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Section I, Chapter I

Contents

SECTION I

CENTRAL ORGANIZATION; PERSONNEL

CHAPTER I

ORGANIZATION IN THE OFFICE OF THE SURGEON GENERAL

Shortly after the United States declared war on Germany the task of organizing for the physical reconstruction of our disabled soldiers was initiated.1 The common chairman of the committees appointed by the American Orthopedic Association and the orthopedic section of the American Medical Association in May, 1916, was commissioned in the Medical Reserve Corps, United States Army, in May, 1917, and ordered to Europe to study and report on orthopedic work in the British Army.1 Two officers were detailed in July, 1917, to study and coordinate the various activities of this special branch of surgery.1 The reports of these officers indicated that the problem of physical reconstruction was too broad to be confined to orthopedics alone, as it applied to all branches of medicine and surgery.

The first proposal concerning the work which was later to become the function of the reconstruction service was offered as a part of the plan for the organization and development of the orthopedic department in the Surgeon General's Office and provided for a physical-therapy department and curative workshop in each orthopedic hospital.2 The shops were primarily for the therapeutic effect, but the thought then was that they might lead eventually to reeducation for trade. It was urged by the officers referred to above that cooperation be secured with various organizations for civil aid in the development of the curative workshops and the later reeducation for trade, but they emphasized the necessity of keeping the prospective patients under military medical control until they would be able to assume wage-earning positions or enter upon an arranged and definite course of occupational training. There was, meanwhile, considerable incoordinated investigation of the subject by various departments of the Surgeon General's Office, as indicated by the following memorandum:3

AUGUST 15, 1917.

Memorandum for the Surgeon General.
Subject: Reconstruction, reeducation, and aftercare of disabled soldiers.

1. At a meeting of officers, including a representation from each specialist division, the following decision was reached:
Recommended that the Surgeon General designate one officer to at once make a preliminary study of the whole question, to submit at the end of two weeks a report showing the present status of this question in the United States from the legal, sociological, labor, vocational, military (attitude of Secretary of War), technical (medical, surgical, etc.), attitude of the Medical Section, National Council of Defense, and such other phases as may be shown to be pertinent during the investigation.
2. On submission of this report it is believed that the creation of the machinery which is to do this work can be begun.

T. C. LYSTER,
Lieutenant Colonel, Medical Corps.


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DIVISION OF SPECIAL HOSPITALS AND PHYSICAL RECONSTRUCTION

On August 22, 1917, the division of special hospitals and physical reconstruction was formed in the Office of the Surgeon General, not only to supplement the existing divisions to the end that coordinated provision might be made for specialists' treatment and training for sick and wounded soldiers abroad, for the reception, classification, distribution, treatment, and care in the United States of invalided officers and men, and for curative treatment and education for them, but also to take measures for securing employment for them when discharged.4

One member of the Medical Corps was placed in charge of the division by the order creating it.4 Five additional officers were on duty therein on October 15, 1917.5 Their specific duties at that time were not stated, but the enlarged roster of January 31, 1918, shows the duties assigned to each officer and gives an idea of the scope of the early plans.6

In addition to the chief of division, there was a representative of the division of head surgery; a technical adviser, commercial and professional education; a surgical adviser, physical reconstruction; a technical adviser, industrial education; a technical adviser, agricultural education; an officer to abstract literature on reconstruction and reeducation; an officer concerned with educational propaganda; a representative of the division of neurology and
psychiatry; three architects.6

The work of the division of special hospitals and physical reconstruction was conducted through four sections-special hospital sites, buildings, and grounds; special surgical and medical reconstruction plans; therapeutic use of work and other physical remedies; information and literature.7

The first section assisted in selecting sites for hospitals, designing buildings where needed, examining existing buildings for hospital purposes and suggesting the necessary alterations, in selecting means for the therapeutic use of work, and in developing special hospital equipment, including that required for physical therapy.7 The personnel consisted of medical officers and architects.

The section of special surgical and medical reconstruction had charge of the development of plans for the necessary special treatment of the blind, of the deaf, of speech-defect cases, and of other conditions requiring special plans.7 It assisted various professional divisions in preparing for special features of their work.7 This section was operated by representatives from the divisions of general surgery, head surgery, orthopedic surgery, neurology and psychiatry,
internal medicine, and genitourinary surgery.7

The section devoted directly to the therapeutic use of work assisted in the development of plans for curative shops and laboratories.7 This section acted in an advisory capacity in the selection of the proper application of work in so far as the medical requirements permitted with a view to future vocation and in the investigation of the occupational possibilities for handicapped men and their use in the military service. The work of this section was performed by technical advisers in such occupations as applied to the treatment of sick and wounded.7

The section of information and literature had charge of the analysis of reconstruction literature, educational propaganda, and the preparation of monographs for officers.7


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The division was occupied for several months in surveying its field of endeavor, in laying plans, in preparing literature, in selecting hospitals, and in making plans for hospital building.8 An intensive study was made of existing literature on reconstruction, which indicated, among other points, that 50,000 to 75,000 reconstruction cases would be received per year from each 1,000,000 men overseas. Plans were made for establishing curative workshops and vocational schools in connection with certain hospitals. Conferences were held with vocational schools and with industrial establishments with a view of providing training of a vocational nature. Studies were made of the educational work being done for disabled men in the Canadian and European armies; also, investigations were made of the possibilities of employing disabled men at various occupations. For securing teachers it was proposed to establish a training school at one of the first reconstruction hospitals to be established and there to train as teachers men from civil life, was well as a certain number of disabled soldiers.

After careful investigation and study plans were prepared for the care of the blind and for those suffering with injuries to the organs of hearing and speech.8 The work of the industrial surgeon was fully studied and outlined, including liaison with other departments of the Surgeon General's Office and civil agencies. The possible effect of Army reconstruction measures upon the rehabilitation of those crippled in civil industry was considered.

Much work was done in investigations along the following lines:8 Examination of a large number of buildings offered for lease to the Government for use as hospitals, the majority of which were unsuitable; development of plans for physiotherapy in hospitals; preparation of pamphlets and moving-picture films to aid in bringing about the proper mental readjustment of men injured in war.

In the earliest organization,9 as shown in Chart I, three points were emphasized in the reconstruction program: (1) That the reconstruction work was expected to fall under the jurisdiction of the orthopedic department; (2) that only such reconstruction work would be undertaken overseas as was expected to return the patient to duty; (3) that military reconstruction would lead directly and shortly to industrial rehabilitation.

The statute authorizing the Bureau of War Risk Insurance, as amended October 6, 1917,10 provided for rehabilitation for permanent disability, but failed to name any governmental department to furnish the courses; also, it authorized a special enlistment for men permanently disabled, but specific authority for such enlistment was not given by The Adjutant General until January 2, 1918.11 The statute is as follows:

304. That in cases of dismemberment, of injuries to sight or hearing, and of other injuries commonly causing permanent disability, the injured person shall follow such course or courses of rehabilitation, reeducation and vocational training as the United States may provide or procure to be provided. Should such course prevent the injured person from following a substantially gainful occupation while taking same, a form of enlistment may be required which shall bring the injured person into the military or naval service.

On March 21, 1918, an officer of the Medical Reserve Corps, an eminent surgeon, was assigned as chief of the division of special hospitals and physical reconstructions The Surgeon General's instructions to him were to take immediate steps to coordinate all activities of both military and civilian interests relating to physical reconstruction.


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One of the first steps taken by the division under its new chief was the formulation of a building program for the proposed reconstruction hospitals. This plan was submitted March 30, 1918, and formed the basis for all building designs and hospital distribution policies thereafter.13 It provided for the construction of a "departmental" type of hospital in each hospital district of the United States, in addition to the few which were already operating a reconstruction service, that type having facilities for the care of all classes of cases, for the housing of all personnel, and having grounds for the development of recreation and agriculture. The buildings for the different departments were to be of standard type, in groups about the special buildings for physiotherapy,

CHART I. - Early organization for physical reconstruction in the Office of the Surgeon General

curative workshops, etc., and the capacity of each hospital wals to be 1,000 beds, with expansion possibilities to 2,000. The proportion of beds assigned to the various departments was to be based on the following Statistics of returned invalided soldiers of the Canadian forces:

Beds per 1,000

Surgical:

240

General surgery

160

Orthopedic surgery

100

Head surgery

Medical:

General medical (heart, genitourinary, gassing, and trench fever)

300

Nervous and mental (war neuroses and epileptics)

120

Tuberculosis

80


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Provision was made for 50 per cent of the patients to receive physiotherapy, for 37½ per cent educational work, and for 37½ per cent in the curative workshops.13 It was considered that an area of 75 acres would be required for the first 1,000 beds and 25 acres for each additional 1,000 beds, exclusive of ground to be used for agricultural purposes. Two-story ward buildings with a capacity of 80 beds each, of terra cotta block construction, were recommended.

For the early requirements of reconstruction it was proposed to erect at once one hospital of twice the standard capacity, somewhere between the two main ports of debarkation, and at an early date one of the standard capacity in each of five districts, so located as to provide for the entire country.13 Wherever practicable, the use of existing buildings at posts and camps was recommended, especially for use as quarters for personnel, but the alteration of hotels for hospital use was not considered advisable from either the financial or the practical point of view. The plan also included consideration of special hospitals and additions and alterations necessary in existing hospitals functioning as reconstruction hospitals.

The plan was not adopted in detail, as a memorandum of April 29, 1918, designated certain existing hospitals to receive the various classes of reconstruction cases from overseas and from camps and stations in the United States, as follows:14

APRIL 29, 1918.

Memorandum for all officers of the Surgeon General's Office:

1. The following hospitals have been designated as points to which patients will be sent for physical reconstruction.
2. These hospitals will receive cases from abroad and from camps and stations in the United States.
3. The necessary special staff of all types will be assigned to these hospitals as rapidly as possible.
4. Arrangements have been made for the prompt classification and evacuation of cases from ports to these hospitals. Steps are under way to further improve and expedite this evacuation.
5. Arrangements have been begun for the transfer of cases from camps and stations to these hospitals. It is expected that these arrangements will be completed shortly to the end that every case needing reconstruction will be promptly transferred from camps and stations to the designated hospital.
6. List of hospitals:
For the insane (overseas patients) -
All enlisted men arriving at Newport News and New York-Fort Porter, N. Y.
Officers (these officers can be treated in a ward of No. 1 which has been established at Bloomingdale)-General Hospital No. 1, Williamsbridge, N. Y.
Epileptics and those suffering from functional neuroses-Temporarily to General Hospital No. 9, Lakewood, N. J.
Pulmonary tuberculosis cases -For the present, to Fort Bayard, N. Mex.; General Hospital No. 16, New Haven, Conn.; General Hospital No. 17, Markleton, Pa.; United States Army Hospital, Waynesville, N. C.
NOTE.- Other hospitals are in preparation at Azalea, N. C., Denver, Colo., and Otisville, N. Y.
Cardiovascular cases - General Hospitals No. 6 and No. 9.
Drug addicts - Temporarily to General Hospital No. 9, Lakewood, N. J.; to General Hospital No. 10 when completed.
Chronic arthritis-General Hospitals No. 6 and No. 9.
NOTE.- All cases which will benefit by special treatment provided at Hot Springs, Ark., will be recommended from these hospitals for transfer to that hospital.
Cases suffering from effects of gas - General Hospital No. 2.


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Other general medical cases - General Hospitals Nos. 2,5,6, and Walter Reed General Hospital.
Surgical cases:
Orthopedic - General Hospital No. 2.
Amputations (other than amputations of fingers and toes)- Walter Reed General Hospital.
Blind - General Hospital No. 7, Roland Park, Baltimore, Md.
Cases of total deafness, speech defects not purely neurotic, otitis media-General Hospital No. 11, Cape May, N. J.
Venereal disease (where treatment indicated is that of venereal disease only) - General Hospital No. 5.
Wounds, other injuries, or other surgical conditions of the genitourinary system (venerea or nonvenereal) - General Hospitals Nos. 2, 5, 6 and Walter Reed General Hospital.
Diseases or injuries of the eye and its appendages, the ear, nose, and throat; injuries and neoplasms of the skull and brain (including traumatic epilepsy), spinal cord, and peripheral nerves; diseases and injuries of the face, jaw, and neck (exclusive of the thyroid gland) - General Hospital No. 11, Cape May, N. J.
Other surgical conditions - General Hospitals Nos. 2, 5, 6 and Walter Reed General Hospital.
7. These hospitals are prepared to care for both officers and enlisted men unless otherwise indicated.
8. Under the plan of evacuation now in operation the hospital to which a patient goes is determined by his major disability.

ROBT. E. NOBLE,
Colonel, Medical Corps, N. A.

On approximately the same date a letter of general instructions was sent to each of the hospitals named with the following introductory statements:15

Physical reconstruction is the completest form of medical and surgical treatment carried to the point where maximum functional restoration, mental and physical, may be secured. To secure this result, the use of work, mental and manual, will be required during the convalescent period. This therapeutic measure, in addition to aiding in greatly shortening the convalescent period, retains or arouses mental activities preventing hospitalization, and enables the patient to be returned to service or civil life with the full realization that he can work in his handicapped state, and with habits of industry much encouraged if not firmly formed.

Hereafter no member of the military service should be recommended for discharge from your hospital until he has attained complete recovery or as complete recovery as it is to be expected he will attain when the nature of his disability is considered.

The designation "occupational therapy" for therapeutic work, mental or manual, was discarded, being thereafter included in the term "curative workshop schedule." 15 Reconstruction aides teaching handicraft, and any enlisted assistants they might have, were to be placed under the control of the educational officer of the hospital, and notation was to be made on the patient's clinical record of the work he performed. It was the intention to provide additional teaching personnel of suitable enlisted men by selection from those physically not qualified for full duty, by induction of others into the service, and by the employment of civilians if necessary.

On May 6, 1918, the administration of the section of reconstruction aides for physiotherapy in the Surgeon General's Office, which had theretofore been under the direction of orthopedic surgery, was transferred to the division of special hospitals and physical reconstruction,16 and on May 13, 1918, the title of the division was changed to the division of physical reconstruction.17

A reorganization of the division became effective May 31, 1918, creating the office of adjutant and the following designated sections: 18 (1) Personnel;


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(2) evacuation of patients from camps and of overseas patients from ports of embarkation; (3) physiotherapy; (4) educational; (5) architects; (6) care of permanent blind; (7) care of totally deaf and those suffering from speech defects; (8) education of the public and of the military service; (9) records; (10) professional consultants.

ORIGINAL PLAN FOR PHYSICAL RECONSTRUCTION

The preliminary investigations were so far advanced on November 7, 1917, that the Surgeon General submitted to the Secretary of War the following tentative plan for physical reconstruction and vocational training: 19

WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, November 7, 1917.

Memorandum for the Secretary of War.
Subject: Plan for physical reconstruction and vocational training.

1. It is recommended that the following plan be adopted.
2. The point has now been reached where it is necessary to begin the construction of buildings for school purposes and to arrange for the employment of teachers. It is therefore necessary that the plan receive the approval of the highest authority to which it must go preparatory to expenditure of existing appropriations, the submission of estimates for additional appropriations, and of recommendations for legislative and other action which may be necessary.
3. Reception and distribution of invalided men. The sick and wounded invalided from abroad should, so far as is possible, be received in one hospital. This hospital is to be located, if the site can be secured, on Staten Island, about 600 yards from quarantine. It will consist of the necessary buildings and staff to rapidly classify and distribute all character of cases. To provide for the rapid distribution of cases, it is necessary that local authority be competent or made competent to take final action on recommendations of the commanding officer of the hospital. If this authority can not be lodged in the commanding officer of the hospital, it should be no farther away than the commanding officer of the port of embarkation.
4. With such necessary modifications to make a smooth working machine, the following typifies the procedure at the hospital: The patient on admission to a service had his vocational and social history taken by competent persons employed for this purpose. If the hospital disposes of as many as 240 cases per day, at least 20 of these workers will be required. (See blank form attached, Exhibit A.) The patient would next be thoroughly examined by the proper medical officer, his previous history reviewed, and his present physical condition accurately recorded. If there is definite evidence that further medical or surgical treatment is required, the ward officer will make recommendation to the chief of service to that effect, suggesting transfer to one of the hospitals in the patient's home district which shall have been designated to receive cases of the kind and indicating the character of treatment needed. The chief of service will forward all of the papers to the commanding officer with his recommendations. In this type of case the question of vocational training is not considered at the receiving hospitals, but is left to be determined at the general hospital to which the patient is transferred.
5. The duty of selecting a hospital to which patients under this category are to be transferred should be placed by the commanding officer of the hospital upon the chiefs of service. It is very important, requiring a complete knowledge of the activities of the various hospitals and an accurate record from day to day of the number of beds available at each.
6. Should it appear to the examining surgeon that any patient is not in need of further treatment of any kind, having attained the maximum benefit possible, and is in his present physical condition able to follow his previous or other useful occupation without special training (the vocational and social survey must be carefully studied in all cases), he will recommend discharge on surgeon's certificate of disability. Such cases will be referred to a


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board made up of one specialist, according to the service from which the man comes, one internist, and one vocational officer. If the board agrees with the recommendation and finds that the man is physically unfit for further service, it will recommend his discharge. If, however, the board be not convinced that he has attained the maximum cure and that he is able to follow a useful occupation, it will not recommend his discharge, but will recommend transfer to a suitable general hospital in his home district. Upon these boards is placed the duty of final decision as to whether or not further improvement is to be expected from treatment and of deciding whether or not by training of any kind which is provided the man can be improved in social worth. These boards will therefore be cautioned to use extreme care in all cases and a sufficient number of them provided to enable the necessary special study of individuals.
7. Should it appear to the examining surgeon that although a patient has attained the maximum curative results possible, yet because of permanent damage sustained is certainly or probably unable to follow his previous or other useful occupation without special training, he will indicate what occupations are in his opinion possible for the patient after training.
This report with the patient will be at once referred to a vocational officer direct. The vocational officer will carefully review the case and will indicate by recommendation on the papers the occupation or occupations which he thinks the patient will be able to pursue after training and the point to which he thinks the patient should be sent to undergo training. This point will always be a general hospital in his home district, subject to exceptions indicated, even though the actual training is to be done at some other point-as, for instance, if the training is to be given at an agricultural college in Massachusetts the patient will be sent to a general hospital, preferably the one nearest his home, and from this point sent to the school. This allows the giving of a short furlough where desirable.
8. In those cases such as severe brain and spinal cord injuries where the condition is such that there is no hope of improvement by medical or surgical treatment, and who are so entirely crippled as to be quite unable to follow any occupation, as the term is usually understood, even after training, the recommendation will be for transfer to the general hospital which is especially equipped for their care which is nearest the home of the patient, except that in cases where friends or relatives are at the hospital ready to receive them and are evidently able to care for them they may be examined by a discharge board, discharged on surgeon's certificate, and placed in the care of friends. As a matter of policy it is desirable in all cases that these helpless patients be sent to hospitals near their homes.
NOTE.- It may be desirable, if a considerable number of these cases accumulate, to arrange for their discharge to a soldiers' home or special hospital for permanent care.
9. This receiving hospital will be equipped and staffed so as to classify and distribute the maximum number of patients expected during any one month.
10. In the event that patients arrive at ports other than New York, it will be necessary to have a service similar to this at the general hospital located at or near these ports. Under present plans large general hospitals will be available at practically all ports on the Atlantic seaboard.

GENERAL HOSPITALS IN WHICH PHYSICAL RECONSTRUCTION WORK AND VOCATIONAL TRAINING OF CRIPPLES WILL BE UNDERTAKEN

11. I have divided the United States into 16 districts. The basis of this division is the geographical area from which divisions of the National Army were recruited. As a result of this division we have 16 hospital districts. The attached memorandum, Exhibit B, shows these hospital areas, the States included in each, and a sufficiently accurate estimate of the number of men now in the Army from each district, including the National Army,National Guard, and Regular Army. It also shows the number of hospital beds which will be needed to serve each district, assuming an annual rate of 5 per cent of the quota from each district. This is perhaps below what is to be expected if the campaign is vigorous and casualties severe.
12. With the number of hospitals indicated established and in running order by next July it will be a relatively simple matter to anticipate such further increase as becomes


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necessary. Please note that the sites indicated for these hospitals and the number of beds to be placed at each are entirely tentative. Since the memorandum was prepared it has become evident that a number of the sites are not suitable and that it will be more economical to use other sites in place of some indicated. It is not possible to give a more accurate list of sites just now. An active campaign to discover all possible existing buildings which might be used and to determine the best sites is under way. The memorandum does not show sufficiently the general distribution which it is planned to give to these hospitals. There will be an excess of beds on the east coast. This will be necessary. The excess will not be so great as to be noteworthy. It is planned in selecting these sites to use existing posts if they can be obtained for approximately 20,000 beds. About nine of the camp hospitals of the National Guard are expected to be completed and utilized if available. The remainder will be located so far as possible in existing buildings leased for the purpose, with a minimum of new construction, bearing in mind the desirability which will undoubtedly exist of continuing quite a number of these institutions for a number of years after the war to complete the physical reconstruction and training of a certain number of soldiers.
13. General hospitals will be divided into two classes-one class to receive nothing but officers and enlisted men invalided from abroad, the other class to take all other cases.
14. What is a reconstruction hospital? A reconstruction hospital must be equipped to care for and give final treatment to sick and wounded men. It must include, in addition to the usual things seen in hospitals, what have been called curative workshops. Detailed plans for these have not yet been made. It must include facilities for giving all forms of special treatment, including hydrotherapy, etc. (See Exhibit C, which outlines what I call a "physical remedy unit.")

Taking a 1,500-bed general hospital as a typical unit, the services would be divided approximately as follows:

Medical....................................................................300
Surgical....................................................................600
Orthopedic..............................................................400
Paralyzed.................................................................. 50
Specialties, eye, ear, etc., approximately (each).. 50

It is evident that this is only an outline. A bed will serve as well for one kind of a case as another, and if there is an undue increase in one class it will be a simple matter for the commanding officer to make the proper adjustment.

VOCATIONAL TRAINING

15. Certain types of vocational training can well be begun while the man is still at the hospital. This is especially true of those occupations which are commonly called commercial. It is therefore recommended that in connection with at least one hospital in each district there be provided a commercial school to teach 250 men, with the necessary equipment and personnel. For a general outline of the plans of this school see Exhibit D.
16. For teaching agricultural work there is in course of preparation the outline of courses which can be profitably undertaken by crippled men within a period of, say, nine months. Arrangements must be made for the introduction of these courses at the various good schools which now teach agriculture.
To inaugurate these courses will no doubt entail some additional expense at the schools selected, and it may be desirable that the Federal Government defray this. The teaching staff may have to be augmented. The method of placing the men in contact with the courses given in these schools appears to be simple. All that is required is to send an officer there, preferably a medical officer if they be available; perhaps wounded officers could be utilized. This officer will have charge of what will probably be a small company, as at any other military establishment. He would be responsible for the discipline, maintenance, and general welfare of the men, leaving to the president of the school the direction of their study.
17. The matter of training men in professional lines is partially worked out but not completed. The general principles of this will be to provide the courses at Government expense at existing schools, allowing the man to attend and leaving their oversight to the


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officers detailed there for duty. If at a school having agricultural classes, they would be attached to this class; otherwise under the officer on duty there. In exceptional instances where no officer was available, the man can be left on his own responsibility, being carried on the roll of some near-by command.
18. The matter of industrial training is much more difficult and more complicated. It is perhaps the least promising of the four fields for handicapped men. It is requested that this somewhat pessimistic statement be considered as tentative only. It is expected that a complete study of this subject will be ready shortly. In this connection your attention is invited to the fact that several very experienced men have rendered this opinion; namely, that it is the most promising of the four fields for handicapped men.
19. It will be noted that to carry out this scheme will require the retention of men in the military service for a period varying from a minimum of six months to a longer period for those taking larger courses. This is not at present provided for. For the duration of the war the authority of the Secretary of War would be sufficient. For those who are to be held after the declaration of peace there would be required in most instances special legislative authority. Without being certain that the interpretation is correct, I think that one section, 304, of the soldiers' and sailors' insurance bill contemplates the reenlistment into the service of men who need training. It would seem to be a much simpler and better method for all concerned to not discharge the men at all prior to the completion of their course if they are to receive training. In my judgment the ultimate effect of the two is the same. There appear to be manifest advantages in retaining them in the service-among others, his training will undoubtedly be much more quickly completed. He is comfortably cared for, well looked after, and in general much "better off" remaining in the service than if discharged and allowed to go out for a few months or a year and then come back for his training. If he is once discharged, he goes under, at least theoretically, no control, and unless he has his home or friends is subject to many evident temptations from which he might be eventually safeguarded if retained in the service.
20. Another matter which must receive attention in the very near future is the provision of artificial appliances. A study of these is being made, and a recommendation will be submitted shortly to the general effect that all amputated or others who need artificial appliances should be furnished with them before their discharge from the service. This is believed to be possible and much more satisfactory
21. In reference to the training of the blind, a small general hospital especially equipped for this purpose is to be established. It will be in operation before it is needed. The same applies for the deaf. At both of these it will be necessary to employ a certain number of skilled teachers. It will also be possible in these, as in probably other schools, to make great use of volunteer services.
22. Your attention is further invited to the fact that in making the plans for these hospitals we are bearing in mind, so far as it is possible under the emergency demands, the development of public opinion to the degree warranted to retain similar hospitals for the training of men handicapped by industry. Figures available, which are by no means complete, indicate that the number of men who might be improved by retraining after disease or accidents in industry is equal to the number that will be handicapped by war casualties
23. With further reference to the question of employment for handicapped men, the general plan is to have at each hospital the properly qualified employment agent, who may be an officer or civilian. It is believed that this office could be installed with profit at a relatively early date. It will be the duty of the employment officer, under the general direction of the commanding officer, to have employment available for men who are discharged on certificate of disability. To this end he will keep a card index showing each patient's condition and potentialities. He will canvass his entire district by mail, by journeys, through relatives. and by a representative volunteer committee to be appointed for this duty in his district by the Secretary of War. He will keep himself fully informed regarding the desires and potentialities of the men, so that on discharge suitable employment will await each. If any patient intends to go out of his district to reside, he will communicate with the employment officer nearest the point to which the man is going, by wire if necessary, regarding the cases.


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24. This is a tentative outline of the scheme. It is in my opinion the desirable way in which to carry out physical reconstruction and vocational retraining.

(Signed)W. C. GORGAS,
Surgeon General.

EXHIBIT A. VOCATIONAL AND SOCIAL SURVEY FORM, AND PROCEEDINGS OF DISCHARGE AND DISTRIBUTING BOARDS

(By special vocational worker)

A. GENERAL

1. Name.................Rank....................Company.............Regiment
Name of hospital.................................................
Address (home)...................................................
Age (last birthday)..................Birthplace (city, county, and State).................................
If born abroad, date came to United States.....................Religion.........................
Nationality of father.......................; of mother.................................................
Occupation of father............................................
2. Man's dependents:

CHART

3. Elementary schooling:

Where obtained..............................Kind of school...............................Years...............................
.....................................................
(If more than one place or country, give time, etc, in each)
Age on leaving.................................................Grade on leaving...................................................
Reason for leaving........................................
(Needed to earn money; preferred to go to work; no higher school available, etc.)
Subsequent education:
(a) High or Secondary School. Place..............................Name of school.....................................
Course taken.........................Years.......................Grade on leaving........................................
If not, how much was completed?..................................................
Reason for not completing course......................................................
(b) Trade or technical school. .Place...........................Name of school.........................................
Course taken........................Years..........................Was course completed?...........................
If not, how much was completed?.....................................
Reason for not completing course..........................................................
(c) Business college...................Place...........................Name of college.......................................
Course taken........................Years...........................Was course completed?..........................
If not, how much was completed?..................................................
Reason for not completing course.....................................................
(d) College or university...........Place............................Name of college.........................................
Course taken......................Years...........................Was course completed?..........................
If not, how much was completed?.......................................
Reason for not completing course......................................................
(e) Evening classes....................Place............................Name of school......................................
Course taken.......................Years...........................Was course completed?........................
If not, how much was completed?........................................
Reason for not completing course.......................................................


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(f) Correspondence school..........Place........................Name of school.......................................
Course taken............................Years........................Was course completed?.......................
If not, how much was completed?....................................
Reason for not completing course......................................
(g) Private study (give subjects)...........................................................
Any other education?..........................................

Industrial history

4. Trade or principal occupation...................................How long followed.....................................
If learned by apprenticeship, or how?.......................Average wages.........................................
Other work (a)....................................How long followed?.....................................................
(b)....................................How long followed?.....................................................
(c.)...................................How long followed?...............................................
(d )...................................How long followed?.................................................
(e)...................................How long followed?...........................................
(f)....................................How long followed?.....................................
(g)...................................How long followed?................................

B. SPECIAL

5. Man's preference for future occupation:
First preference..........................................Reason for it.......................................................
Second preference.....................................Reason for it......................................................
6. Personal characteristics:
A. (a) Recreations........................................(b) Hobbies....................................................
(c) Favorite reading....................................................
(d) Habits, as drinking..............................
B. (a) Personal appearance......................................
(b) Manner.........................................
C. Intelligence (general capacity): Grade..........................................
D. Occupational stability: (a) Grade.............................................
(b) If candidate is changeable, state type of change..............................................
(c) Extent of change...................................
(d) Cause of change..................................
(e) If candidate is changeable, has the vocational officer reasons for thinking that he will become
stable?...................................If so, what?...........................................
E. Disposition: (a) Sociability..............................(b) Has candidate any emotional
characteristic that the vocational officer would consider either a business asset or a
business handicap?.........................................(c) If so, what?............................................
F. Conduct as soldier (get from record)......................................
7. Training during convalescence (subjects and results)..........................................
8. Type of vocations for which ability and aptitude are evident...................................
9. Vocational officer's preference and reasons for it.................................................
Remarks:.......................
10. Method and place of training recommended......................................
11. Estimated period............................................
Date...........(Signature)..............................
Place....................................

C. REPORT OF DISCHARGE AND DISTRIBUTION BOARD

12. Last medical board held at...................on.................191.........
Recommendations it made:.........................


15

EXHIBIT B

CHART


16

CHART

EXHIBIT C

STANDARD PHYSICAL THERAPY UNIT FOR BASE AND GENERAL HOSPITALS, UNITED STATES ARMY

This unit is planned to contain special apparatus for hydrotherapy, mechanotherapy, and electrotherapy treatment; also a gymnasium and exercise room. There are to be placed in a U-shaped building consisting of two wings 24 by 150 feet, connected at one end by a continuous section 24 by 48 feet. One glass-inclosed porch 10 by 96 feet runs the entire length of the building, connecting with corridors extending to other buildings and hospital. A porch 8 feet wide, not inclosed, extends along three sides of the building facing the court. A hot-water-supply building, 16 by 16 feet, is placed in the posterior part of tile court; the hydrotherapy department placed in the right wing. Beginning at the extreme posterior, it consists of the following:

One douche room, 24 by 48 feet, with a concrete floor draining to a center grade (in this room is the following apparatus: Four electric hot-air bath cabinets placed upon a platform raised 6 inches from the floor; one special Baruch control table for the control of the water to needle, shower, Sitz bath, and Scotch douches; one needle shower, with curtain; one seat bath; four plain shower baths); shampoo table with Leonard valve control to shampoo shower, also one special shoulder bath, one special hip bath, with connections for Leonard valve control at this table; one 12 by 12 sedative pool bath, maximum depth 4 feet, inclosed by wooden screen (this is supplied with a Lawler regulator controlling mixed water to pool and a gate valve for outflow); one scales; one drinking fountain; one sink, with drain board The next section, 24 by 24 feet, is divided into dressing room, 12 by 24 feet; toilet, 8 by 9 feet; continuous bathroom, 12 by 15 feet.

The dressing room will be equipped with benches, chairs, and hooks for clothing. The toilet has a concrete floor. It will have two washbasins, two seats, and one urinal. Continuous bathroom also has concrete floor with center grade. It will be equipped with two tubs 8 feet 6 inches long. With each is a Leonard valve control for regulating temperature.

The next section, 24 by 24 feet, is divided into two rooms, each 12 by 24 feet, for packs and special arm and leg baths. Pack room has a concrete floor which drains to center and is


17

equipped with seven white-enamel pack cots and pneumatic rubber mattresses, linen closet,blanket warmer, and pack sink with drain board.

The special arm and leg bathroom has concrete floor with a trough trench drain along inner wall. There are three local "eau courant" arm baths and three "eau courant" leg baths. Each bath has a Leonard valve control and a flexible pipe leading to trench drain to carry away outflow of water. These baths are constructed so that the arm or leg can be immersed and kept in a whirlpool of water at a given temperature. In this room is a drinking fountain.

Massage room, 20 by 30 feet, is made to have 10 white pine massage tables, 30 inches high. Corridor 4 feet wide connects the special bathrooms with the front of the building to avoid passage through the massage room.

In front of this massage room is a room 20 by 24 feet containing electric bakers. There will be six wall plugs for seven electric bakers-five, size No. 1, and one, size No. 2. There will also be six white pine tables to use in connection with these bakers.

In the front section and on the left of the room for electric bakers is a room, 22 by 30 feet, for electrotherapeutic treatment.

In the center of the front section of this unit is an office, 12 by 20 feet, which is connected by a corridor with right wing. A desk is placed in the center of this room. All patients entering or leaving building must be checked in or out through this room.

To the left of the office and extending across the front part of the building is a room, 24 by 40 feet, for mechanotherapy. This room contains the following apparatus:

Special apparatus for -
1. Circumduction of arm and shoulder joint;
2. Rotation of arm and shoulder joint, active and passive;
3. Lowering of arms with flexion of forearm;
4. Flexion and extension of wrist;
5. Flexion and extension of forearm;
6. Pronation and supination of forearm;
7. Circumduction of hand;
8. Flexion and extension of fingers;
9. Extension of the thigh and leg;
10. Flexion of the thigh and leg;
11. Flexion and extension of the knee;
12. Circumduction of the foot;
13. Pulley weight apparatus for various exercises.

The entire left wing, 24 by 126 feet, is devoted to a gymnasium, exercise room, and space for such future extension as may be required.

In the inner corner and just back of the room for mechanotherapy is a lavatory having two toilets, a washbasin, and a urinal.

EXHIBIT D

SUGGESTED PLAN FOR A SCHOOL TO TRAIN CRIPPLED MEN FOR COMMERCIAL OCCUPATIONS

The plan herewith submitted is based upon the assumption that the men who attend this school have been examined by a committee which has determined that they can profitably enter upon preparation designed to fit them for employment in a commercial occupation. By commercial occupation is meant one dealing in the selling, accounting, recording, and correspondence necessary in commerce. It also includes those occupations classified by the civil service as clerical, or stenography and typewriting.

The plan is not predicated upon an assumption that a given number will wish to be trained in any specific occupation, but is planned to offer training in almost all of the more common commercial occupations and to care for 250 men regardless of the number to be trained for particular lines. It seems advisable to make provision for offering these men the choice of training for a wide variety of occupations rather than to arrange a necessarily limited number of classes upon an assumption of what that choice may be, which at best would be only a conjecture, regardless of the nature of the study upon which that assumption might be based.


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It is impossible to formulate any estimate of the number of men who will desire, or who should receive, instruction for each occupation. While it is quite probable that the injuries which they receive will be similar both in number and character to those suffered by soldiers of the allied armies in Europe, at the same time any estimate of the nature of the injuries, the former education, and the vocational desires and aspirations of the men from any particular section of the country could not be depended upon as a basis for planning a school. For these reasons the plan is extremely flexible and can readily be adapted to meet the needs of almost any group in so far as commercial training is concerned.

At the close of the war there will no doubt be many generous employers who will at once offer employment to injured soldiers and who will be willing to pay a fair wage whether it is earned or not. These philanthropic motives of employers can not be accepted as a basis for the establishment of a school, nor is it fair to expect employers to subsidize these handicapped men. Any plan for educating the wounded soldier must accept as its function making him, in so far as possible, an independent, wholly self-supporting, self-respecting workman who receives his wage because he earns it and is in no sense an object of charity.

The soldiers and sailors' insurance law provides that the disabled man's pension shall not be affected by his becoming able to contribute to his own support, and there are conclusive arguments in support of this provision. The experience with the disabled soldiers of all the European armies has demonstrated that men will make no efforts nor follow any training which will operate to diminish or discontinue their pensions. Training and subsequent employment are necessary to insure the maintenance of their social integrity, and therefore must be provided.

Existing institutions are not organized or prepared with space, teachers, and courses to give these men the instruction which is required to meet their special needs. A majority of the existing commercial schools are designed primarily to instruct young people in their later teens. Such schools as do give commercial instruction for adults are almost exclusively evening schools, with the exception of colleges and universities offering commercial instruction which usually limit this work to senior college and graduate students. The subject matter of these college courses is, as a rule, theoretical and adapted to only such persons as have completed a junior college course. The men whom the herein proposed school is designed to teach will not be in a condition physically to travel distances to and from class each day and in many cases will not be physically able to do the same amount of work that able-bodied students do in classes. Other factors, such as the diversified courses needed, dissimilar abilities and mental condition of the men and their reluctance to appear at a disadvantage among other students, require that they be trained by themselves and not in classes with men and women not similarly afflicted. The only means by which the situation may be met seems to be the establishment of special schools conducted in the military hospitals.

Considerable emphasis should be given to the fact that these men have given up in most cases fairly remunerative positions to go to the defense of their country. Their positions have been taken by others who did not go with the Army. The returned soldier's claim on an opportunity to earn a livelihood is not to be considered a concession to be granted, but rather a right to be recognized. The national emergency has made it necessary for him to leave his position, and he has in the national service not only lost the ability to follow his former occupation, but has had his range of possible occupations limited. It is altogether reasonable to expect the men who have made no such great sacrifice for their country to so readjust them selves occupationally that the employment for the disabled soldier will be possible to the lines to which his injury has limited him. The solution of the problem of the man whose position is jeopardized by the readjustment lies in his taking advantage of the present opportunity to prepare himself for advancement by attending one of the schools now in existence.

The selection of training to be given can not be based upon the idea of an even distribution among all the occupations regardless of the limitations of the injured man. Each individual soldier gave up at the call or command of his country a position which presumably he was capable of filling satisfactorily. It is the duty of the country, in so far as possible, to reinstate him in a position where he can do the work in as satisfactory a manner as before.

In determining a basis for the selection of occupations, or of training preparatory to an occupation, for disabled soldiers, men with two types of disabilities must be considered -


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namely, those who have been so incapacitated that they are incapable of ever becoming, by their own efforts, entirely self-supporting, and those capable of self-support when they have been properly trained. For the latter type the basis for selection of an occupation of should be -

(a) The occupation must be such that the injured man can, with his limited physical equipment, perform all the duties which the work requires.
(b) The occupation must be one in which there is a constant demand for workers.
(c) It must offer the possibility of employment and a livelihood.

Men whose disabilities prevent their becoming at best more than only partially self-supporting should be trained for occupations in which (a) they can probably find employment; (b) which will occupy their time and prevent their becoming idlers; (c) which will call for the exercise of their entire physical and mental resources.

Many, if not all, of the occupations designated as commercial can be entered readily by injured men if they have had the necessary preliminary training. Because of the opportunities which these occupations afford for the attainment of a fair degree of success and the possibilities of earning a good livelihood therein, it is planned to offer thorough training in these lines to the men returned from the battle field. Unlike many of the industrial occupations in which the value of a workman depends to a large extent upon his expertness in the manipulation of materials-that is, on his muscular dexterity-success in commercial work depends to a large extent upon a man's mental equipment. The two elements which determine the value of a workman in almost any occupation are intelligence and muscular dexterity, the proportion of those two elements varying in different occupations. It is obvious that when one of these elements is diminished the other must be increased if the man is to maintain his former wage-earning capacity and a corresponding standard of living.

In a few of the commercial occupations the crippled man is under no handicap whatever. The work is such that no considerable amount of manual work is required, and the man who has lost one arm and has had the proper training can do all the work required quite as well as one who has not experienced his misfortune. Selling real estate and insurance are examples of work of this character. Some other occupations call for very little use of the lower limbs, and therefore the man who has lost one leg, or in some cases even both legs, can perform all the tasks required. Stenography, bookkeeping, and accounting are examples of this type.

In selecting men to be given training of this character and in admitting men to this school men lacking the necessary minimum of schooling will not be assigned for commercial training. It is realized that many men unfortunately situated in their youth were unable to attend school beyond the completion of the eighth grade, but have by their own efforts, through study and reading, together with their experience, enlarged their own education and mental capacity. On the other hand, many men who in their youth had the advantage of a full common-school course have, by bad habits both mental or physical, allowed their mental powers to atrophy to such an extent that all efforts to stimulate mental growth would be futile. The determining factor in admitting men to the commercial school will not, therefore, be the possession of a common-school certificate but the verdict of the vocational committee of the hospital in which the man has been cared for. Generally speaking, however, no man will be admitted to the commercial course if he has not had the equivalent of an eighth-grade education.

The school unit is planned to take care of a group of 250 men. It is assumed that the injuries which these men have suffered will be approximately the same in character as those suffered by men in the allied armies. According to the statistics published in the report of the Inter-Allied Conference held in May, 1917, of 250 men who have suffered amputations, 95 have had amputations of an upper limb and 155 of the lower limb. The number who have suffered amputation of both arms or of both legs is practically negligible, since these statistics show that only 2 among each 10,000 have suffered the amputation of both arms and only 30 of both legs.

Courses to be offered

It is impracticable to offer specialized courses with special instructors for all of the varied lines of commercial activity. The plan submitted herewith provides for thorough and complete courses in stenography and typewriting, telegraphy, salesmanship, bookkeeping, accounting, and advertising, with provision for giving specialized instruction in numerous


20

other lines by means of texts, courses, and lesson sheets, which may be secured for individuals desiring these specialized courses from the extension divisions of the various State universities and the correspondence schools.

Organization of school

The school is to be operated as a part of a military hospital, but with a principal or director working under the direction of the commanding officer of the hospital. No man will be allowed to enter upon preparation for a line of work without the approval of the proper medical authority. Should the proper medical authority of the hospital at any time ascertain that the school work is proving injurious to the health or recovery of the soldier, he shall at once cause the work to be discontinued.

With these limitations, the director or principal shall have full charge of the instruction. He will plan the courses, arrange the classes, supervise instruction, and secure special instruction sheets and courses from various sources for men interested in special lines of work. He shall also seek to secure the cooperation of local business establishments to the end that the students may have the benefit of practical experience in the line of work for which they are in preparation. He shall also seek to secure lecturers from among local business men, such as insurance agents, advertising managers, printers, lithographers, engravers, floor walkers, office managers, etc. In addition he shall provide evening lecturers and motion-picture illustrations of the manufacture of various products, of efficiency methods, office organization, methods of selling and advertising, etc., under the general regulations governing the school.

Plan of teaching

There are some lines of work which are fundamental in all lines of commercial employment. Among these are English and mathematics. In recording occupations a knowledge of bookkeeping and the principles of accounting are necessary. In general office work a knowledge of shorthand and typewriting and the composition of good business letters is essential. In all lines of selling the man must know and practice the principles underlying successful salesmanship.

Therefore, regular classes in English, mathematics, shorthand, typewriting, advertising, letter writing, bookkeeping, and accounting have been provided for. The instruction in these fundamentals will not only give the man a knowledge of the subject, but will also develop power of concentration and methods and habits of study which are necessary to the success of the entire plan of the school.

The above subjects may be regarded as the constants in the plan. The variables - that is, the special subjects-will be taught in the following manner: The department will provide carefully developed printed or mimeographed courses or lesson sheets, which if studied and understood will give the men the necessary training in that subject. In many cases the excellent courses prepared by the universities for giving home-study courses to their extension students and the courses of the correspondence schools will be utilized. To supplement these courses and to inspire, stimulate, and assist the student, provision will be made for a man fully informed on the subject matter of the course to meet and consult with the student at regular stipulated times. By this means, training in the following lines will be offered: Cost accounting, municipal accounting, railroad accounting, auditing, banking, insurance, real estate, business law, store management, industrial management, lunchroom management, algebra, trigonometry, surveying, bonds and investments, proof reading, window decorating, and preparation for various civil service examinations.

This plan, which has been so admirably developed by the extension departments of various universities and proven so eminently successful with thousands of students, has the following advantages:

(1) With a limited equipment the school can offer instruction in an almost unlimited number of subjects.
(2) The student can advance as rapidly as his ability and his application to the work will permit. The man, moreover, who does not apply himself diligently will be stimulated by his consulting instructor. The slow student can proceed at a rate which allows him to do the work thoroughly without retarding others who grasp the work more readily.


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(3) The student develops initiative and self-confidence and does not rely too much on his teacher, as students in classes are oftentimes inclined to do. He gains the power of self-education and the habit of relying upon himself, which will prove valuable after he leaves the school.
(4) By using courses which have been developed carefully by the universities and revised by these institutions after considerable experience with the students, the high quality of the instruction is insured.
(5) An instructor can meet a large number of students in a short space of time, giving each the necessary special attention and assistance.

Procedure

Soon after the soldier arrives at a general hospital having a commercial school a committee composed of the superintendent of the hospital, the principal of the school, and the man himself will carefully consider his vocational and educational record and determine the particular occupation for which he shall be trained. The principal will then give the man a program of subjects he is to study and classes he will attend.

The soldier will each day attend the classes giving the fundamental subjects required by his course, and during the school hours when he is not attending classes he will be in the assembly study room, where he will be assisted and supervised in his study by an instructor. When the student takes up a special line of work for which regular classes are not held, he will prepare his lessons in writing and submit them to an instructor. When he desires assistance, he will report at a designated hour to the instructor in charge of the work.

Each student shall be assigned to a "faculty adviser" who shall be expected to carefully supervise his work, encourage, and advise him. The faculty adviser will act in the capacity of friend and counselor and be held, in a measure, responsible for the progress of the students assigned him.

The faculty adviser shall cultivate the friendship and endeavor to secure the confidence of the students assigned to him. He shall carefully note the conduct and progress of his charges and at all times be in a position to give advice or suggestions. Should difficulties arise between any man and his instructor, the faculty adviser shall endeavor to adjust the matter in a satisfactory manner. Should the adviser find that a student is incapable of continuing the course in which he is entered, the adviser should tactfully advise that the course of the student be changed.

Weekly reports of class attendance and the grade of work of each student should be filed in the office of the principal. Whenever the work of a student is unsatisfactory, notice of this should be sent to the student's adviser from the principal's office. When the student has progressed to the extent that his discharge seems advisable, the adviser shall notify the principal to this effect. The principal will, from data with which he is provided, determine the possibility of employment in the man's home community. He will communicate with prospective employers, and when a position shall have been found will take up with the proper Army authorities the matter of the man's discharge. When a position and the discharge have been secured, the man will be handed his discharge, a certificate of graduation from the school, and an offer of a position.

Qualifications of teachers

For the teaching of the manual activities required by the occupations, teachers will be provided who have themselves overcome the handicap of physical disability-that is, in so far as possible one-arm men will teach one-arm men, etc. The teachers of commercial work shall be men who have had practical commercial experience in the lines of work which they are to teach. In so far as possible they shall have also had some experience either in the handling of men as foremen or superintendents or in actual teaching of their line of work to adults.

Subjects included in various courses

(a) Stenography, shorthand, typewriting, multigraph operation, mimeograph operation, filing, English composition, letter writing, spelling, punctuation, etc. Student may also select additional work in the following subjects: Accounting, commercial correspondence, and rapid calculation.


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(b) Salesmanship (principles of salesmanship); English (effective use of language, choice of words, etc.); sales letters (student to study certain special lines such as insurance, real estate, automobiles, textiles, shoes, furniture, or other merchandise sheets on these subjects prepared by insurance companies, university extension divisions, correspondence schools, and commercial establishments).
(c) Bookkeeping and accounting (bookkeeping and principles of accounting; penmanship and selling); student may elect cost accounting, railroad accounting, auditing, banking.
(d) Advertising (principles of salesmanship, practical psychology, study of printers' type, spacing, engraving, etc.); English (the student will here receive instruction in the practical layout of advertisements with drawing board, lettering pen, brushes, etc., showcard writing, sales letters, etc.).
(e) Civil-service course (this course will seek to prepare men to successfully pass the civil-service examination of city, county, State, and national civil service commissions) - shorthand and typewriting; spelling and composition; bookkeeping and principles of accounting; mathematics; letter writing; geography; history.

Whenever a group sufficiently large to warrant the organization of a special class wishes to have class instruction in any particular line of commercial work or civil service, such as preparation for postal clerks, a class will be formed and a teacher be provided. In all of these courses provision shall be made for extreme flexibility. When a man's previous training or experience makes training in certain subjects unnecessary, he shall not be required to take this work. When any man wishes to specialize in any particular branch of any line, he should be allowed to do so. In general, no more than one year's instruction is to be offered, and whenever the hospital authorities are convinced that the man is capable of earning a fair livelihood in an occupation and a position has been secured for him he shall be released from the school and permitted to enter upon employment, provided the medical authorities are convinced that his physical condition is such that he will experience no injurious effects therefrom. So long as the school remains in session, any soldier who has been released from the school who finds that his instruction is inadequate may be readmitted to receive additional instruction.

Character of instruction

In all the work offered in this school instruction should be of an extremely practical nature. Wherever possible, pupils should do work of the character for which they are being trained for the hospital organization. For example, students in stenography after they have attained some proficiency may be assigned to do the letter writing of physicians, the principal, and teachers; students in bookkeeping should keep the accounts for the institution; arrangements should be made, whenever possible, for students in salesmanship to spend a portion of each week acting as salesmen for local stores, local insurance companies, automobile concerns, etc.; students in advertising should spend some time visiting advertising departments of stores, printing shops, engraving offices, etc.

Each teacher should have a certain specified time when he will be in his room for the purpose of consulting with students who wish special help or who wish some training differing somewhat from the regulation work of the school.

Students taking special courses of university extension divisions or correspondence schools, such as insurance, real estate, or cost accounting, will have the opportunity to receive individual assistance from their teachers. In some cases it may be possible to engage the services of a business man, such as an insurance agent, who will devote one or two evenings a week to consulting with men preparing for his line of work.

Teachers

The above unit for the training of 250 men will require the services of 11 teachers as an initial number, in addition to the principal or director, as follows: One teacher of English grammar and composition, one teacher of mathematics, one teacher of bookkeeping, one teacher of accounting, one teacher of stenography, one teacher of typewriting, one teacher of advertising, one teacher of salesmanship, one teacher of geography and history and similar academic subjects, one teacher of telegraphy, and one teacher of the use of artificial limbs.


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Necessary equipment and approximate cost

10 portable blackboards, at $10

$100.00

150 kitchen tables, approximately 30 by 36 feet, at $3
each, to accommodate two men

450.00

300 chairs, at $1.50

450.00

20 typewriters (assorted makes), at $50 (this is the special
rate at which schools purchase typewriters)

1,000.00

20 typewriter tables, at $6

120.00

1 mimeograph

100.00

20 drawing boards, at $0.75

15.00

20 student telegraph outfits

150.00

Pens, pencils, paper, ink, etc

400.00

Total

2,785.00


Should it be found desirable to train mail clerks, special mail cases such as are used in post offices should be provided.

The following machines are very desirable and would add greatly to the effectiveness of the instruction: One adding machine, one multigraph, one addressograph, and one billing machine. Arrangements can no doubt be made whereby instruction can be given in their use in banks and other establishments of the city in or near which the hospital is located.

Bookkeeping. - The form of an account; the merchandise and each cash account; accounts with persons; the journal, ledger, and trial balance; bills receivable and bills payable accounts; the expense account and the interest account; the proprietor's account; closing the ledger; the statements; the cash book, purchase book, and sales book, how to figure interest and discount and how interest and discount affect bookkeeping entries; the accounting of drafts; the use of controlling accounts; special ledgers and various labor-saving devices in bookkeeping; the principles of single entry; changing from single entry to double entry; closing double-entry books through the journal; adjustments in ledger accounts; merchandise sales and merchandise purchases accounts; the elements of business practice; continual practice in all the principles that are presented.

Commercial correspondence. - Choice of words; how sentences are constructed; problem of the paragraph; how to punctuate; mechanical form of the letter; the paper; letterhead and envelopes; use of stereotype expressions; essentials of all business letters; orders, acknowledgments, and remittances; inquiries, recommendations, and house letters; complaints and how to adjust them; letters of application; letters of inspiration; credit and collection letters; the sales letter-principles of salesmanship and their application; follow-up systems; preparation and use of the form letter-its possibilities and limitations; duties and qualifications of the correspondent-helpful aids in his work; filing systems; postal information; general requirements of foreign correspondence.

Insurance. - Origin and nature of insurance; kinds of policies; definitions; parties to the contract and form of the policy; insurance interest; representation and concealment; warranties; special requirements of policies; principles of waiver; time of forfeiture and waiver; losses covered by the policy; recovery and subrogation.

Cost accounting. - The elements of cost; the terminology of the science; cost conditions in particular industries; the cost-finding unit; labor and wage systems; distributions of department and general burden; office and selling expenses; installation of a cost-accounting system; fitting a cost system into the general accounting system of a business; stores system; the use of cost findings in the determination of business policies.

Retail-store management. - Store organization; scientific management in retailing; how to analyze a retail store; the four chief departments and their functions; lines of authority and relation of departments. Store policy--what it means; attitude toward customers; trade-marked and nationally advertised goods; the one-price system; store democracy; telephone courtesy; treatment of special classes of customers; store service. Standards of efficiency--the store itself; standards for sales people; standard condition for employees; training of employees; how to judge their efficiency. Cost of selling--what is profit; taking the inventory; determining the turnover; classification of expenses; how to figure profits.


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Buying. - where to buy; buying methods; when to buy; buyer's qualifications; how to get knowledge of goods; what to buy; how much to buy; how to study needs of a community; pricing the stock. Retail advertising-some general principles; store news; when to advertise; mediums; descriptions; headings; illustrations; prices; work of the advertising manager; cooperation between selling and advertising. Retail credits and collections-some of the more important general considerations. Relation of the store to its sales people and to the public; bases of compensation; profit sharing; welfare work; education of employees; treatment of the public; appendix containing list of trade papers and books on retail salesmanship.

Retail selling. - Introduction-the purposes of retailing; fundamental problems of retail selling; factors in selling. The salesman-reasons for salesman; qualities of successful salesmen; the salesman's preparation and technical knowledge. Analyzing the goods--selling qualities; how they may be discovered; methods of demonstration of goods. Psychology of selling-how to study people; how the brain and nervous system are constructed; how the brain works; how the mind gets ideas; explanation of memory and how to improve it; human instincts and their application in business; the explanation of habit. Steps in a sale--practical methods of attracting attention to goods; arousing interest and desire; when and how to close the sale; methods to be used with different classes of people; how to meet common objections; meaning and use of suggestions. Special problems in selling--personality and what it means; how to develop the right personality; how to develop tact in selling; the proper attitude toward customers. Losses and leaks in retailing--the salesman's part in reducing them; suggestions for reduction of store expense. Principles of art applied to retail stores; principles of form and color; application of those principles to the store itself; the display of goods, store decorations, store fixtures, and window trimming.

Advertising. - The nature of advertising-what it will accomplish if properly used; why the progressive store must advertise; the class of goods which are best suited to advertising. Definition of a selling point-how to find selling point of merchandise; how to use selling points effectively after they are found. Writing the advertisement-how the selling point may be most effectively expressed in language; the headlines and the subhead; various types of headlines; kind of headlines to use in different situations. The layout--how to make a layout for a one-article advertisement; type measurements; the point system; how to figure the amount of space an advertisement will occupy; body-type sizes; faces and names; the same for display type; printing terms; borders and illustrations studied from both the mechanical and artistic point of view; proof reading. The relative importance of small and large space-how to make the most of small space; the salient features of display for the many article advertisements. Planning the whole retail advertising campaign--the yearly plan; necessary reports on which to base advertising; division of the appropriation both as to time and medium; the value of newspaper and street--car cards as mediums. A discussion of other forms of advertising mediums, such as store circulars, store paper, package insert, and a number of others. The sales letter-how to write a strong selling letter; what subjects to touch upon; when to use selling letters; outline for a mail--order campaign, including the various details which must be considered in order to make a successful bid for business by mail. Window display-interior display and arrangement; show cards. Correlating all the sales efforts of the retail store--questions of policy; training of clerks; store records; word-of-mouth advertising; how to take advantage of the regular trade movements; store organizations; and similar matters of importance.

Principles of accounting. - Fundamental accounting principles-the field of accounting; scope of individual accounts; classification of accounts; use of controlling accounts. Development of special books or original entry-classification of books of account; development of journal, cashbook, sales book, and purchase book; use of multicolumnar books. Partnership accounts-accounting clauses in partnership agreement; investment and drawing accounts; division of profit and loss; methods of figuring interest on investment; admission of new partner; dissolution. Merchandise account-wrongly kept as mixed account; methods of recording inventory, purchases, and sales; the trading account; perpetual inventory. Revenue account and statement-technical and statement form of profit and loss account; sectionalization of revenue account to provide complete information. Balance sheet-what it shows; difference between balance sheet and statement of assets and liabilities; different


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forms of balance sheet; arrangement of items; comparative balance sheets; consideration of balance-sheet items from standpoints of proprietor, banker, and auditor. Good will, reserve funds and accounts, and depreciation-valuation of good will; finding the earning power of a business; good will as an account; reserve funds and accounts distinguished; difference between depreciation, fluctuation, appreciation, and maintenance; depreciation factors; methods of writing off depreciation and recording it. Preparation and use of schedules and exhibits--uses of exhibits and charts for different businesses; instructions for their preparation. Introduction to corporation accounting-kinds of corporations, their powers and advantages; the stock system; value of shares; kinds of stock; stock books and other books of a corporation; summary of Wisconsin law relating to private corporations. Opening corporation books--converting partnership into corporation; increase and decrease of capital stock; new stock issues; treasury stock; surplus and dividend accounts; manipulation of reserves to decrease dividends. Basis of capitalization--consideration of invested capital earning power and assets and good will as bases for capitalization. Bonds and funds-kinds of bonds; sinking funds; accounting for discounts and premiums on stocks and bonds. Profits, dividends, and corporation tax-definitions; payment of dividends (Wisconsin law); relation between dividends and various kinds of assets; stockholders' rights with respect to dividends; corporation tax law, its violation of accounting principles; official explanation of the law; possible changes. Voucher systems-recording of expenditures; receipts; voucher receipts and checks; monthly payment of systems; voucher register; test proofs. Prevention of fraud by accounting-check of ownership; employees' responsibility; duplicate responsibility; preventing fraud in cash and merchandise accounts; safeguarding personal accounts; protection by cost finding. Designing and accounting system--relation of accounts to business conditions; basis of the system; adaptation to particular conditions; classification of accounts; books to be used.

A number of occupations which are not generally considered commercial occupations are quite similar to commercial occupations in that the demands made upon the worker are more mental or technical than physical.

The work is usually done in an office and not in a shop. For this reason training for these occupations may be given in the proposed commercial school without any considerable additional expense. These occupations differ from commercial occupations in that they require a knowledge of shop processes and practices. They therefore offer excellent opportunities for crippled soldiers whose previous experience has given them the requisite knowledge of shop practice. Among these occupations are those of tracer, architectural draftsman, mechanical draftsman, linotype operator, monotype-keyboard operator, and proof reader.

Men with previous experience in carpentry, but who have a nicety of touch-that is, a fine coordination of the muscles of the hand which will make it possible for them to be neat about the work-may learn tracing and later become second or even first-class architectural draftsmen. Their first training should be in the use of drafting instruments, to be followed by sufficient training and practice to make them expert in lettering. At the same time they should study mathematics and plane and solid geometry. This field is especially promising for men with a fair education and previous experience in carpentry work who, because of injuries to their lower limbs, have become unable to climb ladders and work on roofs and scaffolds.

Injured men with experience in machine shops can follow a similar course to prepare them for work along the line of mechanical drafting and machine designing. Their first train ing should likewise be the use of drafting instruments, lettering, and tracing. They should also study shop mathematics, shop drawing, sheet-metal drafting, strength of materials, elements of mechanics, machine elements, and machine designing.

Linotype and monotype operation offer excellent opportunities for injured printers. The operators of these instruments are seated at their work, which makes these occupations desirable for printers who have received injuries to the lower limbs. To be expert in the operation of either of these machines a man must have had experience in the printing trade. There is a strong prejudice in the printing trade against the teaching of these occupations to any persons except experienced printers, and it would be difficult to find employment for a


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man who knew only the operation of these machines and had not a thorough knowledge of the printing trade. For these reasons it would be unwise to offer instruction of this character to any but experienced printers.

The number of proof readers employed in any community is necessarily limited, as small establishments do not have sufficient work of this character to employ a man to devote his entire time to it. In cities, however, the opportunities for employment are numerous in printing and publishing establishments and in editorial offices. This occupation requires on the part of the worker a thorough knowledge of English grammar and composition. A proof reader should have at least a superficial knowledge of type and type setting and be familiar with proof readers' marks. In addition to good eyesight, the work does not make any great physical requirement, and a man with no lower limbs and only one hand could do the work in a satisfactory manner. For this reason this occupation seems to be a very desirable one to be taught to crippled soldiers with the necessary intellectual ability.

Shop drawing. - Principles of shop drawing-explanation of views and their arrangement in third angle projection; problems in making drawings of well known shop objects; object lines; center, extension, and dimension lines; finish marks; symbols for machine operations. Screw fastenings-bolts; machine and cup screws; studs; forms of threads; multiple threads; thread conventions; tapped holes; drawings of screw fastenings and threaded machine parts. Sections--uses of full and half sections; cross hatchings for different materials; drawing of machine parts shown in section. Sketching--pencil sketching: materials used; method of procedure; pencil sketches of shop objects. Assembly and detail drawings-the construction of complete assembly drawings from detail sketches; making detail drawings from an assembly drawing. Gearing--spar, bevel, and spiral gearing; gear calculations; working drawings of gears; dimensions of gears. Special methods of projection-oblique projection; intersections; isometric drawing; cabinet projection; shading, etc. Special conventions--electrical conventions; conventions used in structural steel work, plumbing, steam fitting, etc.; patent drawings; rules for patent drawings. Advanced problems detail and assembly drawings of complete machines; advanced sketching; intersections and developments.

Shop mathematics - topics treated. - Common fractions-explanation of fractions; reduction of fractions; addition, subtraction, multiplication, and division of fractions; cancellation; practical problems. Money and decimals-wage calculations; wage systems; decimal equivalents of common fractions; addition, subtraction, multiplication and division of decimals; the micrometer; percentage; efficiencies. Circular measure--measurements of circles; speeds of pulleys, belts, emery wheels, etc.; cutting and grinding speeds. Ratio and proportion---simple ratios; proportion; pulley and gear ratios; gear trains; screw cutting. Mensuration--areas and volumes of simple figures; weights of materials; shop rules for plates; calculation of weights of castings from patterns. Involution and evolution--squares, cubes, and higher powers; square root and cube root; practical applications; the law of right triangles; use of mathematical tables. Principles of simple machines-types of simple levers; compound levers; the wheel and axle; gearing; pulleys; the differential hoist; the inclined plane; the wedge and screw; jack screws; efficiencies. Work, power, and energy--definitions; units of work and power; horsepower of belts; rules for belting; horsepower of steam and gas engines; principles of hydraulic and pneumatic machines; nature of heat; expansion and contraction; shrink fits. Strength of materials--tensile, compressive, and shearing stresses; ultimate strength; factor of safety; working stresses; strength of metals; strength of rope; strength of chains. Formulas--the use of letters; substitution in formulas; use of the parenthesis; writing formulas; like and unlike terms; positive and negative quantities; formation of equations. Solution of formulas-addition and subtraction of terms; transformation of equations; cancellation; algebraic multiplication and division; factoring; simple equations; simultaneous equations; quadratic equations. Tables and curves-use of tables; preparation of tables; use of curves; plotting; kinds of curves; reading curves; equation of curves. Geometric constructions-lines and angles; simple line constructions; constructions of angles; circular constructions; constructions of regular polygons; properties of regular polygons; spacing circles; the ellipse; problems in laying out work. Areas of geometrical figures--the triangle, square, rectangle, parallelogram, trapezoid, rhombus, pentagon, hexagon,


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octagon; areas of circles, segments, and sectors; area of ellipses; areas of irregular figures; the planimeter. Solids-volumes and surfaces of prisms; cylinders, pyramids, cones; frustums of pyramids and cones; segments of spheres; rings; flow through pipes; the prismoidal formula; volumes of irregular objects. Trigonometry in the shop--the tangent and cotangent; laying out angles; measuring angles; shop uses of the tangent; applications to gear cutting; use of trigonometric tables; calculating heights and distances; tapers and taper turning; the sine, cosine, secant, and cosecant; dimensions of various screw threads; multiple threads; spiral gears. Solution of triangles--functions of oblique angles; the relations of sides and angles in any triangle; applications to shop problems; areas of oblique triangles. Logarithms--the principle of logarithms; multiplication and division by use of logarithms; use of tables; finding powers and roots by use of logarithms; fractional powers.

Mechanisms and machine elements. - Linkages-tracing path of a point in a linkage; laying out linkage problems for different conditions of operation. Cams-motions commonly used; disk cams with reciprocating or rocking followers; positive-motion cams; cylindrical cams; inverse cams; working drawings. Gearing-definitions; types of gears; spur gears; bevel gears; worm and spiral gears; involute and dycloidal systems; cutting gear teeth; ratchet gearing. Belting-velocity ratio; crowning; stepped pulleys for constant length of crossed and open belts; quarter-twist belts; arrangements for connecting shafts at odd angles. Materials and metal-working operations-founding; forging; machining; punching. Friction and lubrication-causes and effects of friction; coefficient of friction; lubrication; lubricants; methods of lubrication. Screws and screw fastenings-pitch; multiple threads; form of thread; forms of head; machine screws; cap screws; bolts; studs; set screws; nut locks; strength of screws. Other than screw fastenings-keys, pins; cotters, shrink and force fitting; working stresses and factors of safety. Shafting and couplings-materials used and kinds of shafting; strength of shafting under single and combined stresses; horsepower transmitted by shafting; hollow shafting; rigid couplings (sleeve, clamp, flange, Sellers); detachable couplings (lug clutches, friction clutches); couplings for shafts not in alignment (Oldham, Almond, Hooke, flexible disk, and leather link). Bearings-right line bearings; journal bearings; methods of adjustment and alignments; methods of supporting journal boxes on wall, ceiling, and floor; thrust bearings; ball and roller bearings. Pulleys and flywheels--forms and materials; stresses in wheels; proportions of parts; kinetic energy of flywheels. Gearing--Strength of gear teeth; formulas for computing horsepower; efficiency of gearing. Belting and chains-flat belting (materials and application of each); fastenings; horsepower; arrangement of belting and pulleys; care of bolting; cordage-rope driving; wire-rope driving; hoisting chains; chain driving; sprocket wheels; link belt; silent chains.

Strength of materials. - Direct stresses-ultimate strength; elastic limit; factor of safety; working stresses; properties of materials. Bending stresses--moments; reactions; resisting moments; moments of inertia; types of beams; resistance to shear and bending;safe loads; design of beams; comparative strength of beams; standard steel sections. Columns or struts-radius of gyration; column formulas; safe loads; design of columns; use of steel sections; hollow round columns; wooden columns. Elastic deformations-modulus of elasticity; deformations under direct stresses; deflections of beams; twists in shafts; temperature stresses. Reinforced concrete-concrete and steel; compound bars; reinforced columns; reinforced beams; design of beams. Torsion-polar moments of inertia; formulas for torsion; shafts to transmit power; solid and hollow shafts; shaft couplings. Strength of cylinders-riveted joints; lap joints; butt joints; spacing of rivets.

Sheet-metal drafting. - Regular geometric figures intersected by a plane-gutter and cornice miters; ventilating flnes; pipe elbows; funnels; exhaust flues; boot legs; boiler smoke-flue connections. Intersections of geometric figures-steam dome; conical eave-trough outlet; conical foot for hot-air pipe; coffeepot; hopper and chute; ventilator head. Triangulation--transition piece; smoke-flue connection; forge hood; inverted Y-boiler breeching; automobile cowl; footpiece for hot-air stack. Miscellaneous problems--cornice work; bay-window soffit; pedestals; skylights; ship funnels; sheet-metal spheres and other surfaces of double curvature.

Elements of mechanics. - Concurrent forces-components; resultants; conditions of equilibrium; resultants of concurrent forces; parallelogram of forces. Noncurrent forces-


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parallel forces; moments; resultants; couples; parallel forces in space; centers of gravity; stable and unstable equilibrium. Resistance and work-friction; coefficients of friction; motion on inclined surface; work against friction. Simple machines-lever; compound lever; inclined plane; wedge; screw; pulley; differential pulley; efficiency of machines. Gravity and motion-velocity and acceleration; vertical and oblique fall; potential and kinetic energy; motions of projectiles; composition of velocities. Inertia and rotation--inertia and energy; centrifugal force; revolving bodies; rolling bodies; pendulums.

ELABORATION OF ORIGINAL PLAN

Additional data to be included in the plan of November 7 were submitted in memorandum form to War Department December 4, 1917. The memorandum is as follows: 19

DIVISION OF RECONSTRUCTION AND REHABILITATION OF DISABLED SOLDIERS, SURGEON GENERAL'S OFFICE

The division of reconstruction and rehabilitation in the Surgeon General's Office is arranging for the functional restoration and reeducation of the disabled soldiers. This division has now been in operation for almost four months. A definite program of action has been developed and the necessary studies and plans connected with this problem are now nearing completion. In order to secure your ratification of these plans and to set forth the important details of our program, the following outline is submitted:

I. DEFINITION AND PURPOSE

a. Physical reconstruction consists in applying all medical and surgical measures which will functionally restore the disabled to as near normal as possible. Rehabilitation consists in training the disabled man to again be a productive agent in spite of his handicap.
b. All kinds of mechanical appliances and shops of light occupations will be installed in connection with hospitals to assist in this functional restoration.
c. The reeducation of disabled members and the vocational training of men so disabled that they must learn a new occupation by the methods necessary to start this rehabilitation.

They must begin as soon after the injury as possible. In addition a man must be carefully supervised until complete rehabilitation has been accomplished.

1. In England medical reconstruction is completed before the men are discharged from service, but vocational training is voluntary, with the result that only 15 per cent are choosing this training.
2. By military control is not meant the strict Army discipline or assuming the right to dictate as to his training without considering the man's individual desires, but rather the man must be made to understand that before he is discharged from the Army he is to be functionally restored as far as possible and is to receive proper training that will enable him to overcome his handicap. Each case, however, must be handled as an individual.

II. PRESENT ORGANIZATION OF THE DIVISION OF RECONSTRUCTION

a. The ranking officer is supervising all the work of the department and is coordinating the plans for special reconstruction work of the various specialists' divisions of the Surgeon General's Office (as the blind, the orthopedic cases, etc.).
b. An industrial surgeon with rank of major is making a complete survey of the handicapped in occupations in this country, a study of the reconstruction work in other countries, and is planning for the practical application of reconstruction methods now being used in certain industries to our problem for the handicapped soldiers. Two additional specialists in this work will soon be added to the office staff.
c. An industrial vocational expert with rank of major is planning the technical and mechanical work in connection with our curative shops and for the vocational training in industrial lines of the disabled soldiers.
d. A commercial vocational expert with rank of major is making similar plans for schools and training in this line.


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e. An agricultural vocational expert with rank of major is planning for the technical and practical training in this line.
f. An architect with rank of captain is drawing all the plans for the general and special reconstruction hospitals.
g. Two officers with rank of captain are assisting the ranking officer in choosing proper locations and in establishing these hospitals.
h. The ranking officer is working in connection with the  department of special hospitals" in establishing these hospitals.

III. ORGANIZATION OF SPECIAL RECONSTRUCTION WORK IN OTHER DIVISIONS OF THE SURGEON GENERAL'S OFFICE COORDINATED WITH THE GENERAL RECONSTRUCTIONPLAN

a. Reconstruction of the blind:
1. An eye specialist has about completed his plans for special hospitals and special vocational training of all blind soldiers. This work is dovetailed in with the general reconstruction program.
b. Reconstruction of the orthopedic cases:
1. Specific plans for reconstruction of this class of patients are being worked out in the orthopedic division and coordinated with the general plan.
2. Special orthopedic departments will be established in the general hospitals, with fitting rooms for artificial limbs and special types of work for training.
c. Reconstruction of the nervous and mental cases:
1. A psychiatric specialist has been assigned to the special reconstruction problems connected with this type of cases and is working in connection with the general reconstruction division.
d. Reconstruction of the general medical cases.
e. Reconstruction of the general surgery cases.
f. Reconstruction of other special surgical cases.

Special reconstruction plans in these three divisions are to be organized and coordinated with the general reconstruction work.

IV. RECONSTRUCTION HOSPITALS

a. Plans for establishing general and special reconstruction hospitals in the 16 draft districts of the country are rapidly being completed.
b. Plans for the receiving and distribution of the disabled soldiers is also outlined in that memorandum.
1. These will be of the type and character described in the original memorandum submitted for your approval.

V. CURATIVE SHOPS

a. Shops and appliances suitable for light work will be established in connection with every hospital.
1. For purposes of retraining disabled members.
2. For psychotherapy.
3. For productivity and to begin the training of men for new occupations.

VI. VOCATIONAL TRAINING CENTERS

a. Plans for establishing certain types of vocational training, as schools, shops, agriculture, in connection with at least one of the general hospitals in each district are being made.
b. Connections with already established schools for purposes of vocational training are being made.
c. Practical training will be given in industries, trades, commercial lines, and agriculture by placing the men in already established concerns.
d. Many of the men as soon as their medical reconstruction is completed will reenter the employ of their old concerns for their old jobs or to be trained for new work. Proper supervision of these cases is now being arranged.


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VII. WORK NOW BEING DONE IN THE RECONSTRUCTION DIVISION

a. Formulating the various plans for reconstruction of disabled and establishing the hospitals as above outlined.
b. Studies of all the reconstruction and rehabilitation work of other countries and a careful abstract and filing of these studies.
c. A practical, thorough survey of the industrial, agricultural, trades, commercial, and professional fields of this country is being made to ascertain -
1. Occupations of and types of work now being done by handicapped individuals, classified according to specific disabilities.
2. Occupations in which handicapped individuals with specific disabilities are most successful.
3. Occupations and specific work which will be available for our handicapped soldiers classified according to their specific disabilities.
4. Classification of occupations in which specialized training is necessary.
5. Classification of occupational hazards to ascertain if specific disabilities will increase these hazards.
6. The economic demands of each occupation.
d. Arranging for the location of and establishing of a large number of general and special reconstruction hospitals.
e. Arranging for the establishing of all types of curative shops and vocational training centers.
f. Plans are being made for creating the proper mental attitude in the disabled men themselves.
1. A book is now being prepared for this purpose, and plans for a general educational campaign among the disabled are about completed.
g. The Medical Corps.-A book is being prepared to fully acquaint every medical officer with our plans for reconstruction and his duties in connection with this work.
i. Plans for wide publicity of our reconstruction program are now being completed.

VIII. PLACING THESE MEN BACK INTO CIVIL LIFE AND INTO SUITABLE OCCUPATIONS

a. The actual work of this division is completed when military control ceases. It is recommended that the man be not discharged from the Army until his medical reconstruction is completed and he is able to return to his former occupation, or until his medical reconstruction and his training for some new occupation (made necessary because of nature of disability) is completed.
b. It is recommended that the actual placing of these men shall be done by a central or national employment bureau such as that already established. An employment man should be on the staff of this division to act as our representative between the discharging of these disabled soldiers and this national employment bureau.

IX. FINAL SUPERVISION UNTIL REHABILITATION IS ASSURED

a. The war risk insurance act provides for certain amount of both medical and economic supervision over each discharged disabled soldier.
b. The personal and social supervision is provided for in the plans of the civilian relief division of the American Red Cross.

X. EXTENSION OF WORK

It is desirable to make our reconstruction program so comprehensive that -
a. It will be applicable to the disabled of the Navy.
b. Applicable to the disabled in the industrial Army (meaning the employees in allied military occupations).
c. And can be extended and made a permanent plan for the reconstruction and rehabilitation of all civilian disabled workers in the future.


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XI. NEED FOR FURTHER ORGANIZATION

In order to insure efficiency and cooperation among all officers working on reconstruction and rehabilitation of war injured, it would be necessary for this department to be organized at once as a distinct division in the Surgeon General's Office. Efficiency demands the coordination of work of all officers dealing with reconstruction under one chief.

XII. ADVISORY BOARD

Many governmental and private agencies are working on various problems connected with reconstruction and rehabilitation. Some of these agencies are formulating plans favorable to their handling most of this program, while others are planning to carry on certain angles of the problem which they assume belong to them. In other words, these different agencies, unless coordinated, are liable to disorganize our whole program.

England, France, and Canada have been handicapped in the efficiency of their work of reconstruction by having it divided up among several different committees and different civil governmental agencies. Canada is gradually being forced to sweep out many of these committees and completely reorganize this branch of its work. Facts and statements of good English authorities point to the importance of keeping our reconstruction program under military control.

We recognize the value of having the advice and aid of any governmental and private agencies which are directly concerned in reconstruction work. Further, reconstruction and rehabilitation of the war crippled is a national problem and one which involves other branches of the National Government besides that of the Surgeon General's Office. In order to keep the medical and surgical work and the vocational training of these disabled men in the Surgeon General's Office, where it rightfully belongs, and at the same time to make our entire program of reconstruction so comprehensive that it will include these other agencies, we recommend the appointment of an advisory board directly under the Secretary of War or under the National Defense Council.

The board suggested would include: (1) Surgeon General of the Army as chairman, (2) Surgeon General of the Navy, (3) Surgeon General of the United States Public Health Service, (4) representative of the medical section of the National Defense Council, (5) representative of American Federation of Labor, (6) representative of big industries, (7) representative of educational bureaus under Federal Government, (8) representative of American Red Cross, civilian relief division, (9) representative of National Employment Bureau, (10) representative of War Insurance Bureau.

XIV. HOSPITALS

a. As outlined in former memorandum, we recommend establishing a general reconstruction hospital in every draft district of the country, and later, if number of disabled demand, establishing other general hospitals in these districts, the hospitals to be located, as far as possible, near industrial and commercial centers for purposes of training.
b. Special hospitals to be established in every district, except when numbers are so small as to justify only one such hospital-(1) tuberculosis sanatoria; (2) mental and nervous sanatoria; (3) blind and deaf hospitals.

XV. VOCATIONAL SCHOOLS AND SHOPS

These are to be established in connection with each general hospital and where necessary at the special hospitals and further elaborated in special memoranda attached.

XVI. TEACHING FORCE

In each hospital we recommend that an educational director be placed. That director should be a commissioned officer, rank of captain.
a. Teaching corps be established under an office of teaching personnel in the division of reconstruction.
b. It may be necessary in order to secure suitable teachers to take some men from the drafted Army.
c. Salaries for teachers should be from $1,200 to $3,000.


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A SUGGESTED PLAN FOR THE ORGANIZATION OF THE RECONSTRUCTION TEACHING CORPS

It is respectfully suggested that there be established in the division of special hospitals and physical reconstruction of the Office of the Surgeon General a subdivision to be known as the reconstruction teaching corps.

The object of this subdivision is to supply the teaching necessary for the complete rehabilitation of the disabled soldiers during their period of convalescence and reeducation in the Army.

This corps will include (1) men selected from commerce, industry, and agriculture because of their practical experience and general ability in the special line which they are to teach; (2) crippled men from civil life who have been successful in commerce, industry, or agriculture; (3) capable injured men returned from active service who have sufficiently recovered; (4) successful teachers and mechanics selected from the draft army, if a sufficient number can not be obtained otherwise.

Persons selected for this corps may be assembled at some convenient point for three to six weeks of intensive instruction in special methods of teaching suitable to hospital instruction.

A chief personnel officer under the direction of the chief of the division of special hospitals and physical reconstruction should have charge of the teaching personnel. He will by reference to prescribed report and returns keep himself constantly informed as to the numbers, distribution, and competency of the individual members of the subdivision and its state and condition as a whole; he will keep constantly a list of candidates for the subdivision, will conduct the necessary correspondence relating to his duties, and will make recommendations for appointment when vacancies occur. The list of available candidates kept by the subdivision will contain only the names of persons who shall have fulfilled the requirements set up by the special education officers of the division of special hospital and physical reconstruction.

APPOINTMENT

Members of this corps shall be appointed by the Surgeon General on recommendation of the chief of the division of special hospitals and physical reconstruction.

Members of this corps when assigned to particular hospitals shall work under the immediate direction of the director in charge of the education at the hospital.

Members of this corps traveling under orders are entitled at public expense to their transportation, traveling allowance, baggage transportation, as provided in Army Regulations. Travel to and from points beyond the limits of the United States will be by Army transports in all cases where practical. When assigned to duty at military establishments, quarters subsistence will be provided.

PROPOSED PLAN FOR PROVIDING PROFESSIONAL EDUCATION TO DISABLED SOLDIER

It is recognized that professional training can be given only in colleges or teacher-training schools of recognized standing. All experience goes to show that it is very important that the man who is to enter one of the professions shall have completed a course in a professional college of recognized standing.

In providing professional instruction the plan is to take advantage of the opportunities offered by existing schools giving professional courses. A careful survey is therefore being made of all of the recognized schools and colleges giving professional training to learn what courses are offered in each college, the length of the course, the tuition, the living conditions, the amount necessary to maintain a student a year in the college, and all of the information which is needed to determine what school a man shall attend.

Inasmuch as this is an enterprise of the Government, it is proposed to utilize, in so far as possible, those institutions which receive annual grants of money from the Government. When these facilities have been utilized to their full extent, it is proposed to appeal to State institutions and later to semipublic institutions which are endowed from private sources.

A careful survey of each soldier's general and educational qualifications will be made in the receiving hospital by men chosen from various schools and colleges. Only those men who have had the equivalent of a high-school course and are otherwise eligible to entrance in a


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recognized college will be assigned to professional courses. If the man is retained in the Army, his pay as a private will support him during his college courses. It is possible that educational institutions will have scholarships available which will make it unnecessary for the regular tuition to be paid. In nearly all of the agricultural and mechanic arts colleges receiving Federal grants of money tuition is free to residents of the State. As the man is still in the Army, it will be possible to have monthly reports of his progress in the institution submitted to the proper authorities in order that the Government may be assured that he is taking full advantage of the opportunities afforded him.

It is recommended that the man be retained in the Army until the completion of the professional course in the college. He should then be discharged from the Army, and will enter civilian life fully equipped to earn his own living in the profession for which he has been trained.

MEMORANDUM OF SUGGESTED PLAN FOR TRAINING DISABLED SOLDIERS FOR AGRICULTURAL PURSUITS

Group I. - Men with agricultural experience and a partial education in scientific agriculture who desire to complete such education.
Group II. - Men with agricultural experience but with no agricultural education who desire to obtain such education-either of secondary or college grade.
Group III. - Men with or without agricultural experience who desire to fit themselves for practical work in some agricultural pursuit.
Group IV. - Men whose principal occupation will not be agricultural but who will engage in home gardening, fruit growing, poultry keeping, etc., to supplement income from other sources.

I. PRELIMINARY INSTRUCTION IN HOSPITALS
a. For Group I.- Directed individual st dies in special agricultural subjects according to the needs of the individuals carried on until men are in physical condition to be sent to agricultural schools or colleges, together with practice in gardening and shop work for therapeutic purposes.
b. For Groups II and III.- Practical gardening or poultry work in the hospital garden or poultry plant, both for curative and instructional purposes, with supplementary classroom instruction carried on until the men are in physical condition to be sent to agricultural schools or colleges or placed with market gardeners, poultry men, or general farmers to gain experience.
c. For Group IV. - Practical gardening or poultry work with supplementary classroom instruction until the men are either discharged or placed in schools or shops for education in their principal occupation.
All groups should have instruction and practice in the hospital curative work shops in elementary carpentry not only for curative purposes but also for reeducation in the use of carpenter tools and in making simple farm implements.
Groups II and III should have classroom instruction in sciences allied to agriculture, such as chemistry, biology, etc.; also in related general education when necessary.

II. FURTHER INSTRUCTION IN SELECTED STATE AGRICULTURAL COLLEGES (AND OTHER AGRICULTURAL SCHOOLS IF NECESSARY)
a. For Group I.- Men should be placed in regular college classes in institutions selected with reference to the particular subjects desired by the individual men and for other considerations, such as tuition, nearness to home, etc. The men should pursue approved courses and be under general supervision of the Surgeon General.
b. For Group II.-In special classes taught by approved instructors employed by the colleges in work below college grade and suited to the needs and abilities of the men. Each course should consist of a large amount of practical farm work in the special phases of farming desired by the men with laboratory and classroom instruction in the necessary allied subjects.The courses would be from three months to two years in length, depending upon the particular


34

work. (Preparation for dairying work would require three months, for general farming one o two years.) Similar courses for farmers are now given at the majority of the Stat agricultural colleges.
c. For Group III.- In the special classes at the colleges arranged for men of Group II, where such courses seem desirable; in other cases individual men could be placed on approved farms to gain experience in some specified agricultural pursuit, such as fruit growing, market gardening, dairy work, etc.

III. INSTRUCTION
a. For hospitals with approximately 20 men or less enrolled for education in agriculture one instructor will be required. If possible, he should have had technical agricultural education equivalent to four years in a standard agricultural college and be a specialist in either market gardening, poultry, or in both. If more than 20 men are enrolled, 2 instructors will be required. One should be a specialist in market gardening, the other in poultry. Only men with practical experience in these branches should be employed.
b. Instruction in the sciences allied to agriculture, such as chemistry, botany, etc., should be given by the instructors in agriculture.
c. Competent instructors in agriculture for the hospitals will be difficult to find at the present time on account of the large number of agricultural schools being established this year, stimulated by the Smith-Hughes Vocational Education Act, and the large number of men suitable for agricultural teachers employed this year for the first time as county agricultural agents paid by the Federal appropriation to increase food production. An immediate canvass should be begun to locate suitable men. It may be necessary to look to men now in training at cantonments.

IV. SPECIAL PREPARATION FOR INSTRUCTORS
However well trained and experienced in agriculture men obtained for instructors may be, the majority will need from three to six weeks' intensive instruction in special methods of teaching suitable to hospital instruction under a qualified person obtained for this purpose. They should be assembled for instruction at the earliest possible date. The person obtained to instruct them may be afterwards employed as an adviser to the proposed examining board at the receiving hospital relative to individuals desiring education for agricultural pursuits.

V. SUPERVISION AND CONTROL
a. Surgeon General's Office, War Department, Washington: General supervision, assignment of men, approval of plans, courses of study, methods of instruction, living conditions, discharge of men, etc.
b. Department heads and agricultural teachers in each hospital will be under the officer in charge of reeducation for the hospital.
c. Men from Groups II and III assigned to agricultural colleges should be in groups of 20 to 60 and should be provided with living quarters, sleeping quarters, and a study hall in temporary barracks erected on the college grounds under the immediate charge of a resident military officer.
d. All men should be kept in Army service until education is completed.

VI. ASSISTANCE IN BECOMING FARM OWNERS
Provision should be made if possible, to assist the men trained for agricultural pursuits to become landowners and farm operators rather than farm laborers or renters. Probably the most feasible plan to bring this about is for the Government to purchase available farm lands in many different parts of the United States in tracts of several hundred acres, divide them into 30 or 40 acre farms, erect the necessary permanent improvements, and sell to discharged men under a long-term payment plan, similar to the workings of the Danish "Small holdings act" or the "Irish congested districts." Under both of these annual payments are made by the purchasers at the end of each year, the payment covering interest and a fixed amount on the principal. In the Irish plan "Agricultural overseers" are employed for each group of approximately 200, whose work is primarily of an advisory nature. The results of the employment of these overseers has proved the wisdom of their employment.


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MEMORANDUM OF PLAN FOR VOCATIONAL REEDUCATION OF DISABLED SOLDIERS ALONG TRADE, TECHNICAL, AND MANUFACTURING LINES

This training should begin at the earliest possible time so that the disabled men will not have an opportunity to acquire habits of idleness. To this end an occupational and social survey covering the man's previous education, industrial history, etc., should be made at the earliest possible moment, certainly not later than at the main receiving hospital in his country, before if possible.

We shall probably have to deal with the following groups:

I. Men with trade experience but with little if any general and related technical education. These men can be returned to their former occupations or through special trades, technical, or scientific education which may be given, they can be returned to a related or similar position in the same trade or industry.
II. Men with trade training or industrial experience who have also had some technical and scientific training. Such men can be returned to the former trade or industry in the same position or through further trade, technical, or scientific training can be placed in executive work in the same industry or similar industry.
III. Men without trade or technical experience who will wish to be fitted for some trade or technical occupation.
IV. Men who have been in one trade who, because of their handicap or other reasons, do not wish to follow their former trade and will wish to be trained for some other trade occupation or technical profession.
V. Men of technical ability who can be trained to run some small business of their own where they will to a large extent be relieved from industrial competition in plants of large scale production. Example of such small business: Saw filing, lock repairing, etc.; shoe repairing, harness and other leather goods; tailoring, cleaning, pressing, etc.; watch and jewelry repairing.
VI. Men who have entered trade or technical courses of intermediate and college grade who will wish to complete their education along these lines.

PLAN FOR GIVING THE TRAINING

I. In the hospitals:
(a) Prevocational instruct on in curative work shops (buildings, equipment, tools, and teachers needed).
(b) Related general education to make it possible for the man to handle the simple reading and calculations necessary in his occupation (rooms, blackboards, books, and teachers to be provided).
(c) Related technical instruction: Shop talks, demonstrating of tools, methods of production, related drawing, mathematics, science, and business management as related to production. (Needed, special typical tools, drawing-rooms, classrooms, laboratories, books, teachers.)
(d) Special trade instructions where it is not found possible to send the men to existing schools or commercial shops. Examples: Tailoring, lock repairing, saw filing, shoe repairing, etc.
II. In existing schools in the sections served by the hospital: We should not make unnecessary duplication of equipment, but should use existing school plants so far as possible, thus getting the advice and experience from certain well-established institutions. Only such schools should be selected as have equipment and teachers who are able to give instruction on a practical commercial or productive basis.
NOTE.- The men sent to these schools might well be those who have had no previous experience in a given line of work, while those sent to shops or training centers should be men who before their injury had worked in the particular trade of which they are returned.
III. In selected industrial plants or group of plants which may be used as United States training centers:
(a) Men while so placed will be under Army supervision and direction.
(b) Courses and methods to be worked out in cooperation with the industry or individual plant, care being taken that the man is not exploited.


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(c) The assignment of disabled men as assistants to workmen for observation and practice.
NOTE.-This will necessitate setting apart machines in the plant for practice in order not to interfere with production. These to be used for lectures, demonstrations, and experiments by men under training.
(d) Experimenting in cooperation with the industrial surgeons to find the best artificial appliances which will enable disabled men to handle the special work or tools of the job.
It has been amply demonstrated by the cooperative work of Cincinnati, Ohio, Fitchburg, Mass., and other places that trade and technical training can be successfully given in commercial establishments.
IV. Teachers, supervisors, and other specialists: There is a well-known shortage of teachers and supervisors. The existing schools have great difficulty in obtaining such men.
The situation has been made still more acute by the exceptional opportunities in industry. The Shipping Board and Federal Board for Vocational Education have recently taken a number of the more experienced men. A few men may be had from existing educational institutions. Such men will have to fill the more responsible administrative positions. The great bulk of the teachers and assistants will have to come from the National Army in the various cantonments. A few trained teachers will probably be found in this group. There is probably a sufficient number of mechanics and technicians in the cantonments who can be trained to be teachers and supervisors. It is desirable to select men and begin their training at once. We can do this in part by cooperating with the existing schools. From among the rehabilitated soldiers, as fast as the disabled soldiers can be rehabilitated they will make the most effective teachers. Men who have been taken from the National Army for teaching service can be returned to active service as fast as their places can be so filled by returned men.
V. Courses and methods: Use the courses and methods of instruction already developed in the existing vocational and technical schools and commercial plants, adapting them to the special needs of the disabled men.
VI. In carrying on all of this work it will be necessary to have advisory committees to the educational director in the different sections served by the hospitals; such committees to represent the schools, employers, employees, and placement agencies in the section.
VII. Discharge of men upon recommendation to the Surgeon General when they are ready to hold a place in industry or be self-supporting.
VIII. Supervision and help before and after discharge by outside cooperating agencies.

On January 5, 1918, the Surgeon General's tentative plan was returned to him by the Secretary of War with the suggestion that a conference be held with representatives of the War Risk Insurance Bureau, United States Public Health Service, General Labor Committee, Interior Department, Bureau of Medicine and Surgery of the Navy Department, Vocational and Educational Commission, and of any other agency related to the work. 19 Since similar plans were being considered by several other departments, it was the desire of the Secretary of War that the Surgeon General present a plan which would introduce unity and coordination in the whole scheme, apportioning, if necessary, to the Army, the Navy, and the Public Health Service their respective functions in the matter.

The conference was held January 14, 1918, with the Surgeon General, United States Army, chairman, and representatives present from the medical section of the Council of National Defense, Medical Department of the Navy, United States Public Health Service, United States Employees' Compensation Bureau, American National Red Cross, War Risk Insurance Bureau, Treasury Department, Federal Board for Vocational Education, Department of Labor, American Federation of Labor, United States Chamber of Commerce, National


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Manufacturers' Association, Red Cross Institute for Disabled and Crippled Men, civilian medical profession, medical department of the Canadian Army, and the Office of the Surgeon General of the Army." 19

The chairman appointed a committee of 14, consisting of one member from each department represented, except the Canadian Army, with the representative from the United States Bureau of Education as chairman, to draw up a complete program for reconstruction and rehabilitation of disabled soldiers.19

After having met several times the committee made the following report, which expresses the plan which the committee recommended: 19

1. As regards the undischarged member of the military or naval forces of the United States, all medical and surgical work necessary to give, as far as possible, functional and mental restoration shall be directly under the executive control of the Surgeon General's office of the respective services. It is understood that when such medical aids as curative work shops and vocational training are needed to accomplish the above, they are included in the medical and surgical work.
2. That when, in the judgment of the Medical Department, the disabled member had reached as complete a state of physical and mental rehabilitation as possible he is to be discharged from the service if unfit for further service, full or restricted, and will pass under the control of such other agency of the Government as was or might be provided to carry on his continued rehabilitation.
NOTE.-It was the sense of the conference that the facilities for treatment in military and naval hospitals should include everything required to enable members of the military and naval services to receive full mental and physical restoration in all cases where this is humanly possible prior to their discharge from the service, and that, save in exceptional cases, this discharge should not take place prior to such full restoration or until its accomplishment seems to be improbable. No regulations should be made or legislation enacted to prevent the use of Army facilities by the Navy by proper arrangements between the two departments, or vice versa, or to prevent the return of discharged members of either service to service hospitals for further treatment under proper authority.
3. That a board shall be appointed by the President of the United States for the control and direction of the work hereinafter described.
4. This board shall have executive control over the phases of the work represented in rehabilitation of the disabled after the medical and surgical work was complete-namely, continued vocational training, when necessary; placing in employment; economic and social. supervision, to see that rehabilitation is complete and so remains. It may act in an advisory capacity to the vocational officer on the Surgeon General's staffs, with the view of coordinating all vocational training during convalescence with any continued vocational training that is necessary after the man is discharged from the service.
NOTE.- Paragraphs 1 and 2, with the note under 2, indicate what, in the opinion of the conference, are the proper functions of the Medical Departments of the military and naval services with regard to the matter under consideration. Nothing in any legislation which may be required to carry out the provisions of paragraphs 3 and 4 should be susceptible of an interpretation contrary to the sense of paragraphs 1 and 2, with the note under 2.
5. The following tentative draft of a bill is submitted as indicating the legislation necessary to carry out the work which would be required for members of the military and naval forces after discharge.

The proposed legislation referred to was to provide (a) that all treatment of any kind necessary prior to discharge of any person from the Army or Navy should be under the control of the service concerned; (b) for the establishment of a board for vocational rehabilitation, with power to make provision for vocational rehabilitation of (1) such above-named persons after separation from the service, but whose disability was incurred while in the service; (2)


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under certain specified conditions to any of the following: Former service persons whose disability arose after separation from the service; civilian employees of the Government; other civilians; (c) for the repeal of the act establishing the Bureau of War Risk Insurance.

At the second meeting of the conference, January 21, 1918, the report of the committee was adopted, and the recommendation was made to the Surgeon General that he submit the report to the Secretary of War as the recommendations of the conference.19 In forwarding the report to the Secretary of War on January 29, 1918, the Surgeon General invited the Secretary's attention to a provision in the proposed legislation which would extend the vocational training to all disabled persons, under certain conditions; also, he recommended early authorization to proceed with the development of necessary hospital facilities.19

When the proposed legislation was referred to the Judge Advocate General of the Army for remark, he recommended disapproval, principally because the work as proposed would be done by the authorized director rather than the board, and there was no provision for his removal in case of dissatisfaction; the provision for extending rehabilitation to persons who were never in the military or naval service made its application so broad that the attempt to enact it into law would almost certainly fail. 19

On February 13, 1918, the Surgeon General recommended to the Secretary of War that the conference be again convened and that the Judge Advocate General be invited to participate.14 At the same time he reiterated the fact that the problem before the Medical Department was the provision of physical and mental rehabilitation of disabled soldiers before their separation from the service, and urged immediate action on recommendations made to War Department several weeks previously as follows: (1) That no member of the military service disabled in line of duty be discharged until recovery was complete or as complete as could be expected. (2) That physical reconstruction be defined as the completest form of medical and surgical treatment carried to a point where maximum functional restoration, mental and physical, had been secured. (3) That authorization be given to establish reconstruction work in 16 specified hospitals in order to provide 60,000 beds before the winter of 1918-19.

On May 6, 1918, the Secretary of War defined the reconstruction functions of the Medical Department as follows 20

You are authorized to proceed with the scheme for reconstruction of officers and enlisted men of the Army alone without consideration of the other bureaus of the Government involved, this reconstruction to be clearly understood to end at the point where the medical reconstruction ceases--that is, the reconstruction to take place in such cases of officers and enlisted men as come under proper medical treatment by the War Department, leaving for other reconstruction purposes the subsequent treatment after discharge from the care of the Medical Department.

This understanding in the field of work in reconstruction assigned to the Medical Department of the Army did not entirely clarify the situation, since memoranda to the War Department requesting approval of needed hospital construction equipment for physiotherapy, for occupational therapy, and for qualified personnel to administer physiotherapy and curative work in military hospitals were disapproved wholly or in part or were returned by the General
Staff for additional information.19


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Despite the delay incident to this confusion, creditable application of all measures included under physical reconstruction was begun early in 1918 at General Hospital No. 2, Fort McHenry; at Walter Reed General Hospital, Washington; and at General Hospital No. 6, Fort McPherson, Ga.

Arrangements were made with the Bureau of Medicine and Surgery, Department of the Navy, May 10, 1918, whereby such sailors and marines as night require reconstruction were to be admitted to reconstruction hospitals of the Army for treatment and training." The authority for this was confirmed by the Secretary of War on May 27, 1918.

In May, 1918, the functions of the division of reconstruction in relation to the clinical divisions of the Surgeon General's Office were more clearly defined. The section of orthopedic aides was transferred from the orthopedic division to the division of physical reconstruction.16 All officers on duty in this division as representatives of clinical divisions returned to their proper divisions. The interest which it was necessary for this division to maintain in hospital sites, special buildings for schools, shops, physiotherapeutics, and gymnastics was better secured by the organization therein of a section on architecture and by cooperative relations with the hospital division. In the Surgeon General's Office it was understood that the division of physical reconstruction would furnish to the hospitals which were to function in physical reconstruction the required personnel of officers and enlisted men and reconstruction aides for efficiently carrying on occupational therapy, physiotherapy, gymnastics, sports and pastimes, and social service. In the hospitals it was agreed that the clinical officers would prescribe types of occupational and physiotherapy play and drill required to aid in the physical and functional restoration of the disabled men, leaving to the educational and physiotherapeutic officers the efficient application of the reconstructive measures prescribed. In detail, the physical reconstruction program, as promulgated by the Surgeon General on June 3, 1918, was as follows:23

* * * * * *

2. The Medical Department of the Army assumes that the care of the sick and wounded soldiers is incumbent upon the department. In accordance therewith * * * the division of physical reconstruction has developed the machinery necessary for the special work of reconstruction and this may be summarized as follows:
(a) An administrative personnel which includes the special care of disabled soldiers by the several departments of medicine and surgery with a qualified medical officer at the head of each special department. These departments are general medicine, neurology and psychiatry, tuberculosis, heart diseases, gastrointestinal diseases, skin diseases, general surgery, military orthopedics, head surgery (including blindness, deafness, speech defects, brain surgery, plastic surgery of the head, throat, nose, and ear diseases), venereal diseases, and genitourinary diseases.
(b) Inasmuch as this treatment of diseases and injuries embraces not only anatomical but functional restoration, continued treatment requires the use of physiotherapy. Physiotherapy includes such measures as hydrotherapy, electrotherapy, active physical exercises of all kinds, including military or other drill or modified Swedish movements, and passive exercises such as massage, etc. Functional restoration also requires, in addition to what may be termed "physiotherapy," curative occupation in the form of manual and mental work at the bedside and in shops.
(c) An educational department, the function of which is to develop along modern lines the personnel and equipment necessary to administer occupational therapy.


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3. The administrative forces organized in the division of physical reconstruction have been duplicated as to the personnel, including the equipment to administer the reconstructive treatment, in each general hospital where reconstruction work is carried on.
4. The Medical Department of the Army has assigned the following general hospitals for the reconstruction of disabled soldiers:
Insane - St. Elizabeths Hospital, Washington, D. C.; General Hospital No. 4, Fort Porter, N. Y.
Functional neuroses (nervous diseases)-Plattsburg Barracks, N. Y.; Fort Des Moines, Iowa.
Epileptics- Plattsburg Barracks, N. Y.
Pulmonary tuberculosis-Fort Bayard, N. Mex.; General Hospital No. 16, New Haven, Conn.; General Hospital No. 17, Markleton, Pa.; United States Hospital, Waynesville, N. C.
Cardiovascular diseases - General Hospital No. 6, Fort McPherson, Ga.; General Hospital No. 9, Lakewood, N. J.; Fort Des Moines, Iowa.; Corpus Christi, Tex.
Chronic rheumatism - General Hospitals No. 6 and No. 9; Fort Des Moines, Iowa.
Disabilities due to being gassed - General Hospital No. 2, Fort McHenry, Md.
Other general medical cases - Corpus Christi, Tex.; General Hospitals No. 6 and No. 9;
Walter Reed General Hospital; Fort Des Moines, Iowa.
Those requiring orthopedic treatment-General Hospitals No. 6 and No. 9; Walter Reed General Hospital; Letterman General Hospital.
Amputations-Walter Reed General Hospital, Washington, D. C.; Letterman General Hospital, San Francisco.
Total deafness, speech defects, and purulent otitis media-General Hospital No. 11, Cape May, N. J.
Blindness, or near blindness-General Hospital No. 7, Roland Park, Baltimore Md.
Venereal disease and its sequelae (where venereal disease is major disability)-General Hospital No. 5, Fort Ontario, N. Y.
Wounds and injuries or other surgical conditions of the genitourinary system (where the injury or wound is major disability)-General Hospitals Nos. 2, 6 and 9; Walter Reed General Hospital; General Hospital No. 2, Fort McHenry, Md.; Letterman General Hospital, San Francisco; Corpus Christi, Tex.
Wounds or injuries involving the head, including eye, ear, nose and throat, face and jaw- General Hospital No. 11, Cape May, N. J.
Special services of diabetes-General Hospital No. 9, Lakewood, N. J.; Fort Des Moines, Iowa; Letterman General Hospital, San Francisco.
The partial or complete personnel and the full minimum equipment necessary for curative occupation is in active operation at General Hospitals No. 2, 6, 9, 11, 17, and Walter Reed.
5. As rapidly as conditions permit the reconstruction work at all of the hospitals named is being developed. More or less delay has occurred because of the difficulties embraced in the necessary construction of barracks, workshops, etc.
6. At New York and Newport News, the ports of embarkation, the necessary organization for classification and rapid distribution of the disabled men from overseas reconstruction hospitals has been completed and is in satisfactory working condition. The division surgeons have been ordered to report the individual cases of disability who may be reconstructed, now in the base hospitals of cantonments, that they may be transferred to the general hospitals where reconstruction work is carried on.
7. The above statement of the organization of the administration and the continued treatment of disabled soldiers is set forth in this connection to indicate the understanding of the Medical Department of the Army as to the authority of the department in caring for the sick and wounded soldiers and to indicate that physical reconstruction is now in actual operation.
Repetition of the statement gives emphasis to the opinion of the Medical Department of the Army that no soldier should be discharged from the Army until he shall have received the continued treatment which will entirely restore him to health or as nearly restore him as the nature of his disabilities permits.


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8. The Medical Department of the Army has within its personnel, in addition to its regular medical officers, the best-qualified men of the United States in medicine and surgery, including the specialists. These are serving in the Medical Reserve Corps of the Army and in the National Army.
9. Attention is directed to the fact that to carry on the necessary treatment in an efficient way the Medical Department of the Army must have full and definite understanding that such aid will be rendered to the Medical Department of the Army only upon the invitation of the Surgeon General.
Such aid as may be rendered by other Federal agencies or by State, municipal, and private agencies in a cooperative way will be welcomed by the Medical Department of the Army with the full and definite understanding that such aid will be rendered to the Medical Department of the Army only upon the invitation of the Surgeon General.

POLICY OF PHYSICAL RECONSTRUCTION ESTABLISHED

The recommendations of the committee of 14, forwarded by the Surgeon General to the Secretary of War on January 29, 1918, were finally approved by The Adjutant General on July 31, 1918, as follows: 24

The general policy of physical reconstruction as proposed by the Surgeon General's Office for the purpose, primarily, of effecting the maximum restoration of disabled soldiers, using manual and mental work as a curative agent, and, incidentally, of training and educating them for further useful work in the Military Establishment, is approved, with the understanding that such incidental training will not involve the Government in large expenditures and elaborate installation of shops and apparatus, and providing that all existing facilities, both military and civilian, for training and educating the soldier toward the end in view shall be used to the fullest extent.

The fundamental policies and plans for the physical reconstruction of disabled soldiers having been finally approved by August 1, 1918, and the actual performance sufficiently tested in hospitals, the Surgeon General's Office was then prepared to proceed with the work on any scale which the future might demand.

It was necessary for the greatest success of the undertaking to educate not only the Medical Department but the whole Army and the public as well in the possibilities opened to the disabled soldiers by this project, for the degree of ultimate accomplishment depended on thorough appreciation and support by all concerned; therefore, the Surgeon General published in the Official Bulletin of August 1, 1918, the following plans for physical reconstruction of disabled soldiers in the general military hospitals:25

PLANS FOR PHYSICAL RECONSTRUCTION OF DISABLED SOLDIERS IN THE GENERAL MILITARY HOSPITALS ARE ANNOUNCED

LIST OF INSTITUTIONS WHERE REHABILITATION WORK WILL BE CARRIED ON-MANY KINDS OF TREATMENT TO BE EMPLOYED AND MANY VOCATIONS TO BE TAUGHT

The following statement is authorized by the War Department:

The Surgeon General, with the approval of the General Staff, announces the completion of plans for the physical reconstruction of disabled soldiers in the general military hospitals. These plans are formulated with a view to close cooperation with the War Department committee on education and special service in the work of restoring men to full or limited military service, and with the Federal Board for Vocational Education, which is authorized by the law to provide vocational training for disabled men after their discharge from the Army and Navy.

The records of 516 cases treated in four hospitals show 134 men able to return to full military duty, 210 fit for limited service, and 172 who are eligible for discharge. In the last


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group, 12 are classed as helpless or institutional cases, 121 are able to return to their former occupations, and 39 will need further training to fit them for earning a livelihood. These figures show the division of responsibility in the work of reconstruction.

Most pressing need

The task of fitting men for further military service is at present the most pressing need, because wherever an able-bodied man behind the lines can be replaced by one less fit physically but vocationally capable a soldier is gained for active duty. The reconstruction work in the hospitals, therefore, will emphasize technical training in all lines capable of adaptation to the physical limitations of disabled men and in which employment will act as a therapeutic agent. When play and work and study will help a man to get well, this kind of medicine will be prescribed for the patient. If the work he does leads to further service in the Army or to better prospects in civilian life, so much the better.

Hospitals designated

The Surgeon General has designated the following general military hospitals for the work of physical reconstruction: Walter Reed General Hospital, Washington, D. C.; General Hospital No. 2, Fort McHenry, Md.; General Hospital No. 3, Colonia, N. J.; General Hospital No. 6, Fort McPherson, Ga.; General Hospital No. 7, Roland Park, Baltimore (for the blind); General Hospital No. 8, Otisville, N. Y.; General Hospital No. 4, Fort Porter, N. Y.; General Hospital No. 9, Lakewood, N. J.; General Hospital No. 11, Cape May, N. J.; General Hospital No. 16, New Haven, Conn.; General Hospital No. 17, Markleton, Pa.; Letterman General Hospital, San Francisco, Calif.; United States Army Hospital, Fort Des Moines, Iowa.; Plattsburg Barracks Hospital, Plattsburg Barracks, N. Y.; and General Hospital, Fort Bayard, N. Mex.

Policy to be followed

The policy to be followed in these hospitals, as announced by the Surgeon General, is that, hereafter, no member of the military service disabled in line of duty, even though not expected to return to duty, will be discharged from service until he shall have attained complete recovery or as complete recovery as may be expected when the nature of his disability is considered. In furtherance of this policy, physical reconstruction is defined as complete mental and surgical treatment carried to the point of maximum functional restoration, both mental and physical. To secure this result, all methods recognized by modern medicine as conducive to cure will be utilized. In other words, not only the ordinary means of medicine and surgery, including all specialties, will be utilized, but also physical measures such as are employed under physiotherapy, including hydro-, electron, and mechanotherapy, active exercises, indoor and outdoor games, and passive exercise in the form of massage. Provision in the form of adequate buildings and equipment for physiotherapy has been adopted in each of the hospitals.

Functional restoration final aim

Modern medicinal treatment does not end with physical cure. Functional restoration is the final aim of the modern physicians and surgeons. It is conceded that the physical rehabilitation of disabled men is peculiarly dependent upon their mental attitude. The more serious the disability, the greater the danger of mental depression and an indisposition to respond to medical and surgical treatment. The educational work should begin, therefore, at the moment when the man has arrived at the stage where he begins to worry about his future, whether in this country or overseas. The first problem is to divert his attention by simple recreation, through reading, pictures, games, handiwork occupations, and the like, with a view to securing a genuine interest in the attainment of some worthy end-the end most certain to hold his attention and to claim his best efforts in his future vocation. Hence, by gradual steps, he may be induced to supplement his previous vocational experience by academic, scientific, or technical instruction, or to choose a new vocation and begin preparation for it, if such a course is necessary.


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Need of "cheer-up" work

The need of "I cheer-up " work in the hospitals extends to all who are mentally capable of planning for their own future. This means a relatively large proportion of the entire number. The beginning is made at the bedside with handicrafts of various kinds, grouped under the term "Occupational therapy." When the man is able to leave the ward and can be benefitted physically by technical training, he has the opportunity of working at specific trades, either in the curative workshop in specially provided classrooms or out of doors.

The teachers for this work have been secured from the convalescent disabled soldiers who are already skilled in their vocations and from the enlisted personnel of the Army secured by transfer or by induction of registrants disqualified for general military service but qualified for special limited service. These instructors work under the direction of educational officers chosen for their professional standing in civil life and commissioned in the Sanitary Corps of the Medical Department. The General Staff has just authorized commissions for 119 educational officers for this purpose.

Three classes of disabled soldiers

From the military standpoint, disabled soldiers may be placed in three general classes:
(a) Those who can be restored to full duty.
(b) Those who can be fitted for limited service.
(c) Those disabled to the extent of unfitting them for further military service.

It is the announced policy of the Surgeon General that patients of the first class (a) should have, when circumstances warrant it, the benefit of therapeutic treatment through play, work, and study, as may be prescribed by medical officers, in order that their morale may be stiffened, their special skills improved, their future usefulness increased, and their recovery hastened.

Patients of the second class (b) should have, whenever conditions permit and the medical officers approve, such specific training-physical and vocational-as will, in the judgment of the educational officers, best fit such patients for limited service of a particular kind. At present patients are being trained in general hospitals for limited service as general and vocational teachers, typists, printers, tailors, cobblers, harness makers, welders, motor mechanicians, telegraphers, photographers, telephone operators, cooks, storekeepers, electricians, etc.

List to be extended

The list will be extended, with the advice and cooperation of the committee on education and special service of the War Department, to meet other needs as they arise. In connection with the large general hospitals there is abundant opportunity for practice in many trades and occupations. At Fort McPherson, for example, practical experience can be gained in 20 different trades. Moreover, there is immediately adjacent to the hospital a large quartermaster's mechanical repair shop, covering all phases of mechanical repair and construction, to which men can be assigned for limited service or to gain experience.

Patients of the third class (c) should be encouraged in every possible way to accept the benefits accorded them for vocational training by the Federal Board for Vocational Education. To this end they should have, while in the hospital, such physical training and general education as will best promote their physical reconstruction and at the same time contribute most to their vocational training. Patients who do not elect or who are not eligible to continue their education under the Federal board should receive such training as the medical and educational officers deem best in each individual case.

MODIFICATION OF RECONSTRUCTION PLANS INCIDENT TO THE ARMISTICE

The plans for reconstruction, prior to the beginning of the armistice on November 11, 1918, had been based on the expectation of a more or less regular increase in the volume of reconstruction cases due to battle casualties. The armistice, however, changed conditions markedly, as plans for the early return


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of all transportable invalided men were announced shortly after its beginning,26 thus necessitating a speeding up of the reconstruction program; therefore, the Surgeon General, on December 10, 1918, submitted a memorandum on the subject to the War Department.26 The Surgeon General's memorandum reviewed the announced plan for the reconstruction of disabled soldiers; called attention to the fact that the requests for the construction of curative work-
shop buildings at all but four of the reconstruction hospitals had not yet been approved; admitted that the plans for new construction at those and other hospitals would have to be replaced by plans for utilizing existing buildings, and possibly the shops of existing industrial concerns where large cities were in the vicinity; stated that a disabled soldier should have as complete functional
and physical restoration as possible in the military hospital in order to be a fit subject for training by the Federal Board for Vocational Training.

Furthermore, the following modification of the plan published on August 1, 1918, for fulfilling the obligations of the Medical Department to disabled soldiers, was recommended: (1) That general physical reconstruction be applied in the hospitals named: Walter Reed General Hospital, Takoma Park, D. C.; General Hospitals No. 2, Fort McHenry, Md.; No. 3, Colonia, N. J.; No. 6, Fort McPherson, Ga.; No. 9, Lakewood, N. J.; No. 10, Boston, Mass.; No. 11, Cape May, N. J.; No. 26, Fort Des Moines, Iowa; No. 27, Fort Douglas, Utah; No. 28, Fort Sheridan, Ill.; No. 29, Fort Snelling, Minn.; No. 30, Plattsburg Barracks, N. Y.; No. 31, Carlisle, Pa.; base hospital, Fort Sam Houston, Tex. That reconstruction for the blind be carried on at General Hospital No. 7, Roland Park, Md. That modified facilities for curative work be applied in the treatment of tuberculosis at General Hospitals No. 8, Otisville, N. Y.; No. 16, New Haven, Conn.; No. 19, Azalea, Oteen, N. C.; No. 20, Whipple Barracks, Ariz.; No. 21, Denver, Colo.; Fort Bayard, N. Mex. (2) That necessary alterations be made in existing buildings to provide for the curative workshop schedule and physical treatment at the hospitals named, and that a simple curative workshop equipment, value $3,000, be installed at those hospitals not already supplied. (3) That $1,000 be allowed each hospital for material to be used in carrying out the curative workshop schedule. (4) That authority be given to transfer from other hospitals to reconstruction hospitals patients requiring reconstruction treatment. The necessity was emphasized of accepting and enforcing the principle that, as soon as the disabled soldier should have reached the stage of as complete physical and functional recovery as was possible, when the nature of his disability was considered and he was convalescent, he should be transferred to the convalescent detachment in the camp or directly discharged from hospital. (5) That personnel to carry out efficiently the curative workshop schedule should be maintained, either by transferring suitable officers and enlisted men to the Medical Department from other branches of the service or by granting authority for further commissions and promotions in the Medical Department. (6) That $1,000
be granted to each of the 18 base hospitals named below to purchase expendable material necessary to apply a moderate amount of curative work, a sufficient equipment being already available: Camp Gordon, Ga., Camp Jackson, S. C., Camp Lee, Va., Camp Meade, Md., Camp Sherman, Ohio, Camp Taylor, Ky.,


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Camp Funston, Kans., Fort Riley, Kans., Camp Pike, Ark., Camp Travis, Tex., Camp Custer, Mich., Camp Grant, Ill., Camp Dodge, Iowa, Camp Lewis, Wash., Camp Dix, N. J., Camp Devens, Mass., Camp Upton, L. I., N. Y., Camp Kearny, Calif. (7) That convalescent soldiers, disabled by sickness or injury while in the United States, as well as those disabled overseas, be sent to convalescent centers, and that barracks be provided at those centers for quarters, mess, and training purposes, located near the various welfare centers conducted by the Young Men's Christian Association, American Red Cross, etc. (8) That sufficient personnel and equipment be provided at those centers to obtain the maximum restoration of convalescent soldiers by intensive treatment and training. As this treatment and training was chiefly a medical problem, that a medical staff for each center be supplied, consisting of a chief surgeon with the rank of major, a general surgeon, a heart specialist, an orthopedist, a mental specialist, a specialist in diseases of the lungs, and two general medical officers; consultants in surgery and medicine should visit the camp in an advisory capacity. Over exercise or absence from training interfering seriously with the rapid recovery of a convalescent, the chief surgeon must prescribe the amount of physical training, exercise, and mental work to be performed, and control the issuing of passes and the assignment to fatigue duty. (9) That camp commanders detail at once the necessary line officers and enlisted men to form the permanent cadre at these centers to provide administration, supply, and mess as there was need for their immediate organization. The importance of the work to be performed in these detachments of overseas convalescents should be borne in mind and competent line and medical officers chosen for the duty. They should be impressed with the fact that cooperation was necessary in order that the best results might be obtained; that the final object sought was the earliest possible return of these men to civil life, restored to the best possible physical and mental condition.

The Secretary of War approved this modified plan of reconstruction substantially as outlined, but it was directed that the transfers of personnel would be proposed by name in each case, the individuals to be selected by the Surgeon General from those who desired the transfer.26

SECTION OF EDUCATION

During the process of reorganization given above the educational aspect of the reconstruction problem was less emphasized than were the other branches of the activity. The dean of Teachers' College, Columbia University, New York City, who was appointed director of the educational section in April, 1918,27 submitted an outline of the proposed policy of the section on May 29, 1918, which covered the general principles and organization of the section, and another on July 15, 1918, stating the policy as applied to the patients to be served. As these two documents comprise the first outlines of work proposed, they are reproduced here in their entirety:


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MAY 29, 1918.

Memorandum for Colonel Billings, M. C., N. A.
Subject: Policy of department of education in division or physical reconstruction.

AIM

The aim is to promote the physical and functional rehabilitation of disabled soldiers and sailors by means of purposive play, work, and study.

NEED OF EDUCATION

It is conceded that the physical rehabilitation of disabled men is peculiarly dependent upon their mental attitude. The more serious the disability, the greater the danger of mental depression and an indisposition to respond to medical and surgical treatment. The educational work should begin, therefore, at the moment when the man has arrived at the stage where he begins to worry about his future. The first problem is to divert his attention, by simple recreation through reading, pictures, games, handiwork occupations, and the like, with a view to securing a genuine interest in the attainment of some worthy end. The end most certain to hold his attention and to claim his best efforts is his future vocation. Hence, by gradual steps, he may be induced to supplement his previous vocational experience by academic, scientific, or technical instruction, or to choose a new vocation and begin preparation for it if such a course is necessary.

It is understood that whatever recreational, general, or technical training is given to a hospital patient is to be administered in "doses" as prescribed by the medical authorities and as a therapeutic measure.

SCOPE OF WORK

The need of "cheer-up" work in the hospitals extends to all who are mentally capable of planning for their own future. This means a relatively large proportion of the entire number. If the educational staff does its full duty it should reach and interest in some way and to a marked degree a full half of all the men who remain under hospital treatment for a considerable period. A properly conducted school of secondary or higher grade provides one teacher for 10 pupils. Disabled men need even more individual attention than school pupils. Hence provision should be made in each reconstruction hospital for at least one teacher for every 10 men.

Ample provision will be made by Congress for the vocational training of disabled men after their disability. Millions of dollars will be expended and the resources of the entire country will be drawn upon for this purpose. The success of the national program for vocational training will depend almost entirely upon the preparation made for it in the hospital A moral obligation, therefore, rests upon the War Department to see that every possible consideration is given to the man in need of vocational guidance and educational reconstruction.

Much depends upon the personality of those who lead in this work. It should not be done in a mechanical fashion, and mechanically-minded men can not succeed in it. The choicest spirits in the teaching profession must be attracted to it, and in this time of national need such men will respond as a patriotic duty. The one thing needful is the moral, official, and financial backing of the War Department.

PLANS OF ADMINISTRATION

a. In the Surgeon General's Office:
1. A head of the department of education, ranking as a lieutenant colonel, responsible to the chief of the division of physical reconstruction.
2. Subordinate to the head of the department of education, four inspectors with the rank of major. The duties of these inspectors to be divided according to the division of function in the hospitals hereinafter mentioned.
3. Officers of lower grade, secretaries, and clerks as needed.
b. In the hospitals:
1. A director of educational services, ranking with the directors of medical and surgical service, subordinate to the commanding offficer.
2. Four heads of departments, to wit: (a) Recreational, (b) psychological and statistical, (c) academic, (d) technical, subordinate to the director of educational service.
3. Teachers, assistants, secretaries, and clerks as needed. Many of these will later be drawn from the list of competent men who have been disabled in service.


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FUNCTION OF DEPARTMENTS

1. Recreational department: To provide diversion by entertainment with music, pictures, books, lectures, and exhibitions; to give amusement in games and sports; to direct handiwork occupations in the fine and industrial arts; and to cooperate with other agencies, such as Young Men's Christian Association, Red Cross, and the like.
2. Psychological and statistical department: To be responsible for an records that may be deemed necessary for the joint use of the educational departments and the authorities which may subsequently have control of vocational training and placement; to act as consultant on all psychological problems ana to make studies of procedure and methods as requested by the directors of the medical and educational services.
3. Academic department: To provide elementary instruction for illiterates; conduct classes for those who may profit from secondary and higher courses; arrange for correspondence courses and individual instruction of men who wish to return to college and assist in guiding competent men to professional training in the learned professions.
4. Technical department: TG provide instruction in prevocational subjects, such as drawing, design, trade mathematics, applied science; to direct curative workshops; and to give such vocational training as may be found necessary and expedient in the case of individuals who can profit from such specialization in industrial, commercial, and agricultural work.

METHODS

Individual instruction, class work, and group teaching in wards, classrooms, and curative shops. The scarcity of supply of competent teachers in many lines essential to success in this work will necessitate the establishment of training classes in hospitals and making arrangements with existing institutions to train disabled men who may be detailed for the purpose.

EMERGENCY NEEDS

Until men who have been overseas can be selected and trained for teaching it may be necessary, expedient, and economical to employ civilians as teachers and assistants for definite periods of service. Frequently special teachers will be needed for emergency service and equipment will be called for outside the regular supply. The welfare of patients will be seriously jeopardized unless the necessary teachers and supplies can be secured promptly. It is highly important, therefore, that an emergency fund be provided which may be drawn upon by the department as need arises for the purchase of supplies and the payment of salaries to civilians.

STATEMENT OF POLICY

JULY 15, 1918.

Memorandum for Colonel Billings:
Subject: The educational policy of the division of physical reconstruction.

1. Hospital patients, from the military standpoint, are of three general classes: A, Those who can be restored to full duty; B, those who can be fitted for limited service; and C, those disabled to the extent of unfitting them for further military service.
Of the 1,600 patients that have passed through Fort McHenry Hospital only 65 were recommended for immediate discharge as being of no further service to the Army. It is estimated that 25 per cent belong to class A above, 65 per cent to class B, and 10 per cent to class C. The commanding officer at Fort McHenry states that he has just released 30 able-bodied men for overseas duty and has filled their places with patients. He expects to replace all his hospital corps with returned soldiers.
2. Patients of the first class (A) should have, when circumstances warrant it, the benefit of the therapeutic treatment through play, work, and study, as may be prescribed by medical officers, in order that their morale may be stiffened, their special skills improved. their future usefulness increased, and their recovery hastened.
3. Patients of the second class (B) should have, whenever conditions permit and the medical officers approve, such specific training-physical and vocational-as will, in the judgment of the educational officers, best fit such patients for limited service of a particular kind. At present patients are being trained in general hospitals for limited service as general


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and vocational teachers, typists, printers, tailors, cobblers, harness makers, welders, motor mechanicians, painters, machine workers, woodworkers, bookkeepers, statisticians, telegraphers, photographers, telephone operators, cooks, storekeepers, electricians, etc.
The list can be extended with the advice and cooperation of the committee on education and special service of the War Department to meet other needs as they arise. In connection with the large general hospitals there is abundant opportunity for practice in many trades and occupations. At Fort McPherson, for example, practical experience can be gained in 20 different trades. Moreover, there is immediately adjacent to the hospital a larger quartermaster's mechanical repair shop covering all phases of mechanical repair and units to which men can be assigned for limited service or to gain experience.
4. Patients of the third class (C) should be encouraged in every possible way to accept the benefits accorded to them for vocational training by the Federal Board for Vocational Education. To this end they should have, while in the hospital, such physical training and general education as will best promote their physical reconstruction and at the same time contribute most to their vocational training. Patients who do not elect, or who are not eligible, to continue their education under the Federal board should receive such training as the medical and educational officers deem best in each individual case.
5. To carry out this program calls for an exceptionally able personnel. It is expected that within a few months enough teachers can be secured, either by the induction of specialists or by restoration to limited service of partially disabled men, but such men must be trained to teach and their work must be carefully supervised. The experience of Canada shows that one teacher is required for every 10 men under training. The supervisory and directing staff, composed of commissioned officers and civilians, must be large enough and capable enough to make the work effective. Each hospital should have sufficient equipment for its ordinary educational needs and an emergency fund for the procurement of supplies that can not be anticipated and for the employment of civilian instructors when the regular staff is inadequate.

JAMES E. RUSSELL,
Director of Department of Education, Division of Physical Reconstruction.

The activities of the division of physical reconstruction during the summer and fall of 1918 largely concerned the educational section, as the organization of the physiotherapeutical work was so well advanced that it required only occasional statements to the hospitals of the policy concerning individual matters. The educational section became the educational department in September, 1918, and was divided into the (1) office section, (2) field section, (3) psychology section, and (4) publicity section.28 The dean of the University of Minnesota became the civilian director of the department on October 1, 1918.29

Authority was obtained late in September to employ four especially qualified aides in the department office as supervisors of occupational aides to meet the administrative demands of the increasing personnel of that class.30

The pendulum of enthusiasm for vocational work swung so far in the fall of 1918 that curative work and play were being neglected, particularly as applied to the amputation cases, and these features were considered to constitute one, if not the greatest, advance in the care of the amputated.31 It was the consensus of opinion of the medical officers engaged in their care in one general hospital that no effective effort was being made in this direction, and it was
recommended that a corps of persons trained in the particular features of curative work and play for the amputated be organized.31

UNIT COURSES OF STUDY

There were several factors in educating disabled soldiers which did not enter into normal teaching experience. These were the varied mental capacities and the mental states of the students, the relatively short time available,


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and the varied abilities and personal characteristics of the available teaching personnel. In addition, it was necessary to coordinate the work in hospitals with the vocational work which the students would later take under the Federal Board for Vocational Education.

To assist the educational staffs of the hospitals in so organizing their work as to meet these conditions "unit courses of study" were drawn up by a joint committee of representatives from the educational department in the Surgeon General's Office and from the Federal Board for Vocational Education and published in pamphlet form. Each pamphlet consisted of an outline of a short, complete course in one particular phase of a subject, requiring only a comparatively few study hours for completion. Study sheets giving the details of the course necessarily were prepared by the instructors, who also could prepare unit courses of their own for branches of the subjects not covered by the published courses, as the committee had laid down definite specifications covering all courses, but had actually drawn up only a few in each subject. The pamphlets were published during the period from November, 1918, to February, 1919.a

PREPARATION FOR OVERSEAS CASES

During the early months of 1919 the attention of the division of reconstruction was concentrated largely on the problem of the preparation for and reception of the overseas disabled. The fundamentals of the problem having been solved by the approval of the modified program for reconstruction, there remained to be accomplished only the provision and equipment of a sufficient number of reconstruction hospitals to accommodate the patients to be received. There were barely sufficient beds available for the purpose at the first of the year, provided no epidemics or other unexpected occurrence made unusual demands on the hospitals; however, the danger of the narrow margin in the number of reserve beds was decreased considerably by the establishment of the convalescent centers.32 b

At this time there was an anxiety to be discharged among both officer and enlisted patients that amounted almost to hysteria and was universal, leading to a great difficulty in retaining in the service sufficiently long to effect maximum restoration of function any man who was not confined to bed. Everyone seemed to have an almost uncontrollable desire to get out of the service and to go home and do nothing but rest for several months. Patients would make all manner of optimistic statements as to their conditions, obtain guarantees from relatives and friends for necessary treatment after discharge, and in many other ways influence medical officers, against their better judgment, to recommend discharges. To relieve the pressure brought to bear by relatives and friends of homesick disabled soldiers, and because these patients would not respond to the fullest extent to treatment in a military hospital while in this frame of mind, the War Department gave authority on December 31, 1918, to discharge such men, on their own application, who furnished documents from relatives or friends which guaranteed the necessary specialist treatment after discharge, and released the War Department from further responsibility for their treatment.33

a These pamphlets are reproduced in the appendix to this volume.-Ed.
b This subject is discussed more fully in succeeding pages under the heading "Convalescent centers."-Ed


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This provision for discharge caused great anxiety among those responsible for the fulfillment of the reconstruction program, the fear being expressed that the majority of the disabled would return to civil life in a physically unfit condition rather than in the best condition possible, as planned, thereby completely destroying the general utility of the entire reconstruction program and ultimately leading to a pension system through political pressured.34 These fears were not realized; on the contrary, the hospitals were relieved of a large group of dissatisfied patients, and this factor, together with the legitimate discharge of men with the slighter degrees of disability, soon resulted in a great lessening of the burden of the Medical Department so far as available beds were concerned. The peak of the load occurred in March, 1919.35

Toward the latter part of May, 1919, 18 general hospitals and 2 base hospitals, in addition to the 3 general hospitals for tuberculous cases, remained as reconstruction hospitals, with an approximate bed capacity of 28,000, and plans were made to close certain hospitals as the need for them declined; 36 the reception of overseas cases at the hospitals of demobilization camps had already been stopped, and it was the intention to have no activity in these hospitals, except from local sources, by July 1, 1919.

Nine of these 20 hospitals were designated to function longest, as follows: 36 Army and Navy General Hospital, Hot Springs, Ark.; Letterman General Hospital, San Francisco, Calif.; Walter Reed General Hospital, Takoma Park, D. C.; General Hospital No. 6, Fort McPherson, Ga.; General Hospital No. 19, Oteen, N. C.; General Hospital No. 21, Denver, Colo.; General Hospital No. 26, Fort Des Moines, Iowa; General Hospital No. 31, Carlisle, Pa.; and
Department Base Hospital, Fort Sam Houston, Tex.

The following additional 11 hospitals were named as those which would operate long enough after July 31, 1919, to receive and care for the 8,000 more or less chronic cases which were then in general hospitals without later transfer: 36 General Hospital, Fort Bayard, N. Mex.; General Hospital No. 2, Fort McHenry, Md.; General Hospital No. 3, Colonia, N. J.; General Hospital No. 8, Otisville, N. Y.; General Hospital No. 20, Whipple Barracks, Ariz.; General Hospital No. 28, Fort Sheridan, Ill.; General Hospital No. 30, Plattsburg, N. Y.; General Hospital No. 41, Fox Hills, Staten Island, N. Y.; General Hospital No. 42, Spartanburg, S. C.; General Hospital No..43, Hampton, Va.; and Base Hospital, Fort Riley, Kans.

In order that the hospitals named could furnish the required bed capacity, it was directed that the ordinary distribution of patients from ports to the hospitals nearest their homes would be disregarded to the extent that the patients would be sent to the hospitals nearest their homes where beds were available.

DIVISION OF PHYSICAL RECONSTRUCTION ABOLISHED

The activities of the Surgeon General's Office had so diminished by June 20, 1919, that the division of physical reconstruction was discontinued, becoming the section of physical reconstruction in the division of hospitals.37

STABILIZING PHYSICAL RECONSTRUCTION

The number of patients in hospital declined steadily throughout the latter half of the year 1919, which allowed the closing of reconstruction hospitals from time to time and the coincident discharge of personnel.38


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No further questions of policy of any great magnitude arose in the reconstruction section during the year 1919; such questions as did arise will be covered in succeeding chapters. The reconstruction cases remaining in hospital by the latter part of 1919 were necessarily of a chronic nature, the majority having undergone several surgical operations. Since many of them desired discharge at once and their treatment in a military hospital held no particular advantages over treatment in any other first-class hospital, and as the War Risk Insurance Bureau had made provision for their hospital care after discharge, the War Department announced the following policy concerning those chronic cases, on November 7, 1919: 9 (1) That all disabled military personnel, except officers of the permanent Army and special surgical cases, should be granted discharge six months after admission to a hospital in the United States for definitive treatment if discharge was desired and applied for by the individual in writing. (2) That all patients of the same classes, with the additional exception of mental cases, should be discharged after one year in hospital. If too sick to be moved or unable to provide the necessary care for themselves, they were to be retained until provision was made for them by the War Risk Insurance Bureau, Soldier's Home, or the National Home for Disabled Volunteer Soldiers.

No supporting documents guaranteeing further treatment after discharge or relieving the War Department from further responsibility for treatment were required.

REFERENCES

(1) Annual report for the year ending June 30, 1918, division of orthopedic surgery, to the Surgeon General, July 15, 1918. On file, Historical Division, S. G. O.
(2) Letter from Maj. E. G. Brackett, M. R. C., and Maj. J. E. Goldthvait, M. R. C., to Major General Gorgas, August 14, 1917. Subject: Plan of organization and development of orthopedic department. On file, Record Room, S. G. O., 024-14.
(3) Memorandum from Lieut. Col. T. C. Lyster, M. C., to the Surgeon General, August 15, 1917. Subject: Reconstruction, reeducation and after-care of disabled soldiers. On file, Record Room, S. G. O.
(4) Memorandum, Surgeon General's Office, August 22, 1917. Subject: Division of special hospitals and physical reconstruction. Also attached papers. On file, Record Room, S. G. O., 115568-11.
(5) Memorandum on the administrative reorganization of the reconstruction division, Surgeon General's Office, undated and unsigned. On file, Historical Division, S. G. O.
(6) Letter from the chief, division of special hospitals and physical reconstruction, to the Surgeon General, February 2, 1918. Subject: Report for period ending January 31, 1918. On file, Historical Division, S. G. O.
(7) Annual Report of the Surgeon General, United States Army, 1918, 396.
(8) Letter from the chief, division of orthopedic surgery, to the Surgeon General, November 3, 1917, and attached papers. Subject: Weekly report. On file, Historical Division, S. G. O.
(9) Administrative organization for physical reconstruction, prepared in the Office of the Surgeon General, November 24, 1917. On file, Historical Division, S. G. O.
(10) Act, October 6, 1917 (40 Stat. 398).
(11) General Orders, No. 1, War Department, January 2, 1918.
(12) Memorandum office order, Surgeon General's Office, March 21, 1918, unnumbered. On file, Record Room, S. G. O., 356.
(13) Descriptive report of hospitals and buildings for work of the reconstruction division, undated and unsigned. On file, Field Personnel Section, S. G. O.


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(14) Memorandum for all officers in the Surgeon General's Office, April 29, 1918. On file, Record Room, S. G. O., 356.
(15) Memorandum from the Surgeon General, April, 1918. Subject: Physical reconstruction. On file, Record Room, S. G. O., 356.
(16) Office memorandum, Surgeon General's Office, May 6, 1918. On file, Record Room, S. G. O., 024.
(17) Office order, Surgeon General's Office, May 13, 1918, unnumbered. On file, Record Room, S. G. O., 024.
(18) Memorandum from Col. Frank Billings, M. C., for all officers of the division of reconstruction, Surgeon General's Office, May 31, 1918. On file, Historical Division, S. G. O.
(19) Memorandum from the Surgeon General to the Secretary of War, November 7, 1917. Subject: Plan for physicial reconstruction and vocational training. Also attached papers. On file, Record Room, S. G. O., 356 (Reconstruction).
(20) Fifth indorsement from The Adjutant General to the Surgeon General, May 6, 1918. On file, Record Room, S. G. O., 356 (Reconstruction).
(21) Annual Report of the Surgeon General, United States Army, 1918, 398.
(22) Office Order No. 36, Surgeon General's Office, May 13, 1918. On file, Record Room, S. G. O., 024.7.
(23) Report on the physical reconstruction of invalided and disabled soldiers, from the division of physical reconstruction, Surgeon General's Office, June 3, 1919. On file, Record Room, S. G. O., Miscellaneous Letters, A-961.
(24) Letter from the Surgeon General to the Chief of Staff, June 25, 1918. Subject: Physical reconstruction. Also attached papers. On file, Record Room, S. G. O., 353.91-1.
(25) Official Bulletin, August 1, 1918. (Published daily by the Committee on Public Information, George Creel, chairman, Washington, D. C., 1918.) On file, Record Room, S. G. O.
(26) Letter from The Adjutant General, United States Army, to the Surgeon General, December 19, 1918. Subject: Modified program of physical reconstruction. Also attached papers. On file, Record Room, S. G. O., 353.91-1.
(27) Report on the organization and development of the division of physical instruction, undated and unsigned. On file, Historical Division, S. G. O.
(28) Office memorandum, department of education, Office of the Surgeon General, September 9, 1918. On file, Record Room, S. G. O., 024-12 (Division of physical reconstruction).
(29) Letter from L. D. Coffman to the Surgeon General, August 12, 1918, and attached papers. On file, Record Room, S. G. O., Coffman, L. D.
(30) Letter from the Acting Surgeon General to the Secretary of War, September 25, 1918. Subject: Employment of supervisor of reconstruction aides in occupational therapy. Also attached papers. On file, Record Room, S. G. O., 231.
(31) Memorandum from Lieut. Col. David Silver, M. C., to Colonel Richardson, M. C., October 2, 1918. Subject: Curative work for the amputated. On file, Historical Division, S. G. O.
(32) Circular No. 90, War Department, November 25, 1918.
(33) Circular No. 188, War Department, December 31, 1918.
(34) Letter from Third Assistant Secretary of War to Dean Russell, January 9, 1919, and attached papers. On file, Record Room, S. G. O., 353.91-1 (35) Weekly bed reports, hospital division, Surgeon General's Office.
(36) Memorandum for the Surgeon General from the division of reconstruction, May 24, 1919. Subject: Conclusion arrived at with reference to hospitalization. On file, Historical Division, S. G. O.
(37) Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1180.
(38) Annual Report of the Surgeon General, United States Army, 1920, 268, 282, 283.
(39) Memorandum from the Chief of Staff to the Surgeon General, November 7, 1919. Subject: Policy re protracted hospital treatment for military personnel. On file, Record Room, S. G. O., 705-1.