of the charges for the service and the result of his findings in the matter.

9. Immediately upon receipt of coal, samples thereof shall be forwarded to the laboratory, Bureau of Mines, Department of Interior, Pittsburgh, Pa., to be analyzed and tested. Upon receipt of reports relative thereto the medical officer in charge and others responsible shall prepare the necessary documents for the prompt payment of the coal.

10. When coal is purchased f. o. b. mines or other point of origin in carload lots and is weighed at destination and there is a variance between the quantity billed and the quantity determined by weighing, the quantity as billed shall be accepted provided the variance does not exceed 1 per cent. If the difference exceeds 1 per cent, payment shall be made only for the quantity actually determined.

11. Every delivery of coal will be inspected by the officer in charge of the place to which delivered, or by his duly authorized representative, to see that same is in all respects in accordance with the kind and quantity called for in the contract.

12. Wood shall be procured by the standard cord of 128 cubic feet. It should be sawed, dry, not burned or charred, free from small limbs and brush, sawed or cut in 4-foot lengths, and split to convenient size, but not exceeding 6 inches in diameter. Wood that has been cut six months shall be termed "seasoned" wood. Wood that has been cut less than six months shall be termed "green" wood.

L. B. ROGERS, Medical Director.

(Hospital Circular No. 148. Canceled by General Order No. 141-B) CONTRACT FOR CASES AND RETURN OF EMPTY CYLINDERS

AUGUST 28, 1923.

Medical officers in charge, United States Veterans' Bureau hospitals, are instructed to anticipate their requirements and make requisition on central office, in accordance with General Order No. 123, for nitrous oxide and oxygen, as the bureau has entered into a contract with certain manufacturers to supply these gases in cylinders of the sizes described below:

For dental use.-Oxygen, 80 gallons capacity; nitrous oxide, 250 gallons capacity.

For surgical use.— -Oxygen, 450 gallons capacity; oxygen, 1,150 gallons capacity; nitrous oxide, 1,280 gallons capacity; nitrous oxide, 3,200 gallons capacity.

The contract provides a refund for each empty cylinder returned to the contractor. All empty cylinders must therefore be returned by freight or express (least expensive way) promptly on Government bill of lading. The contractors shall be notified when cylinders are shipped and a copy of this notice, together with memorandum copy of bill of lading, shall be forwarded to the supply division in order that refund may be obtained. Due care shall be taken to see that cylinders are returned to contractors from whom received. Shipment of smallsize cylinders shall not be made in lots of less than four. L. B. ROGERS, Medical Director.

(Hospital Circular No. 149)

CONFIDENTIAL NATURE OF RED CROSS INFORMATION

SEPTEMBER 11, 1923.

The American Red Cross has called to the attention of the central office the fact that social histories and personal information supplied by them to hospitals have been given out indiscriminately, and that frequently the broadcasting of this information has resulted in embarrassment to some of their workers.

In the future it is desired that the medical officers in charge regard as strictly confidential all such information imparted to them by the Red Cross, and to so instruct any personnel under their charge who are supplied with this information.

FRANK T. HINES, Director.

(Hospital Circular No. 150. Canceled by General Order No. 68–D)
OCCUPATIONAL THERAPY IN GENERAL HOSPITALS

SEPTEMBER 11, 1923.

1. It is generally conceded that occupational therapy is unnecessary for acute and transient cases. Therefore occupational therapy need not ordinarily be prescribed for general medical and surgical cases when it appears that the period of hospitalization will not exceed four to six weeks.

2. In certain general hospitals there are tuberculosis and neuropsychiatric cases. The occupational therapy provided for these cases should follow the types of occupations and be governed by the instructions laid down for tuberculosis and neuropsychiatric hospitals.

3. It is considered that the forms of occupational therapy provided for tuberculosis and neuropsychiatric patients in general hospitals will be found adequate to meet the needs for occupational therapy for the general cases also. FRANK T. HINES, Director.

1. In selecting duties for patients, including occupational therapy or other activities, medical officers in charge of hospitals will use the greatest care in avoiding any chance of food contamination by patients suffering from, or carriers of, infectious diseases of the nature that renders them menacing in this respect.

2. The more common hazards are those of tuberculosis and enteric diseases. For reasons that will be apparent, syphilitics will be considered as if they were a menace in the handling of food, etc. L. B. ROGERS, Medical Director.

(Hospital Circular No. 152. Amended by Hospital Circular No. 152-A)

DISPOSITION OF PATIENTS' RECORDS

SEPTEMBER 18, 1923.

1. In order to standardize the disposition of records of patients being transferred from one hospital to another you are directed to forward by mail or attendant a copy of the last physical report to the hospital to which the patient is being transferred. This report should give a brief synopsis of the patient's progress while in hospital, and should show the degree of cooperation on the part of the patient with the hospital authorities. A copy of this report should also be forwarded to the district manager of the district in which your hospital is located.

2. In the case of neuropsychiatric patients, a synopsis of the patients' social history should accompany the physical report.

3. The complete clinical record, including laboratory findings, X-ray plates, etc., shall be retained in the files of the hospital from which the patient is transferred.

4. In cases where United States veterans' hospitals are being closed or contracts with private institutions are being terminated, complete records of all patients should be carefully boxed, indexed, and forwarded to the central office. FRANK T. HINES, Director.

(Hospital Circular No. 152-A. Modified by Circular No. 345)

DISPOSITION OF PATIENTS' RECORDS

JUNE 16, 1924.

Medical Division Hospital Circular No. 152, relative to the disposition of patients' records, is amended as follows: 1. In order to standardize the disposition of records of patients being transferred from one hospital to another, you are directed to forward, by mail or attendant, the complete record of the patient while in your hospital (with the exception of the data hereinafter specified) to the medical officer in charge of the hospital to which the patient is being transferred.

2. A copy of the skeleton file, embodying salient data, prepared in accordance with paragraph 5, should also be forwarded to the district manager of the district in which your hospital is located.

3. In the case of neuropsychiatric patients, besides supplying the complete clinical data mentioned in paragraphs 1 and 2, there should also be forwarded a synopsis of the social history of the claimant, if such history is a part of the record or can conveniently be secured.

4. You should retain at your hospital all X-ray plates and also all bulky charts. These can afterwards be furnished if request is made for them.

5. Before forwarding the complete clinical record, with the exceptions noted in paragraph 4, you should prepare a skeleton file relating to the individual case, embodying the salient data in the case, to be kept in your hospital.

6. When United States veterans' hospitals are closed, complete records, including X-ray plates, charts, etc., of all discharged patients will be carefully boxed, indexed, and forwarded to central office, except if patients are transferred to another hospital, records of such patients will be forwarded to receiving hospital in accordance with paragraph 1.

E. O. CROSSMAN, Medical Director.

(Hospital Circular No. 153)

HOSPITALIZATION OF CASES OF AMOEBIC DYSENTERY AND CHRONIC ENTERIC DISORDERS

SEPTEMBER 29, 1923.

1. The Surgeon General of the Army has notified the Director of the United States Veterans' Bureau that Army hospitals are well prepared to care for cases of amoebic dysentery and chronic dysentery of persistent types. These cases have been receiving special attention also at United States Veterans' Hospital No. 65, St. Paul, Minn.

2. Wherever facilities for the treatment of amoebic and other chronic dysenteric cases are not available in Veterans' Bureau hospitals district managers are authorized to hospitalize such cases in Army hospitals nearest to the patient's residence, except that patients closer to United States Veterans' hospital No. 65, St. Paul, Minn., will be hospitalized in that institution.

3. Medical officers in charge of Veterans' Bureau hospitals where any of the above cases are now hospitalized, and where no special wards or other facilities are available for their treatment may immediately request transfer for them through their respective district managers as herein specified.

L. B. ROGERS, Medical Director.

(Hospital Circular No. 154. Amended by Hospital Circular No. 154-A) AUTHORITY TO PURCHASE ILETIN (INSULIN) DURING PERIOD ENDING DECEMBER 31, 1923 OCTOBER 2, 1923.

Contract has been made with Eli Lilly & Co., 224 McCarty Street, Indianapolis, Ind., for furnishing iletin as follows: "Pkg. H-10, 50 units (1 amp.), $1.50 per pkg.; pkg. H-20, 100 units (1 amp.), $2.50 per pkg. F. o. b. Indianapolis.'

You are, therefore, authorized to place orders direct with Eli Lilly & Co., for this product during the contract period, which expires December 31, 1923. Vouchers covering cost should be forwarded to the finance division, central office, citing Contract No. 1112-P as authority for the expenditure. L. B. ROGERS, Medical Director.

(Hospital Circular No. 154-A. Canceled by Circular No. 22) AUTHORITY TO PURCHASE ILETIN (INSULIN) DURING PERIOD ENDING DECEMBER 31, 1923 NOVEMBER 28, 1923.

Medical Division Hospital Circular No. 154, dated October 2, 1923, relative to authority to purchase iletin (insulin) during period ending December 31, 1923, is amended to read: " ‘Pkg. U–10, $0.95 per pkg.; pkg. U–20, $1.65 per pkg. Postpaid.'

You are, therefore, authorized to place orders direct with Eli Lilly & Co., for this product during the period ending December 31, 1923. Vouchers covering cost should be forwarded to the finance division, central office, citing Contract No. 11122-P as authority for the expenditure. L. B. ROGERS, Medical Director.

(Hospital Circular No. 155. Canceled by General Order No. 265)
RESIGNATION OF FIELD PERSONNEL

OCTOBER 4, 1923.

1. In the future when resignations of field personnel are approved and forwarded to the central office by medical officers in charge or others properly qualified, a definite statement should be made as to whether or not replacement is required for the position vacated by such resignation. Such statement will only be necessary in the cases of personnel whose positions are filled from central office, such as nurses, aides, dietitians, etc.

2. Strict compliance with this order will prevent needless delay and correspondence, as it is absolutely essential for the central office to be aware of the wishes of the medical officer in charge as to replacement for positions made vacant by resignation or otherwise.

FRANK T. HINES, Director.

(Hospital Circular No. 156)
HOME TREATMENT

OCTOBER 5, 1923.

The Government is authorized by law to provide hospital care for its beneficiaries. The authorized treatment afforded outside of hospitals is dispensary care or out-patient relief, which includes such emergency medical attention as may be necessary.

The term home treatment" is a misnomer and will be discontinued. "Out-patient relief" will be used in its stead. The last four years has demonstrated beyond peradventure the worth of United States Veterans' Bureau hospitals for the care of its tuberculous beneficiaries. Official records show that many beds in Government hospitals are to-day filled by patients who made tragic mistakes in leaving hospitals for so-called "home treatment."

It is the consensus of opinion of tuberculosis specialists, both in the Government service and in civilian life, including well-known representatives of the National Tuberculosis Association, that tuberculosis is an institutional disease, and that the hospital is the best place in which to render proper treatment. It has been conceded by these tuberculosis workers that patients with active or progressive disease die in larger numbers when treated outside of proper tuberculosis hospitals, or that they make less perfect recoveries.

The Government has made liberal provisions for its beneficiaries. During the past four years every effort has been made to train physicians and nurses in this specialty in order that tuberculous patients may receive care and treatment in United States veterans' hospitals of the highest possible standard.

It is realized there is a small percentage of tuberculous patients, including those approaching fitness for discharge or those with such a slight disease as to make the necessity for hospitalization questionable, and the occasional patients, who for various reasons might do better in their homes than in the hospitals. The selection of such patients to be discharged from hospitals to out-patient relief will always be made by the medical officer in charge, as it is essentially a medical problem. Before submitting his recommendation to the district manager for investigation of home conditions he will assure himself of the patient's knowledge of right living, principles of hygiene, and also of his strength of character and intelligence to keep up the fight and sacrifice necessary to the treatment of his disease. He will also assure himself that the patient will exercise the care necessary to prevent his being a dangerous focus of disease.

The district manager will make a survey of all active or progressive cases in his district of authorized home treatment to determine if the home conditions are such as set forth in bureau regulations and if the patients are following instructions, also actually receiving the high grade of care to which they are entitled as beneficiaries of this bureau. He will also determine if the existing Government agencies and facilities already at hand are sufficient to provide the necessary care. Hospitalization will be immediately arranged for such patients who do not meet these requirements. All other active tuberculous patients will be offered hospital treatment if their physical condition is such that hospitalization is indicated.

Every effort will be made by district managers and medical officers in charge, through every means available, to discourage tuberculous patients with active or progressive disease substituting an inferior care outside of the hospital for suitable hospitalization.

It should be remembered that the terminal case is the most potent source of infection in every community. Nothing could be more disastrous from the public standpoint than the policy whereby patients with far advanced disease, despairing of recovery, are encouraged to return to domiciliary conditions, unless under most rigid supervision.

The medical officers in charge and the district managers will use their best efforts in educating this class of patient, together with his interested relatives, with a view to materially decreasing the number of discharges of moribund cases. This is not to be construed as making void any existing general order or bureau regulation.

FRANK T. HINES, Director.

(Hospital Circular No. 157. Obsolete)

REPORT OF PERSONNEL BY ACTUAL DUTIES PERFORMED

OCTOBER 4, 1923.

1. It is requested that the attached chart of personnel showing personnel by duties performed be filled in in accordance with the personnel on duty at your station, as of October 1, 1923, and returned to the central office, attention medical director, at the earliest possible date. The purpose of this report is to ascertain the number of employees engaged in each of the various duties of the hospital.

2. This report is arranged to indicate in what department employees serve, where their designation alone does not convey such information clearly. For instance, orderlies are subdivided between ward orderlies, laboratory orderlies, office orderlies, etc., as are waiters and waitresses and other classes of personnel. It will be noted that the designation of "attendant" is only to be used in neuropsychiatric hospitals to represent employees in charge of mental cases. This designation has a definite meaning that is well understood in such services, and it should be used only in that way.

3. The designation of ward surgeons is ordinarily definite, but where duties are multiple this may not be the case. To avoid confusion medical officers should be designated as ward surgeons, when such is their principle duty, and other duties, such as reconstruction officer, and specialty, etc., are an incidental part of their work. On the other hand, where the work proper is other than that of a ward surgeon and they do ward surgeon work incidentally, they should be given the designation corresponding to their principle duty. In both instances or in other instances all multiple duties should be stated.

4. By reference to the accompanying chart for personnel, it will be noted that three columns have been provided: "In-patients," "Out-patients,' and "Constant." The sum of the in-patient personnel and the out-patient personnel should represent your total personnel on duty. In the column headed "Constant" there shall be entered for each class of personnel that number of personnel which is necessary for the operation of the station, regardless of degree of utilization of beds. This personnel can be considered the constant necessary overhead, and this column should be filled out with that point in mind. It may happen that certain personnel is performing duties in both the out-patient and in-patient departments of the hospital. Under such a condition that person will be accounted for under the department where he performs his principle duties, and under the other department the word "also" shall be entered.

5. It is urgent that this matter be given your immediate and personal attention to the end that a complete and accurate report may be submitted with the least possible delay. L. B. ROGERS, Medical Director.