periods due to the patients' fatigue levels (mental and physical) and may be gradually increased as patients' work capacities increase.

4. Tonic type of treatment. The tonic type of treatment is the utilization of specific activities through planned individualized programs to improve or maintain muscle and/or mental tone and to aid patients to adjust to their disabilities and hospitalization.

(d) Manual arts therapy

Manual arts therapy is treatment of patients through the professional use of actual and simulated work situations of an industrial and agricultural nature which have vocational significance. It is carried out on medical prescription only. This treatment is administered to patients having tuberculosis, and/or general medical and surgical conditions, and/or neuropsychiatric conditions (psychiatric and neurological).

The purpose of manual arts therapy is to treat patients through the use of activities having vocational significance in order to observe patients in these situations and to report by means of progress notes to the prescribing physician information concerning their treatment reactions which have medical significance and diagnostic value in connection with planning and establishing the medical rehabilitation goals for patients as they relate to their posthospital employment or adjustment to a sheltered environment if discharge is not feasible. There are seven broad categories of activity, viz: (1) Metalworking, (2) woodworking, (3) electricity, (4) graphic and applied arts, (5) agriculture, (6) hospital industries, and (7) general. The treatment consists of work situations built around subject fields comparable to those in industry and agriculture.

The primary distinctions between manual arts therapy and occupational therapy are reflected in their respective treatment objectives and the emphasis that is placed on the technical aspects of the treatment activities utilized together with tools and equipment employed.

The manual arts therapist, in carrying out the medical prescription, utilizes work situations which have vocational significance. These are utilized for (a) their value in testing, developing, and measuring work capacity and the emotional adjustment of the patient, and (b) observing and reporting to the medical staff information concerning patients' treatment reactions. These observations are used in connection with planning and establishing the medical rehabilitation goal for patients.

The occupational therapist, on the other hand, selects activities because of their value in fulfilling the treatment objective without special emphasis on the vocational significance. In treating patients, the occupational therapist employs various activities and occupational fields together with appropriate hand- and power-driven tools and equipment. In utilizing these activities, some of which are the same as those employed by manual arts therapists, as for example, woodworking and printing, the occupational therapist's aim is not to teach the patient the vocational and technical aspects of activities, but rather to improve range of motion, coordination, muscle and mental tone of affected parts; develop and increase work capacity; provide outlets for tensions and provide situations for therapeutic work accomplishments and resocialization.

(e) Educational therapy

Educational therapy is the use on medical prescription of educational activities in the treatment of patients to assist in restoring them to fullest mental and physical capacity compatible with their abilities and disabilities.

The beginning of what we now call educational therapy may be traced historically to recognition by the chronic and long-term patient and his physician of the value of reading and study as a means for making the tedium of the rest cure endurable. Many long hours of bed rest were thus made endurable and profitable for the patient who recognized that such activity provided an outlet for his emotional and intellectual drives. Thereafter it was recognized that this type of activity ultimately enabled the patient to achieve specific and realistic educational objectives associated with his post-hospital rehabilitation plans.

One aspect of our interest in educational activity is concerned with its value as a reconditioning measure. This form of activity imposes relatively low metabolic demands, and it can be prescribed for bed patients as well as ambulant patients in graded amounts, both as to intensity of effort as well as duration. We have found it useful as a reconditioning measure for many types of patients.

but especially for tuberculous patients. Here again, there appears to be sound physiologic basis for this therapy, inasmuch as it accomplishes for the convalescing patient what a training regimen does for the athlete, namely, building work capacity.

We have found that the patients' participation in educational activity and other purposeful controlled physical and mental activities constitutes an important index of his capacity to engage in suitable forms of work, and that is preferable to the traditional criterion of walking, for example, for the tuberculous. The data respecting effects of such activity are important when related to clinical and laboratory findings of the physician.

Educational therapy used in this manner has an added advantage over the diversional activities so widely utilized for bed patients by providing an encouraging psychological factor of vocational significance. This has continuity through the entire treatment regimen and carryover into the post-hospital plans of the patient. This is particularly important for tuberculous patients in view of the frequent need for the patient to engage in a new and less arduous occupation. For neuropsychiatric patients for whom it is essential to provide a means of objectively measuring changes in mental activity levels for diagnostic and prognostic purposes, educational therapy is particularly valuable in the armamentarium of the physician. Used in this way the day by day worksheets showing results of the graduated units of educational activities are preserved in folders for later study by the psychiatrist and the physiatrist, and frequently afford the physicians unique and significant data concerning changes in clarity or confusion of thought on the part of the patient.

We have found that for patients whose post-hospital plans involve the prospect of return to school or to an occupation involving work of relatively light metabolic demand levels, educational therapy can provide in the hospital environment comparable activities which serve as motivation, as emotional catharsis, as reconditioning media and as a basis for evaluating work capacity for an appropriate post-hospital occupation.

This program makes available for suitable patients the Form B General Educational Development Tests, high school level. These tests have been recommended for high school equivalency credit by the Commission on Accreditation of Service Experiences, for Veterans' Administration hospital patients. They often make it possible for patients to receive a certificate for completion of the equivalent of a high school course during the period of hospitalization. This arrangement frequently enables a patient to save as much time in his educational preparation for a vocation as he lost because of hospitalization. The motivational and practical values for the patient are obvious.

(f) Blind Rehabilitation

The objectives of the blind rehabilitation section are: (a) 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, (b) 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; (c) 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 homes at any time. To assist in accomplishing these aims, a central unit has been established at Veterans' Administration Hospital, Hines, Ill., to give accelerated rehabilitation therapy for young and active blinded veterans (and members of the Armed Forces, not yet discharged) whose capabilities indicated they could qualify as members of a sighted community. This central unit serves as a channel through which blinded veterans pass to the stream of society outside the hospital, preventing such men from seeking out the sheltered environment of domiciliaries. It is also a training center for Veterans' Administration personnel who serve as orientators in the blind program in Veterans' Administration hospitals, centers and domiciliaries.

As a joint operation between the Physical Medicine and Rehabilitation Service and Social Work Service, the Department of Medicine and Surgery has conducted, and is conducting, a special follow-up study of the rehabilitation of all blinded veterans with service-incurred disabilities incurred since the beginning of World War II, December 7, 1941.

This study has been accompanied by ameliorative action when it has become apparent that such measures by the Veterans' Administration would be helpful.

Social workers interviewed 1949 blinded veterans during 6 months, this number representing 98 percent of all blinded veterans in this category of disablement. (Those not interviewed during this period have been interviewed subsequently, or efforts continue to arrange an interview.) Inasmuch as the term blind covers a large number of low-visioned veterans by the accepted definition in this country, one of the particular concerns of the service aspect of this survey was to make sure that all men with chances of regaining vision were securing ophthalmological aftercare. A number of special examinations were requested, which in some cases resulted in improved vision or less discomfort to the veteran.

In addition to care of remaining vision, the degree to which blinded veterans are maintaining their rehabilitation over the years is under examination, especially in the areas where problems are complicated by additional disabilities, such as loss of limbs, or deep-seated physical or emotional illness. Both successful and unsuccessful examples of rehabilitation are under study in order to determine causes and improve treatment. There has been a particular inquiry into the kinds of assistance which the veterans themselves believe have been valuable to them. Account is also being taken on a broad statistical basis of the effect of the various efforts by the Government in their behalf, such as the programs of the military establishments during the war, VA counselors and training officers, following the war, and Public Law 309 which furnishes guide dogs and mechanical or electronic devices.

While the blinded veterans are a small group, they have a major problem. They are widely scattered geographically and they require special procedures. The study has identified those among them who currently need the most help and revealed the nature of the long-term problems of blinded veterans in detail.

The rehabilitation application of this study will be a means of determining where additional rehabilitation processes are needed which will assist in greater earning power and satisfaction in activity for blinded veterans.

(g) Audiology and special correction

The function of audiology and speech correction is to administer, supervise, or perform professional, scientific, and technical work involved in the rehabilitation of patients having hearing or speech disorders, or both, including one or more of the following areas of audiology and speech correction: Acousticstesting 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 and 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 conservation-training patients with speech defects resulting from hearing disorders and from articulatory and phonatory ailments in speech correction and conservation by giving a variety of instructions and exercises designated to enable them to regain intelligible speech.

With the addition of about 80,000 Spanish-American War veterans under Public Law 791, 81st Congress, the potential number who may require these services approximates 150,000. Nine Veterans' Administration audiology and speech correction clinics are now in operation, contracts are in effect with 34 civilian clinics, and reciprocal agreements are in effect with the Army and Navy audiology centers. One additional Veterans' Administration clinic is now under construction and contracts are being negotiated with one civilian clinic to provide services in areas not now served. This will bring to a total of 47 the number of Veterans' Administration and contract clinics available to serve veterans with hearing and speech disabilities.

Increased use of these VA and contract audiology and speech correction clinics for issuance of hearing aids has resulted in a decrease during the past 5 years in the issuance of hearing aids from a maximum figure of approximately 14,000 per year to approximately 5,300 during the fiscal year 1953 without any decrease in service to veterans and despite a constantly increasing number of beneficiaries being served. The number of hearing aids issued is constantly decreasing and is estimated to be considerably less for the past calendar year than for fiscal year 1953. Assuming an average cost of hearing aids of $117 the difference in purchase price alone would be $1,638,000.00. It must be pointed out that this decrease has occurred over a period of approximately 5 years and did not take place only during the past year. Savings during the past calendar year are approximately one-fifth this figure.

Furthermore, during the past calendar year, due to utilization of audiology and speech correction clinics for questionable cases examined for compensation purposes, it is estimated that an average of 15 individuals per month have been found not to be entitled to, but who were previously receiving, disability compensation. This would mean a savings of more than $100,000 per year, continuing presumably during the life expectancy of the patient involved. (h) Executive assistant

Under the direction of the Chief or Acting Chief, Physical Medicine and Rehabilitation Service, the executive assistant, where assigned, is responsible for the integration and coordination of the various sections and the functioning of the Service in all respects which do not require the services of the physiatrist. In this capacity, his position is subordinate only to the Chief, or Acting Chief of this Service.

As medical rehabilitation specialist he develops with chiefs of treatment sections a common understanding of the practical significance of the rehabilitation techniques employed in the Physical Medicine and Rehabilitation Service and the physical and mental requirements of the contemplated rehabilitation objective for the patient in order that an integrated approach may be made to obtain maximum development of the patient's residuals for performance in a job or in a sheltered environment.

He is responsible for the performance of all administrative duties pertaining to the operation of this Service, excepting those which are the responsibilities of the chiefs of the sections. In such matters, he reflects the policy of the Chief, or Acting Chief, of the Service, and relieves him of concern for administrative matters, thus enabling the latter to give maximum attention and supervision to the treatment aspects of the program, including diagnostic, preventive, therapeutic and prognostic procedures, as well as the policies affecting the program.

11. MEDICAL REHABILITATION BOARD

The Physical Medicine and Rehabilitation Service is also responsible for the functioning of the Medical Rehabilitation Board in Veterans' Administration hospitals. This board has been established to consider the problem of patients who are making uncertain progress toward achievement of treatment goals, or whose disability poses formidable obstacles in terms of in-hospital or posthospital adjustment. The board, through joint effort in collaboration with the patient, endeavors to help him clarify his own objectives, become aware of his own potentialities and use every available service required to achieve the best medical, social, emotional and vocational rehabilitation result, including employment. The chief medical director, in addition, has directed that transfers of patients for domiciliary care should not be initiated until the Medical Rehabilitation Board has thoroughly reviewed the case and is convinced that the fullest use has been made of potentialities for rehabilitation while the patient is in a hospital status, and it has been medically determined that he is feasible for domiciliary care. The permanent membership of the board comprises the Chief or Acting Chief of the Physical Medicine and Rehabilitation Service, as chairman; the executive assistant of the Physical Medicine and Rehabilitation Service, as secretary; and a representative of social service and one of hospital Vocational counseling service, as members. The patient's own ward physician and/or the chief of the service on which the patient is being treated invariably is named to serve on the board while the patient is under consideration. The chairman invites participation by additional staff members directly concerned with the rehabilitation of the patient under consideration, and others who may be able to contribute to a more comprehensive understanding of the patient's problems and assist in reaching appropriate solutions.

12. STAFFING POLICY

Since Veterans' Administration hospitals vary so much in size and in the types of patients hospitalized, there is much variation in the organization patterns of the Physical Medicine and Rehabilitation Service. Thus, in general medical and surgical hospitals under 150 beds, normally only physical therapy would be provided. Occupational therapy is added in hospitals of 150 beds or more. Corrective therapy is employed in hospitals of 250 beds or more. Educational therapy, manual arts therapy and the executive assistant are authorized in

hospitals over 500 beds in size. Blind rehabilitation and audiology and speech correction sections are established where the numbers of patients requiring these services warrant their use, as mentioned previously. This pattern may vary somewhat when the number of chronic, long-term patients with rehabilitation problems justifies the use of additional treatment sections required for such patients. Any hospitals with only a portion of the usual physical medicine and rehabilitation component organization may request authorization to establish other sections. Approval will be based on the justification presented and on the personnel ceiling and funds available. The executive assistant position may be established in hospitals under 500 beds when a combination of factors, such as those mentioned above and the lack of a full-time chief of service, requires his assistance to the acting Chief. In hospitals where all or large segments of the patient population suffer with tuberculosis or neuropsychiatric conditions, the normal complement of treatment facilities in physical medicine and rehabilitation would be provided, since these patients usually require prolonged treatment and present numerous rehabilitation problems.

13. MEDICAL REHABILITATION FILMS

The following films prepared by the Physical Medicine and Rehabilitation Service in conjunction with the Presentation Division have contributed practical treatment techniques and training aids not only to the Veterans' Administration but to other Federal, State, and civilian agencies. These films are being used for instruction in the educational programs of medical schools, hospitals, and clinics.

Living With Limitations, Physical Medicine and Rehabilitation for General Medical and Surgical patients: A review of this film, in the October 14, 1950, issue of the Journal of the American Medical Association states, "This excellent motion picture was prepared to show that the services of physical medicine and rehabilitation not only are extremely helpful for the more dramatically handicapped but serve a useful purpose as a part of the armamentarium which every physician with patients suffering from certain common disabilities can call on to assist him in achieving their recovery and rehabilitation. * * * It is apparent that the Government hospitals are demonstrating to civilian hospitals the importance of having well-organized and complete services to provide for rehabilitation of the whole man, to prepare each patient physically, mentally, socially, and vocationally for the fullest life compatible with his abilities and disabilities."

What's My Score: Demonstrating the ability of the paraplegic patient to handle jobs in competition with nonhandicapped veterans and showing basic steps in his training to get around and help himself, this picture has had wide utilization as a teaching aid for medical schools and rehabilitation clinics and has been requested frequently by vocational advisement personnel.

The Long Cane: This film depicts the treatment of newly blinded veterans in the Veterans' Administration central unit for this purpose, Hines, Ill. It creates a social awareness of the presence of these patients and the means of dealing with their retraining and rehabilitation. But recently released, this film promises to fill a real need for progressive methods in this field.

You Can Lick TB: Illustrating the problems of motivating the tuberculous patient to work closely and cooperatively with the doctor and the modern rehabilitation methods provided in the hospital, this film has had wide circulation in both VA and non-VA hospitals for purposes of patient and professional orientation.

Activity for Schizophrenia: This film stressing medically prescribed individualized physical activities in the treatment of mental illness has been televised under the title "Road to Reason" on all of the major networks in this country. It was awarded honorable mention, international picture exhibition, at Venice, Italy. It is used extensively as a teaching aid in medical schools and educational institutions of this country.

Prescription for Work: This film depicting a light mechanics procedure through which the work capacities of patients are determined is being used widely in tuberculosis hospitals, and to a lesser degree in general medical and surgical, and neuropsychiatric hospitals. This film has been requested by the French Government for use in its rehabilitation programs to determine the capacity of the severely handicapped for vocational adjustment. It is being used extensively in industrial training programs in this country.