SECTION III
IN MILITARY HOSPITALS IN THE UNITED STATES
CHAPTER III
IN GENERAL AND BASE HOSPITALS
INITIATION OF RECONSTRUCTION
Though one phase of reconstruction-surgical treatment with its after treatment-was carried on at all times during the World War, the beginning of the execution of the reconstruction program of the Medical Department in the military hospitals occurred early in 1918,1 when organized efforts were initiated in a few general hospitals. Necessarily, these early beginnings were crude as to organization and equipment, for the reconstruction program of the Surgeon General had not yet been approved by the War Department, and in consequence funds were not directly available for personnel, equipment, and buildings. Such facilities as were available or could be obtained from sources either military or civil were adapted to the purpose and reconstruction was undertaken in a small way. This stage fortunately occurred before any battle casualties arrived from overseas, so the experimental period largely had passed before the great need for the service occurred.
The first definite instructions concerning the operation of reconstruction services in hospitals were published by the Surgeon General in March, 1918. 1 In accordance with these instructions all therapeutic work, excluding physiotherapy, was to be classed as occupational therapy, and divided into (a) ward occupations, for men confined to bed or to invalid chairs, consisting of handicraft and educational activities; and (b) such other work in the shops, on farms, etc., as could be performed by more active patients. It was also provided that a selected chief educational officer, usually from the Sanitary Corps, was to be assigned to each hospital operating a reconstruction service and to have charge of the assignment of aides for ward occupations and immediate charge of the curative workshop schedule. No patient was to be assigned ward occupational work until the ward surgeon had entered on his clinical record the fact that he was physically fit for such work, and no patient was to be assigned to work in the shop, on farms, etc., except on written prescription of the proper medical officer, such prescription to state the functional result to be obtained, the length of time the patient should work, whether the work should be light or heavy, and whether indoors or outdoors. The selection of the type of work which would best fill the prescription was to be left to the chief educational officer. Equipment and raw material for carrying out the curative workshop schedule were to be obtained on requisition as medical property.
Originally it was planned to construct special buildings to house the reconstruction work a and such buildings were furnished at a few places, but the great majority of hospitals had to adapt to the purpose such buildings as could be made available.2
a The plan of the special U-type building for physiotherapy is shown in Vol. V of this history,
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The general hospitals designated in April, 1918, as reconstruction hospitals were to have the following personnel:3 (1) An educational officer, to be assigned by the Surgeon General's Office, who was to have charge of the curative workshop schedule; (2) reconstruction aides, class 2, teachers of handicraft, assigned by the Surgeon General's Office; (3) teachers from enlisted men already in the service who were physically not qualified to perform full military duty but who were mentally and temperamentally qualified for this work, such men in other branches of the service to be transferred to the Medical Department on a "partial duty status"; (4) The local organization to conduct a recruiting campaign for enlisted men for the same purpose; (5) employment of civilians as teachers if necessary.
FIG. 1.- Occupational therapy in the early stages of its use in the Army
The educational officer, under the general directions of the commanding officer, was charged with the employment of all patients whom the chiefs of services considered would be benefitted by the work.3 He was to assign them such work as would fill the requirements of the prescriptions written by the medical officers and to report, to and confer with the latter on the results accomplished. A tentative minimum list of necessary equipment and raw material was supplied, such property to be issued by the property officer to the educational officer as required 3 All finished articles made from material supplied by the Government were to be turned in to the educational officer for such disposition as should be directed.3
In order that patients who needed reconstruction could be centered in the designated general hospitals where the necessary facilities were available, the
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commanding officers of all base hospitals were notified on May 21, 1918, to transfer to general hospitals all patients who might be benefitted by special treatment not available at base hospitals.4 Patients who were blind, were totally deaf, had had amputations other than fingers and toes, or had pulmonary tuberculosis were specifically mentioned for transfer.
TYPES OF WORK PROVIDED IN JUNE, 1918
The following types of minor craftwork were offered in occupational therapy in June, 1918: Basketry, weaving with hand and bead looms, design, blockprinting, wood carving, knitting by hand and with machines, toy making, leather work, and the making of mops, bags, nets, etc. 5
FIG. 2.-This and Figures 3, 4, and 5 show minor craft work for patients confined to bed
There was some criticism of the type of work employed on the grounds that it catered to the superficial interest of the men, was too childish to attract mature men, and that the continued occupation with it tended to hospitalize the men and prolong their confinement to the ward.6 It was also contended that the employment of female reconstruction aides was inadvisable, as it was difficult to coordinate them with the rest of the hospital organization, and it was not desirable to employ women in this type of work in military hospitals. These contentions were disproved by experience as the occupational work became better organized. 5
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FIG. 6.- Handicraft-toy making
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ADMINISTRATION OF THE CORPS OF AIDES
At this time (June, 1918) it was decided that all work by reconstruction aides should be administered under the immediate supervision of the hospital educational officer.5 To this end a special form, the physical reconstruction register, Form 58, was devised and approved in July, 1918. This form was filled out for every man admitted to a reconstruction hospital, and the filed copies later formed the bases of studies of our war experiences.5
Instructions for the classification and administration of the personnel of the corps of aides were issued by the Surgeon General on September 27, 1918. 6
FIG. 7.- Occupational therapy-ward work
In accordance with these instructions, women appointed to teach handicrafts and other subjects to patients in military hospitals were to be called "reconstruction aides in occupational therapy." Reconstruction aides in occupational therapy were to be divided into three classes--aides, head aides, and supervisors. Whenever two or more aides were serving in a hospital, one of these was to be designated as head aide and was to have authority in all matters of administration. Junior aides were to work under her direction. Where more than10 aides were serving in a hospital, there was to be an additional head aide. Where two or more head aides were serving in the hospital, one of these was designated as chief head aide and was to have general supervision of the work. The function of the other head aides was to be the supervision of particular portions of the work under the general direction of the chief head aide. When the organization became complicated, a supervisor was appointed to have
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FIG. 8.- Group of physiotherapy aides, General Hospital No. 2, Baltimore
FIG. 9.- Group of 7 occupational aides, General Hospital No. 2, Baltimore
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administrative authority over all other aides. In general hospitals where there was a chief of the educational service the supervisor, chief head aide, head aides, and aides were to be responsible, according to their proper ranks, to the chief of the educational service. There was to be necessary oversight by the medical officer, as in case of all educational work, and through him to the commanding officer of the hospital in all matters relating to the content, method, and administration of the work. Where there was no chief of the educational service, the head aide was to be directly responsible to the chief of the clinical service in which the work was being done. In all cases the work was to have the necessary supervision of the medical officers of the hospital. In personal matters and in matters of conduct, both on and off duty, all reconstruction aides in occupational therapy were to come under the jurisdiction of the chief nurse of the hospital. In these matters they were to be subject to the same rules and regulations as nurses.
COOPERATION WITH THE FEDERAL BOARD FOR VOCATIONAL EDUCATION
The Federal Board for Vocational Education was not directly concerned with the vocational education of soldiers previous to their discharge from the military service, but admission of its representatives to reconstruction hospitals was authorized in order to coordinate the education of individuals in hospital with the educational courses to be given after discharge.7 On September 25, 1918, the Surgeon General notified all commanding officers of hospitals functioning in reconstruction work that the educational work in hospital was under the charge of the Surgeon General's Office, whether given for therapeutic purposes or for vocational preparation for special or limited Army service, and directed that the commanding officer of the hospital give all necessary cooperation to the representative of the board, under such regulations as the commanding officer should make, in the case of men who would be discharged from the military service after completion of their hospital treatment.7 It was suggested that the representative of the Federal Board for Vocational Training be furnished an office, given access to patients who had been recommended for discharge for disability, such men's educational and vocational history, both personal and of work performed, and such recommendations as to their future education or occupation as the educational officer might care to make. No military or medical histories would be furnished, as this was contrary to Army regulations, nor was permission to be given the representative to interview patients in the wards. While the Army was making every effort to prepare men for military service, it was considered inadvisable to permit the promiscuous circulation in hospitals of the representatives of an agency which was necessarily concerned solely with the training of men for civil pursuits and who were required to make the opportunities which they offered as attractive as possible.
THE EDUCATIONAL SERVICE IN THE FALL OF 1918
An educational service was well established in 17 hospitals by November 15, 1918, and less completely in 3 additional hospitals.8 The different classes of work that were to be given at this time, were as follows: 8 (1) Bedside occupations to take the patient's attention from his disability and occupy his mind.
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At first diversional and entertaining, these became definitely vocational, economic or social in value. (2) Ward, shop, or farm occupations and study to occupy the patient's time in worth-while work, and thus develop in him a good mental attitude toward his disability, his treatment, and the hospital. (3) Ward, classroom, or farm operations and study in preparation for reeducation, for those entitled to reeducation, under the Federal Board for Vocational Education.
An average of about 38 per cent of patients in a reconstruction hospital were enrolled in the educational service courses at the time in question, but this figure is probably considerably higher than that of the actual attendance
FIG. 10.- Occupational therapy when fully organized-weaving room
at classes, for which no figures are available. 8 Handicrafts were slightly over 50 per cent more popular than academic study in the wards, while academic subjects and games and exercises had the largest enrollments for those who were not confined to the wards.8 Enrollment in educational classes was voluntary, and the size of the class depended largely on the popularity of the instructor. Later it was considered advisable in many hospitals to adopt some form of compulsory attendance, the withholding of pass privileges or the assignment to some hospital duty being the penalty for failure to participate in the educational work.
Instructions were formulated in the fall of 1918 and later published as a handbook which completely covered the duties of officers in the educational department and their relations to other departments of the hospital.9 Chart II
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shows the organization of the educational service in at hospital at. the time in question. This organization continued through the reconstruction period with butt little modification.
ACCOUNTING FOR MATERIALS USED IN OCCUPATIONAL THERAPY
In the fall of 1918 an inclination became evident among the disabled patients to expend their time in occupational work which had no particular value in preference to the more advantageous courses in education, and to make articles either for keepsakes, for gifts to friends, or to sell for profit. This state of affairs was one of the bases for criticism of occupational therapy
FIG. 11.- Occupational therapy—handicraft room
and led to reports pointing out the necessity for confining ward occupations to those who were unable to go to shops and classrooms and for discouraging the making of baskets, bead chains, trays, and similar articles for sale. 10
In an effort to confine these activities to the proper and most advantageous channels instructions were issued in October, 1918, governing the procurement of and accountability for the materials used in occupational therapy as follows: 10 Ordinarily raw materials were to be procured and expended much as other articles of medical supply. Such completed articles as were of use in the operation of the hospital were to be taken up on the property account; those of no use to the hospital and of no salable value were not to be taken up. Materials for articles which would be of no utility to the hospital, but would have a salable value, were to be purchased from the hospital fund and
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FIG. 12.- Handicrafts for convalescents
FIG. 13.- Instruction in automobile mechanics
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were to be carried as "durable property" of this fund until transformed into completed articles. The finished product was then likewise to be carried until disposed of, usually by sale. The gross proceeds of sale were to be debited to the hospital fund, and any profit could be distributed pro rata among the patients engaged in their fabrication. In special cases the patient who made the article could dispose of it at his pleasure, otherwise than by sale.
An agency for the sale of the articles manufactured in all military hospitals that were of no use to the hospitals was maintained in Washington, D. C., for a time, but this later became the agency for Walter Reed General Hospital
alone, and other hospitals were directed to dispose of their products through the post exchanges or other local agencies.10
These regulations caused some dissatisfaction among the patients, as in the main they desired the manufactured articles for such disposal as they saw fit, and led to the donation of materials from civilian sources to individuals and the purchase of materials by patients in order that the restrictions imposed need not apply. These conditions led to the following further instructions: 10 (1) The purchase of raw materials was to be made only from the hospital fund.b
b This does not refer to requisitions for materials.-Ed.
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(2) Purchase of raw material by individuals was not expected or required, and the acceptance by individuals of donations of material to be fabricated into articles for sale was to be prohibited. Donations to common stock or to individuals for fabrication for gifts or personal keepsakes, was to be permitted. (3) Sales of finished articles by individuals were not to be permitted. The proceeds of all sales were to be taken up as accruing to the hospital fund.
TYPES OF WORK PROVIDED IN FALL OF 1918
The following ward occupations and courses in the curative workshop schedule were being taught in the fall of 1918: 11,12
WARD OCCUPATIONS
(a) Handicrafts.- Basketry, bead work, bookbinding, book-end making, block printing, carving, chair caning, carpentry, colonial-mat making, designing, knitting, knotting, leather work, needlework, novelty box work, pottery making, picture framing, rug making, rake knitting, slipper making, string work, toy making, stenciling, water-color painting, weaving and whittling.
(b) Other work.- Arithmetic, bookkeeping, business English, English, higher mathematics, history, mechanical drawing, penmanship, reading, science, shorthand, spelling, and typewriting
CURATIVE WORKSHOP SCHEDULE
(a) Academic.- Arithmetic, civil-service subjects, English, English for foreigners, geography, history, mathematics, higher mathematics, penmanship, reading, science, and spelling.
(b) Commercial.- Bookkeeping, banking, insurance, accounting, correspondence, commercial law, stenography, and typewriting.
(c) Technical, etc.- Automobile driving, automobile mechanics, automobile repair, abattoir work, animal breeding, agriculture, applied art and design, barbering, basket making, building trades, blacksmithing, box making, bookbinding, cabinetwork, cartooning, chair caning, concrete working, curative walks, decorating, drawing, mechanical drafting, electrical work, farm management, furniture repairing and factory work, gardening, hospital duty, jewelry making, light work (road grading, etc.), linotyping, laundry work, locksmithing, leather working, machinist, general mechanic, mechanical engineering, metal working, motion-picture operating, monotyping, oxyacetylene welding, paintbrush making, painting, photography, piano tuning, poultry raising, physical exercises, printing, picture framing, planing-mill work (including sash, door, and interior trim), plumbing, pipe fitting, making orthopedic apparatus, radio operating, radio electrician, rug weaving, recreation (for normal and psychopathic), saddlery, sign painting, shoemaking, shoe repairing, tinsmithing, toy making, telegraphy, tractor repairing, tractor driving, tailoring, vulcanizing, hand and machine weaving, wood finishing and veneering, woolen mill work, and upholstering,
IN GENERAL HOSPITALS
The following account of the work in occupational therapy as it had developed by the close of the year 1918 at Walter Reed General Hospital is given, because this hospital enjoyed unusual advantages as to completeness of equipment, personnel, etc.
AT WALTER REED GENERAL HOSPITAL 13
ORGANIZATION
The department of occupational therapy was divided into five sections- administrative, psychological and statistical, general or academic, technical, and recreational. The department acted as a training and demonstration
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FIG. 14.- Patients' class in wireless telegraphy
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FIG. 16.- Patients learning to use left hand in writing
FIG. 17.- Patients working in jewelry class
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school for other hospitals and an experimental laboratory for trying out methods of teaching, outlines of subject matter, types of equipment, and the selection and training of personnel.
ADMINISTRATIVE SECTION
The administrative section performed the duties of a record and property office. This required a large staff of clerks because of the rapidity of the growth of the department, the large "turnover" of patients, and the compilation of reports and data for the Surgeon General's Office.
PSYCHOLOGICAL AND STATISTICAL SECTION
The psychological and statistical section was primarily responsible for the psychological and educational surveys of individual patients. It made an intensive study of the problems encountered under the curative workshop schedule, the adaptation of curative methods to particular patients and specific disabilities, the application of trade tests and vocational guidance, and the measuring of intelligence by approved methods. The department was very successful in measuring the increase and strength of the movement of ankylosed joints and stump limbs. In detail the work performed comprised :13 (1) Psychological and educational surveys-interviews, psychological examinations, and records of personal, social, educational, and vocational history; these furnished guidance in assigning the patient to appropriate educational work, in making special adjustments in assignments to attain particular curative or functional results, and in helping to make a judicious selection of vocation. Intelligence ratings from group examinations or from individual examinations-these revealed cases of low-grade mentality or mental defect and special cases of maladjustment.
(2) Psychological service for medical officers-mental ratings and analyses of special cases referred by ward surgeons. (3) Trade tests and vocational surveys- surveys preliminary to assignment to a special kind of training or to a particular state in a course of training, reports on mental and vocational fitness for full military duty, special service, limited service, domestic service, development battalion, surgeon's certificate of disability, and vocational placement. (4) Problems of learning-studies of the most economical and successful methods of learning, qualitative mental analysis, studies of special mental abilities and disabilities, the diagnosis and correction of cases of unsatisfactory progress in educational work, detailed examination of learning to write with the left hand and of learning typewriting. (5) The measurement of the amplitude of voluntary movements. These measurements serve the twofold purpose of encouraging and inspiring the patient by demonstrating to him in objective fashion that he was really improving and of informing the surgeon and physiotherapist regarding the rate and locus of improvement. (6) Mental attitude and morale. No single factor exerted a more powerful influence upon the patient's convalescence and subsequent rehabilitation than the mental attitude of the patient himself. The patient who had abandoned hope and indulged in self-commiseration and gloomy forebodings reached a condition which thwarted the best efforts of the surgeon and the educator. Lethargy was the inevitable result, and experience in the military hospitals of our allies had shown that so long as despondency, pessimism, and instability persisted the case was utterly hopeless. On the other hand, a cheerful optimism
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on the part of the patient, a spirit of self-reliance and determination to cooperate, were so vitally important as to be indispensable.
Meetings of the staff and patients were, held once a week in the Red Cross House or in the post auditorium. The purpose of these meetings was to present to the patients the advantages of taking work with the department of occupational therapy. The presence of officers from the Surgeon General's Office, demonstrations by the different departments, and talks on opportunities both in the hospital and outside made these meetings of great significance to many of the men.
GENERAL OR ACADEMIC SECTION
The academic or general department offered subjects from the most elementary grade through high-school grades. The department was particularly successful in reaching large numbers of patients who had not had the advantages of school training and who were desirous of taking courses which required some academic background.
TECHNICAL SECTION
The technical program comprised a wide variety of subjects and offered-valuable instruction to the men who were mechanically inclined. The automobile department early seized upon the idea of doing practical work repairing cars. This gave thq patients opportunity to put in practice what they had learned in class discussions. The drafting section was particularly successful in arousing the interest of the men, and gratifying results were obtained. Both farm and greenhouse work proved to be profitable. The woodworking department, in addition to its curative work, did a great deal of post repair work and made possible many conveniences in the shops. The rug weaving section constantly appealed to patients, and many new types of curative exercises were developed. The jewelry section interested the men, and especially fine work was produced. Modeling developed the artistic temperaments of several men and provided them with a pleasing occupation while in the hospital.
RECREATIONAL SECTION
The recreational department handled the formal exercises and play hours of the patients fairly satisfactorily. At the beginning the work was severely handicapped by a lack of equipment and the lack of a permanent commissioned officer to supervise it; however, with the arrival of three or four instructors, the work was subdivided so that specialization was made possible, and a great deal of ward work was carried out. One instructor was able to devote most of his time to the amputation cases. Cooperation with the orthopedic section made this work more profitable. One of the large rooms was turned over to the recreational department to be used as a gymnasium. In addition to indoor sports, classes in dancing were organized for the men. The department closely cooperated with the department of physiotherapy and the American Red Cross.
BUILDINGS AND EQUIPMENT
Five new curative occupational buildings, erected southwest of the American Red Cross Building, were occupied by the department. These buildings, 24 by 144 feet, constructed of stuccoed hollow tile, were modern in every way,
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well lighted, well ventilated, pleasant, and with interior arrangements and equipment planned to make them places where men could find health, strength, knowledge, and pleasure in constructive work. These buildings were utilized as follows: Buildings 93 and 94 contained (1) the school and administration offices; (2) the psychological laboratory (here were made measurements and recordings of the daily increase in movement in injured or disabled hands, arms, and legs, and the curative occupational and vocational needs of individual patients were analyzed); (3) the commercial department (instruction was offered in touch typewriting, shorthand, and stenotypy); (4) the academic department (instruction was given in elementary, secondary, and advanced academic and civil service subjects; the courses in this department offered excellent opportunities for mental occupations and the chance for reviewing forgotten studies or acquiring new ones); (5) the library (a constantly growing collection of scientific and reference books, current periodicals, and journals of the various trades, occupations, or professions). Building 95 contained (1) the electrical department (instruction was offered in electrical work, including Morse and radiotelegraphy, motor and general repairing, wiring, testing, etc.); (2) the engineering and drafting department (courses in elementary and advanced mechanical, architectural, and topographical drafting, tracing, and blue printing); (3) office and exhibition rooms of the ward occupation department. Building 96 contained the machine shop, where instruction in machine shop practice was given, and the cinematograph department, in which instruction was given in motion-picture machine operating, repair, and inspection. In building 97 there was the laboratory for orthopedic appliances. Here orthopedic appliances were manufactured and fitted, and instruction was given in their uses. Building 98 had (1) the woodworking department, where instruction was given in practical woodworking; (2) the oriental rug department (in textile weaving and designing, the special devices used were adapted particularly to the curative needs of the patient). An additional building contained (1) the printing and linotype department, where instruction was offered in hand composition and linotype operating, proof reading, and presswork; (2) the jewelry and metal department, wherein training in finer handicrafts, stone setting, jewelry making, and repair was given; (3) photography department (courses were given in commercial photography, developing, printing, and motion-picture film developing and repair).
AIDES
The work of the aides at Walter Reed General Hospital started February 15, 1918. The first work consisted of knitting colored wool squares for blankets and some machine knitting. The men, for the most part, were bed patients and welcomed the opportunity to do something. Gradually the work spread through the different wards as the need of it became evident, facilities were made available, and the work was systematized and organized.
The following activities over which the aides had supervision were carried on in the wards: Chair caning, cardboard construction work, woodwork, block printing, rush seating, brush making, bookbinding, modeling, rug making, stenciling, mop making, designing post cards, plasticine modeling, drawing,
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leather work, hand knitting, rake knitting, frame knitting, machine knitting, weaving, basketry, bead work, making colonial mats, netting, cord work, crocheting, and embroidery.
To train the aides adequately for their work and to secure personnel, a school for reconstruction aides was started in 1918. It was postponed for a time, due to the influenza epidemic, but was reopened as soon as this became less serious. The course of training consisted of practical work with the patients under the supervision of experienced aides, and of lectures of both a general and professional nature. The school was discontinued soon after the signing of the armistice.
There follows a few of the types of correlation and coordination in the educational and occupational service:
WITHIN THE HOSPITAL
Relation of educational service:
1. To the commanding officer or adjutant in all lines of activity, buildings, facilities, and policies.
2. To the medical and surgical services with regard to the assignment and progress of patients.
3. To the physiotherapy service with regard to physical training.
4. To the commanding officer, medical detachment, in regard to furloughs, records, and discipline of enlisted instructors.
5. To the Red Cross and chaplains in regard to the recreation of patients.
6. To the post property officer in regard to the construction and repair of property in the curative workshop.
7. To post mess officer in regard to the production of farm and greenhouse products.
8. To the quartermaster for supplies and repair work.
9. To the laboratory service and to the section of Roentgenology in regard to photographic work.
10. To the limited service board, involving recommendations and vocational ratings of patients assigned to domestic duty.
11. To the surgeon's certificate of disability board in regard to the discharge of patients from the service.
12. To chaplains and various officers in maintaining morale.
13. To the post and to the division of reconstruction, Surgeon General's Office, in the professional training of educational directors, instructors, and reconstruction aides.
OUTSIDE ACTIVITIES
Relation of educational service:
1. To the Federal Vocational Board for educational histories and recommendations for further training of soldiers discharged from the Army.
2. To the personnel division and to development battalions for ratings on men for special lines of work in limited service.
3. To the Civil Service Department of the Government and private corporations and individuals in response to requests for qualifications of discharged men for positions.
FUNCTIONAL TREATMENT FOR ORTHOPEDIC CASES 14
In filling out the medical officer's prescription blank (Form 2) for orthopedic patients, the ward surgeon was asked to check one or more of seven special types of functional treatment (abduction, adduction, flexion, extension, pronation, supination, and circumduction), together with the parts of the body to which he wished such treatment applied. Curative workshops, classrooms,
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and laboratories were the places where the medical officers' prescriptions were "filled." The instructors in the several branches followed the directions as accurately as the drug clerk with this difference-the medical officers did not prescribe the exact compound, but rather stated the nature of the illness and defined the direction and limitation of the curative service work. Upon the instructor there fell, therefore, a great responsibility-namely, to organize his work around a therapeutic idea based upon the prescription method of approach to the problem and so developed under him as actually to give functional treatment.
DEFINITIONS AND EXERCISES
To furnish a basis for the accurate interpretation of prescriptions for functional treatment, there had been listed careful nontechnical definitions and descriptions of the types of movement required to fill each of the 43 prescriptions made possible by the lists on the back of Form 2. The definitions had been arranged under the types of treatment as main heads, with the names of the joints to which treatment was to be applied as subheads. Flexion of the knee, for example, was found described in the section headed "flexion" under the subheading "knee."
It should be noted that three types of treatment-namely, eversion, inversion, and rotation-while not specifically included in the list of treatments, were intended to be embraced under other types of treatment there specified. Eversion was included under "abduction of the ankle," inversion under "adduction of the ankle," rotation of the humerus under "circumduction of the shoulder," and rotation of the hip under "circumduction of the hip" Rotation of the trunk had been omitted for the reason that in the curative workshop treatment, it was practically impossible to distinguish that type of treatment from circumduction of the back. Prescriptions for treatment of the neck had also been omitted, since practically all the muscular movements which such treatment demanded were exceedingly ill-defined, if not entirely lacking, in the curative workshop activities.
As a suggestion of the types of work which might prove of service in providing the treatment called for by orthopedic prescriptions, there had been added after each definition one or more examples of curative workshop activities which involved the movements there described. These examples had been chosen mainly from woodworking, metal working, and agriculture, though a few had been drawn from typewriting, pottery making, and one or two other occupations. The suggested operations had been classified in two groups. The first included types of work which necessarily involved for their proper performance the use of the muscles under consideration, and the second included types of work which involved the use of the special muscles for their most efficient performance, but which might be accomplished, though to less advantage, through the use of other sets of muscles. The second type of work was of slight value in cases where the patient was inclined to avoid by every possible means the use of the muscles needing treatment. The first type, on the other hand, should be used with caution, lest the patient injure himself by too energetic or too continuous exercise of an affected joint.
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It was not intended that the examples given should be more than suggestions of the types of work which should be undertaken in response to medical officers' prescriptions. For each patient the instructor should lay out a course of work leading by gradual stages to the attainment of the functional results desired by the medical officer and including such special activities as were necessary to reach these results. That most of these activities might be chosen with equal value from widely varied workshop occupations was shown by the examples given below; so, even while retaining as his fundamental aim the functional cure of the patient, the instructor might take into account also the patient's psychological, vocational, and educational needs. From both points of view the assignment of workshop occupations to the patient must be a strictly individual matter.
The pressing need in the treatment of orthopedic cases by occupational therapy was for a detailed scientific study of such workshop operations as those suggested below to determine the exact muscular movements involved in these operations and the functional results which might be expected from their practice. Such a study would make possible at least a partial systematization of the treatments which were suggested in necessarily disorganized fashion. It was for the purpose of affording a definite basis for study along these lines by making possible an accurate interpretation of prescriptions that the following definitions were presented:
Abduction (motion away from the axis of the body; turning outward)
Thumb: Motion of the thumb away from the median line of the hand in the plane of the palm, as in the spreading of thumb and fingers.
Exercises: (1) Glass setting; potting plants, typewriting (right thumb), piano playing, hand forming on potter's wheel, etc.; (2) use of miter box, holding broad piece in position (left thumb), etc.
Fingers: Motion of the fingers away from the median line of the hand in the plane of the palm, as in the spreading of the fingers.
Exercises: (1) Use of special large handle top on screw driver (right hand), use of special large plane knob (left hand), typewriting, piano playing, use of ball glove (left hand), etc.; (2) glass setting, firming soil in flats (greenhouse work), etc.
Wrist: Motion of the hand, bending at the wrist in the plane of the palm in the direction opposite the thumb.
Exercises: Hammering, use of monkey and Stillson wrench in horizontal position, use of large auger, use of flat wrenches, piano playing; etc.
Elbow: No abduction possible.
Shoulder: The movement of the humerus produced by raising the arm straight sideways, to or above shoulder height.
Exercises: Turning crank of large radius, as on grindstone, portable crane, etc. use of pulley shift levers arranged to make this motion necessary or most convenient, pitching hay, practice of wigwag signaling, etc.
Back: No abduction possible.
Toes: Abduction negligible.
Mid-tarsus: No abduction possible.
Ankle (abduction of foot): Turning the foot outward and upward at the ankle; position similar to that of foot of person with weak ankles in skating, foot resting on inner side.
Exercises: (1) Use of specially tipped pedals on grindstone, foot-power lathe, jig saw, etc., operation of loom with heel fixed so that turning of foot is necessary for working different pedals, use of special pedals on hayrake or tedder, etc.; (2) work on uneven ground, as in plowing or on a hillside, etc.
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Knee: No abduction possible.
Hip: Motion of the hip produced by raising leg straight toward side, without rotation
Exercises: (1) Driving disk harrow or mowing machine, riding horseback, etc.; (2) straddling, as in working on long piece in lathe, etc.
Adduction (motion toward center of the body; turning inward)
Thumb: Motion of the thumb from the position of extreme abduction toward the median line of the hand, across the palm.
Exercises: (1) Milking, etc.; (2) use of cabinet scraper (adjustment), etc.
Fingers: Motion of the fingers from the positions of extreme abduction toward the median line of the hand in plane of the palm.
Exercises: Use of special small hand top on screw driver (right hand), use of special small plane knob (left hand), kneading soil for greenhouse use, etc.
Wrist: Motion of the hand, bending at the wrist in the plane of the palm toward the side of the thumb.
Exercises: Hammering, use of monkey or Stillson wrench in horizontal position, use of large auger, use of flat wvrenches, piano playing, etc.
Elbow: The movement of the humerus produced by bringing the arm from a position of abduction down to or beyond the median line of the body, in the line of the body.
Exercises: Turning crank or large radius, as on grindstone, portable crane, etc., use of pulley shift levers arranged to make this motion necessary or most convenient, pitching hay, use of seythe, practice of wigwag signaling, etc.
Back: No aclduction possible.
Toes: Adduction negligible.
Mid-tarsus: No adduction possible.
Ankle (adduction of foot): Turning the foot inward and upward at the ankle, position similar to that of foot of person with weak ankles in skating, foot resting on outer side.
Exercises: (1) Use of specially tipped pedals on grindstone, foot-power lathe, jig saw, etc., operation of loom with heel fixed so that turning of foot is necessary for working different pedlals, use of special pedals on hayrake or tedder, etc., (2) work on uneven ground, as in plowving or on a hillside, etc.
Knee: No adduction possible.
Hip: Motion of the hip produced by moving toward and beyond the median line of the body, the other leg being so displaced by adduction as to allow motion of the leg under treatment in a plane parallel to that of the front of the body. (Example: The patient lies on a plane surface on tile side of the leg under treatment, with the other leg held by second person in a position of abduction. He then raises the affected leg in line with the body, with the knee straight and wit bout rotation.)
Exercises: Planting by hand, and covering with the foot, etc.
Flexion (the bending of a joint so that the parts which it connects are approximated)
Thumb: The natural bending of the thumb at its joints, as in "making a fist," with the thumb covered by the fingers.
Exercises: Grasping round objects, such as levers, tools, materials, etc., use of hand dibble and other garden tools, carrying objects by means of handles, specially adapted if necessary. etc.
Fingers: The natural bending of the fingers at the joints, as in "making a fist."
Exercises: Grasping round objects, such as levers, tools, materials, etc., use of hand dibble and other garden tools, carrying objects by means of handles, specially adapted if necessary, etc.
Wrist: The bending of the wrist so that the palm approaches the inner side of the arm.
Exercises: (1) Use of woodcarving tools, working in "high relief," use of sickle, etc.; (2) driving horse, sowving seeds broadcast, use of hand pump with vertical piston and horizontal handles, etc.
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Elbow: The motion of the elbow produced by bending the forearm toward the upper arm till the hand touches the shoulder.
Exercises: Hammering, planing, filing, shoveling, hoeing, use of long-handled rake, use of spray pump, etc.
Shoulder: The movement of the humerus produced by raising the arm straight forward and upward from the natural position by the side.
Exercises: Planing, use of ax or sledge hammer, operation of overhead lever as on drill press, use of overhead rope shipper in machine shop, hoeing, use of mattock, threshing by hand, etc.
Back:
Forward bending-bending the trunk at the hips, from vertical to horizontal, with trunk kept straight.
Exercises: Planing, sawing, hoeing, cultivating by hand, practically all work below waist level.
Side bending-bending the trunk at the hips, in the plane of the body, from vertical to right or left.
Exercises: (1) Use of scythe, etc.; (2) pitching hay, guiding plow in rough land, etc.
Toes: Bending the toes toward the sole of the foot, as in "making a fist" with the foot.
Exercises: Pushing heavily loaded wheelbarrow in soft ground, spading (pushing spade into ground), etc.
Midtarsus: Bending downward the fore part of the foot (from the middle of the instep to the toes), as in "making a fist" with the foot.
Exercises: Pushing heavily loaded wheelbarrow in soft ground, spading (pushing spade into ground), etc.
Ankle: Motion of the foot (bending at the ankle) straight upward in the line of the leg in such manner that the angle between the upper side of the foot and the shin becomes acute.
Exercises: (1) use of foot-power machines with treadles or specially adapted pedals, etc.; (2) planing (for right foot), pushing heavily loaded wheelbarrow, etc.
Knee: Bending the knee from the straight position until the heel touches the buttock.
Exercises: (1) Laying floors, use of adapted foot-power machinery, bicycle riding, etc.; (2) planting, transplanting, and thinnhig; weeding root crops, etc.
Hip: Motion of the hip produced by raising the leg (knee bent) until the knee touches the chest.
Exercises: (1) Use of adapted foot-power machinery, operation of horserake, etc.; (2) stooping and sitting on heels to work at low level, as in laying floors, etc.
Extension (the bending of a joint in such manner as to diminish or extinguish the angle formed by flexion)
Thumb: Forcible straightening and bending back of the thumb from the position of grasping.
Exercises: Glass setting, hand forming on potter's wheel, piano playing, etc., holding broad piece in miter box, left thurmb, etc.
Fingers: Forcible straightening and bending back of the fingers from the positions of grasping.
Exercises: Use of cabinet scraper, sharpening flat-bladed tools, glass setting, pulling on object too large to grasp, such as drill-press lever with special handle, etc.
Wrist: The movements of flexion reversed and carried as far as possible in the opposite direction.
Exercises: (1) Filing, use of wood-carving tools, working in "high relief," pitching hay, use of spade, etc.; (2) feeding material to circular saw, band saw, jig saw, planer, use of trowel, etc.
Elbow: Forcible straightening of the arm from the position of flexion.
Exercises: Planing, sawing, hammering, filing, shoveling, hoeing, operation of spray pump, carrying heavy objects by handles, etc.
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Shoulder: The movement of the humerous produced by bringing the arm from the vertical position above the head forcibly straight forward, downward, and backward.
Exercises: Hammering above head, use of sledge hammer or ax, use of two-hand crosscut saw, operation of overhead lever, as on drill press, use of overhead rope shipper in machine shop, use of Norcross or wheel hoe, etc.
Back: Bending of the trunk from the position of forward bending to the vertical and backward.
Exercises: Planing, sawing, hammering overhead, sawing overhead, hoeing, pitching hay, etc.
Toes: Bending the toes toward the upper side of the foot.
Exercises: (1) Work overhead requiring standing on tiptoe, use of special pedals as on a grindstone, jig saw, etc., requiring pressure from toes alone, etc.; (2) thinning, transplanting, weeding, tying tomatoes, picking beans, etc.
Midtarsus: Bending upward the fore part of the foot (from the middle of the instep to the toes).
Exercises: (1) Work overhead requiring standing on tiptoe, use of special pedals as on grindstone, jig saw, etc., requiring pressure from toes alone, etc.; (2) thinning, transplanting, weeding, tying tomatoes, picking beans, etc.
Ankle: Motion of the foot (bending at the ankle) straight downward in the line of the leg, as in standing on tiptoe.
Exercises: (1) Work overhead, requiring standing on tiptoe, use of foot-power machines, specially adapted if necessary, etc.; (2) walking down hill, as in wheeling barrow, etc.
Knee: Forcibly straightening the leg from the position of flexion.
Exercises: Use of foot-power mortising machine or grindstone, use of foot-power potter's wheel with disk drive, use of horserake.
Hip: Motion of the hip produced by forcibly bringing the leg into the line of the body and backward from the position of flexion.
Exercises: Work requiring standing and walking, use of foot-power machinery, pitching hay, use of scythe, forking manure, etc.
Pronation (the turning of the palm of the hand downward, applied exclusively to forearm and hand)
Wrist-elbow: Motion of the hand from position with the palm up to position with the palm down.
Exercises: (1) Use of screw driver or awl (counter-clockwise motion), use of wood-carving tools, etc.; (2) use of garden trowel, potting operation, use of shovel or spade, etc.
Supination (the turning of the palm of the hand upward, applied exclusively to forearm and hand)
Wrist-elbow: Motion of the hand from position with the palm down to position with the palm up.
Exercises: (1) Use of screw driver or awl (clockwise motion), use of wood-carving tools, etc.; (2) use of shovel or spade, etc.
Circumduction (the circular movement of a limb)
Thumb: Circular movement of the thumb about its normal axis.
Exercises: Typewriting, etc.
Fingers: Circular movement of the fingers about their normal axes.
Exercises: Typewriting, etc.
Wrist: Circular movement of the hand bending at the wrist about the axis of the forearm.
Exercises: Turning of small wheel, as on cross feed and carrier of lathe, use of hand drill, spraying inside greenhouse, etc.
Elbow: Circumduction negligible.
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Shoulder (rotation of humerus): The movement of the humerus produced by rotating or twisting the arm, extended to the side at right angles to the body, from the extreme at which the elbow is down to the extreme at which it is up and reverse.
Exercises: Use of large screw driver, use of scythe, use of long-handled shovel, etc.
Back: Circular movement of the trunk about the vertical axis of the body.
Exercises: Use of scythe, etc., use of large tap wrench in horizontal position, use of large auger, pitching hay, etc.
Toes: Circumduction negligible.
Midtarsus: Circumduction negligible.
Ankle: Circular movement of the foot about its normal horizontal axis.
Exercises: (1) Operation of loom with heel fixed so that turning of foot is necessary for working different pedals, etc.; (2) following plow in rough ground.
Knee: Circumduction impossible.
Hip (rotation of hip): Movement of the hip produced by rotation of the leg in manner corresponding to rotation of upper arm to produce rotation of humerus.
Exercises: Use of large tap wrench in horizontal position, use of large auger, use of scythe, pitching hay, use of long-handled shovel, etc.
IN BASE HOSPITALS
The signing of the armistice necessitated the provision of many more hospital beds for reconstruction purposes than originally had been planned in order to care for the expedited return of the patients in overseas hospitals.
When certain base hospitals were designated in December, 1918, to establish reconstruction services, the following letter of instructions was sent to each:10
1. An educational officer has been assigned to your hospital, as it has been designated to receive disabled soldiers from overseas. It is desired that everything possible shall be done to make these men happy and contented while under treatment and have them go back to civil life with the determination to profit by the opportunities which the Government is offering them with a view to their success in after life. The experience of the last 10 months in general hospitals has shown that an educational officer at the head of the curative mental and manual work department can do a great deal to keep up the morale of the men by seeing to it that they are either employed in profitable study or availing themselves of vocational training opportunities or that their recreation is intelligently directed.
* ** ***
3. As soon as possible a consultant, experienced in educational administration and familiar with the work as developed in the hospitals, will be sent to assist you, your medical staff, and the educational officer with the development of this work.
4. Experience has shown that the following types of work can be done, and the educational officer should devote himself to developing these groups with a view of interesting men in this and other work which may be done as curative measures and of value vocationally:
(a) Bedside work where men are confined to the bed or wards: Many men are interested in the minor craft work, and reconstruction aides, both men and women, are employed for this and any other work in the interest of this service. As soon as the condition of the patient will permit, the bedside and the ward work should be made the beginning of serious study, and the place where information is given as to a man's future opportunities under the Federal Board for Vocational Education and his rights under the war risk insurance act. All reconstruction aides and other members of the educational service should familiarize themselves along these lines and inform the men of their opportunities. In addition to this, the beginnings can be made in English for foreigners, training in citizenship, left-hand penmanship, and other training in the use of the left hand for men with right arm amputations, shop mathematics, shop sketching, use of the slide rule, typewriting, bookkeeping, and other trade extension work for men with some mechanical training and experience, vocational guidance for men who will return to the trades and commerce, and educational guidance for those who will go back to school and college.
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(b) If space can be secure(d, classroom work can be done in typewriting, stenograply, bookkeeping, penmanship, English, mathematics, drafting, and in other subjects. A minimum equipment for these lines of work is being sent to the hospital. The exact list of equipment is sent under separate cover. The war camp service of the American Library Association has agreed to send several hundred books for texts. Where adequate space can be secured, work can he done in telegraphy, printing, shoe repairing, engraving, jewelry work, and the theoretical work of automobile instruction. In the case of the latter it will be necessary to have one or more engines, rear axles, transmissions, magnetos, carburetors, starting and lighting systems, batteries, etc. (It is believed that these can be secured either by donation or by memorandum receipt from the reclamation section of the motor transport division.) If the camp utilities and other shops are suitably located or transportation can be secured, much profitable trade instruction and prevocational work can be obtained by cooperating with these departments. The following opportunities exist in some of the camps: Oxyacetylene welding, blacksmithing, shoe repairing, clothing renovation, barbering, carpentry, telephone and telegraph exchange, care of pumps, motors, generators, etc., in connection with the water and sewerage systems, and laboratory work in connection with auto work in other hospital departments.
In fact, the camp has practically all of the vocational opportunities found in the maintenance of a city of equal size, and the hospital assignment offers opportunity during convalescence for adjustments with the work-a-day world which the patient will reenter after discharge.
5. Representatives from the Federal Board for Vocational Education and the War Risk Insurance will cooperate with the educational officer in instructing his staff, so that they may give information to the disabled men.
6. Upon the educational officer devolves the responsibility of bringing together those educational, vocational, and social forces which are an essential part of the treatment given to hasten the cure and to promote a high standard of morale while the men are under treatment or awaiting their discharge. This officer must organize, subject to your approval, an educational service which will coordinate the volunteer agencies now working in the hospitals, develop interest in stuedy and vocational opportunities and training useful in civil life, and select and train a personnel to handle educational service, inform patients, his associates, and all concerned of the various governmental agencies available and useful to discharged men.
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FINANCIAL ASSISTANCE BY THE AMERICAN RED CR0SS
Following the extension of reconstruction work to base hospitals, the service enlarged so rapidly that the authorized expenditures of money and supplies could not meet the immediate need.15 In this crisis the American Red Cross placed at the disposal of the department of education an emergency fund of $200 per month for each reconstruction hospital, to be expended on the order of the chief educational officer of the hospital for supplies, equipment, or service which were needed immediately and not readily procurable from Army-supplies or funds.15 Monthly reports of expenditures in detail were to be made to the Surgeon General. The situation was relieved to such an extent by May, 1919, that steps were taken for the discontinuance of the fund.16
THE RECONSTRUCTION SERVICE AS FINALLY DEVELOPED
Prior to July, 1919, the two component parts of the reconstruction service--the educational and the physiotherapy departments-had operated more or less independently in the reconstruction hospitals. The Surgeon General at that time, however, ordered that a chief of the section of physical reconstruction be appointed in each reconstruction hospital in order to coordi-
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nate the work with other hospital activities. 17 The sections of the reconstruction service now comprised psychological and statistical, recreational, general or academic, technical, and physiotherapy.
PSYCHOLOGICAL AND STATISTICAL SECTION
The duties of this section of the educational department were as follows: 9 (1) Responsibility for psychological, social, educational, and vocational surveys of individual patients; (2) special service in connection with the problems of learning encountered in the curative workshop schedule; (3) cooperative
FIG. 18.- Instruction in automobile repairing
responsibility for all measures intended primarily to direct; and control the mental attitude of patients; (4) responsibility for all statistical work connected with the curative workshop schedule; (5) such a service in connection with the training of the educational staff as might be needed.
The individual surveys required personal interviews to obtain the patient's personal and social history; an educational rating as a basis on which to plan reconstruction courses; an intelligence rating as a criterion of mental capacity for future training; a trade rating for future vocational reference; an analysis of mental attitude, interests, special abilities, and morale as a basis for estimating initiative and effort; and an analysis of the range and character of voluntary movement in disabled parts for use in the application of occupational therapy 18
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FIG. 19.- An invalid instructor in oxyacetylene welding
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The fundamental purpose of the diagnostic picture obtained was to allow the formulation of a constructive remedial program; the patient was to be shown what he could do and how he could do it and be helped to find a healthy, optimistic, and creative attitude toward life.
Social surveys showed that the main problems connected with the new patients concerned Government compensation, Government insurance, allotments, Liberty bonds, back pay, reconstruction work, furloughs, artificial limbs, recreation, information from home, and hospital regulations.18 The problems connected with those who were soon to be discharged concerned the family, social and financial status, reputation and industry, educational life, housekeeping standing, deterioration since the war, the attitude of parents toward the patient, the attitude of the man toward his community, marital complications, love affairs, preparation, of the family for the type of patient's injury, need of supervision in the home, living accommodations, church or ecreational opportunities, and opportunities for future training.
Fig. 20.- Oxyacetylene welding as a vocation for men with arm amputations
These problems were cared for by individual action or by reference to such agencies as the reconstruction department, American Red Cross, American Library Association Federal Board for Vocational Education, insurance officer, and ward surgeon. Five hundred and thirty-two such cases were handled in one week in one hospital.18 As an indicator of the value of the service from the treatment standpoint, 103 cases were referred during one month in the same hospital by ward surgeons.
The school and trade ratings showed a surprisingly low average, due to the previous combing out of trained men for special work, so that few of the higher classes were used in the ranks of combat troops.18 Such ratings were of value in estimating a man's qualifications for future employment, both for limited service and after discharge. They furnished information as to the amount and
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type of previous experience and the degree of ability, skill, and judgment. In the trade test, ratings were given as novice, apprentice, journeyman, or expert; 30 trades were represented in one group of 119 patients rated, 32 in another group of 75, and 54 in a group of 156. Of 231 patients rated, 145 had had two or more years' experience.18
The occupational survey included the main occupation, years engaged, just what the worker did, name of firm employing, kind of business, department or branch, weekly wage, reasons for leaving, stability of employment, whether member of a union, second occupation, third occupation, Army occupation, Army experience, and patient's occupational preference, with reasons there for. 18 The general tendency was for the disabled soldier to pass through a
FIG. 21.- Instruction in electrical work
period of instability, with his preferences shifting fr'om one occupation to another and almost any type of constructive activity making a strong appeal to his imagination.
The purposes of the tests were 18 (a) to indicate to the disability board whether or not the man should be retained in service; (b) to indicate to the limited service board the branch of service or occupation to which he should be assigned; (c) to assist in making proper assignment in the curative workshop and to the stage at which training should begin; (d) to assist in vocational counsel and guidance; (e) for future use by the Federal Board for Vocational Education.
Certain classes of patients required special attention to direct and control their mental attitude.18 This was true to some extent of nearly all disabled
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FIG. 23.- Motion-picture operating
FIG. 24.- Work in the greenhouse
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FIG. 26.- Shop for instruction in shoe repairing
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men. The aides with their ward occupations served the purpose in the majority of cases, but men with amputations required special supervision, and particularly did those who had lost an arm.
One-armed instructors were employed to demonstrate the methods employed in making one arm perform the duties of two, as in the employment
FIG. 27.- Commercial course-typewriting for hand amputation
of devices for tying shoes and neckties, putting on a collar, eating, rolling cigarettes with one hand, etc.18 It was the ability to do those little things that made the handicapped man independent in his home and led him to experiment with more difficult problems. In right-handed men who had lost the right arm, the left had to be taught to perform many minor duties, such as writing. Games had a particular psychological value in that they aided materially in building
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up a mental background of self-confidence, self-respect, self-control, and social cooperation with others. It was remarkable how much of the inactivity of an artificial limb was due to habits which could easily be eliminated by a trained psychologist who was familiar with the general principles of motor coordination. An intensive study of all considerations bearing on the question of a possible change of occupation for 18 amputation cases (10 arm and 8 leg) resulted in the following opinion: 18Change of occupation desirable, 6; change not necessitated, 12. Of the latter, however, four desired a change in order to find occupations more to their liking.
Measuring and recording progress of cases under treatment, where practicable to do so, were of value to those in charge, and the visible demonstration
FIG. 28.- Measuring abduction and adduction of the wrist, psychological and statistical division
was of psychologic value to the patient by showing the rate of improvement and through competition with the others by ascertaining who could show the greatest improvement. Measurements of both strength and range of movement of joints furnished the bulk of this work.18 Some of the apparatus used are shown in Figures 28 to 30, inclusive.
RECREATIONAL SECTION
The recreational section of the educational department came into existence late in 19l8.9 It was charged with the arrangement of entertainments for patients in so far as these were needed to supplement and coordinate recreation provided by other agencies; cooperative responsibility with the department of psysiotherapy for recreation through games, sports, etc.; cooperative respon-
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sibility with the department of physiotherapy for physical training intended for special therapeutic purposes; and supervision of military drill and instruction in military regulations for patients as requested by medical officers.
The purposes of the recreational section were to induce in the individual patient a state of mind and in the institution a general spirit that facilitated recovery, to provide beneficial therapeutic exercise for all patients, to provide for the patients such diversion and training as would contribute to recovery and at the same time fit them for better service to the Army and society after recovery, and to maintain in the able-bodied personnel a spirit of cheerfulness and interest in the work in the institution.
FIG. 29. - Measuring flexion and extension of the wrist, psychological and statistical division
The activities were divided into classes--those for which the American Red Cross and other welfare organizations through the American Red Cross were to be responsible and those to be conducted by the educational service.19
The American Red Cross was to be responsible for 19 entertainment and recreation in convalescent houses and wards and for the able-bodied personnel, the purposes of which were to maintain, through the American Library Association, a library of technical works, approved fiction, current magazines, periodicals, newspapers, and library service; to organize, encourage, and conduct reading circles, debates, and story-telling hours; to provide training in amateur theatricals; to arrange for and equip bands and orchestras; to provide leadership for the development of singing, individually and in groups; to furnish, equip, and maintain a writing room; to furnish and maintain an equipment of indoor games, player piano, phonographs, rolls, and records; to
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furnish stereoscopes and photographs of educational value; to present entertainments; or organize and supervise social functions; and to supply fruit, flowers, smoking materials, and refreshment. In addition, outdoor games were to be arranged for the able-bodied personnel. The supplemental services comprised arrangements for personal religious services and ministrations in wards at the request of individual patients.
The recreational functions of the department of education were the general supervision of all recreational activities in cooperation with the American Red Cross, the selection and supervision of approved games and sports to attain desired therapeutic results, the working out of special exercises for each of the larger groups represented in reconstruction work, in cooperation with other departments the provision for the editing and publishing of the hospital paper, and the training of the staff devoted to recreational work.
Recreational activities proved so popular in hospitals that it was sometimes necessary to curtail organizational programs in order to allow time for patients to participate in the educational work.19
GENERAL OR ACADEMIC SECTION
The general section comprised instructional agencies devoted to academic studies and related matters.9 These agencies ranged from the teaching of illiterates to read English, through the ordinary grade and high school subjects to preprofessional courses, and included the necessary reports, schedules, selection of textbooks, and organization and training of teaching personnel.
FIG. 30. - Measuring abduction and adduction of the ankle, psychological and statistical division
The occupational aides worked mainly under the general division, although portions of their work were subject to the supervision of each of the other divisions.
UNIT COURSES OF STUDY
The unit courses of study comprised one of the really constructive achievements of the educational service, those in the academic and commercial fields being particularly popular, 20 as each-was complete in itself for the subdivision
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FIG. 31.- Corrective exercises in the gymnasium
FIG. 32.- Contest in drill, manual of arms, field-day exercises
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FIG. 33.- Wheel-chair race, field-day exercises
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of the subject which it covered. Furthermore, upon completion the student felt that a definite step toward his goal had been taken. The most popular and most valuable of all were the "Americanization" courses, 21 which included American history and American Government, with elementary courses for illiterates. These courses were designed primarily for noncitizens who desired to qualify for citizenship papers and for others with no adequate knowledge or
appreciation of this country and its Government.
TECHNICAL SECTION
The work of this section was divided into three fields-shop work and trade instruction, commercial work, and agriculture.9
FIG. 35.- Rug weaving, for mobilizing stiffened joints and adherent tendons of the hands
In the shop work special attention was given to the therapeutic use of work from the standpoint of functional restoration.9 Men who could only partially flex the fingers were given work which required the grasping of tools, which had special handles that were gradually decreased in size as finger flexion increased. Men with stiffened ankles were caused to run foot-power machines, and such work as planing loosened stiffened elbow and shoulder joints. Coincident with the functional improvement each man's time was so occupied that he was becoming familiar with the rudiments of a new trade or increasing his knowledge of an old one.
Instruction in automobile mechanics was probably the most popular and most successful of all courses given by the technical section. The equipment of motor repair shops was available for use in every hospital or in the camp,
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and quite complete courses were given. Salvaged automobiles, trucks, and motors were dismantled and used for demonstration purposes, and actively functioning repair shops were established where service was free of charge. Those engaged in blacksmithing, plumbing, carpentry, etc., were given actual work where it was needed about the hospital.
On the whole the results obtained in the curative workshops as experienced at General Hospital No. 3, Colonia, N. J., and which may be taken as a fair average, were satisfactory for individuals, but the number talking the courses was unexpectedly small, due either to superior attractions of other activities
FIG 36.- Carpentry for mobilized elbow joints
or to the short time available in the average case, thus not permitting the complete acquirement of a trade.22
In agriculture very little practical instruction could be given in farming operations per se, owing to the lack of suitable land and equipment.9 Such practical instruction as was given was accomplished mainly by visits to neighboring farms, truck gardens, etc. Extensive truck gardens were established in a few instances, but the work largely was confined to theoretical courses, farm accounts, farm management, and the science of agriculture. Instruction in stock raising was on a more practical basis in a number of instances where herds of swine, sheep, or cattle, and flocks of poultry could be maintained. Figures Nos. 46, 47, 48, and 49 are views of activities of the agricultural division.
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PHYSIOTHERAPY SECTION
The organization of the subdepartments of physiotherapy is shown in Chart III. Table 1 gives an outline of the equipment furnished; many minor and nonstandard accessories are not listed.
TABLE 1.- Physiotherapeutic equipment for 500, 1,000, and 1,500 bed reconstruction hospitals
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A weekly report of all physiotherapeutic work was sent to the Surgeon General's Office. The objects of this report were to give an idea of the number of cases treated and the number of treatments given in comparison with the number of aides on duty, to show the sources of the cases so that if any departments were not making full use of physiotherapy the advantages offered by this service might be brought to their attention, to give an indication of the variety of treatments employed in order that undue stress might not be laid upon any particular
CHART III.- Organization of the department of physiotherapy in a reconstruction hospital
subdivision by the director in charge, and to check the arrival and departure of personnel.23
The most evident value of physiotherapy occurred in the treatment of orthopedic and neurosurgical cases. The employment of physiotherapy in these two classes of cases became progressively more frequent with experience until there was scarcely a case in these two services which was not referred for such treatment. The appended table shows the comparative use to which the different branches of physiotherapy were put in a general hospital.24
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Chart - Report of physiotherapeutic activities, General Hospital No. 6, Fort McPherson, Ga., January 1, 1920, to June 1, 1920
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The following account of the physiotherapy service, General Hospital No. 6, Fort McPherson, Ga., is given as being representative of the service elsewhere.
No definite organization for reconstruction was attempted at first at General Hospital No. 6.24 The physiotherapy clinic was started as one part of the general surgical department of the hospital. As no very clear idea of the mission of such a department existed, every kind of case imaginable was turned over to the new clinic. It might be said that most of the first patients
FIG. 39.- A foot-power machine, for active exercise of the calf muscles
were those whose treatment was a puzzle to the medical and surgical staffs and to whom the new clinic could, possibly, do no harm.
In September, 1918, the first reconstruction aide in physiotherapy arrived at the post. 24 Just what to do with her was a problem to the staff. She, was assigned finally to the reconstruction division (occupational), and under this division the aidles who continued to arrive worked for several months. Each month more and more cases were intrusted to their care. From 5 cases assigned
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to the first aide in September the number increased to 200 by December 15, 1918.No physiotherapy center was established by the aides; all the work was done in the wards from bed to bed.
About this time new life was brought to the work by the additional force of a unit of 11 aides originally mobilized in New York for overseas service.24 These aides were assigned to duty among the convalescent men, for the most part patients who had practically reached a maximum of improvement; consequently little in the way of definite results could be seen. However, even under these unfavorable circumstances, the work very soon attracted the atten-
FIG. 41.- Treadle machines for mobilizing the knee joint in below-the-knee amputations
tion of the surgical staff, who more and more requested the services of the aides for their post-operative cases.
Ward A had the distinction of having the first surgical massage room. A small room adjoining the office was turned over to the aides, and the patients who were able came to this room for their treatments. This step aided effectively in establishing a professional atmosphere. Within a few weeks each of the wards was looked over and a room somewhere downstairs was found that could be turned over as physiotherapy headquarters for that particular ward. The men were assig-ned their time at which to report each day; failure to come was recorded and the patient reported to his ward surgeon. It might be noted
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that little of this reporting was ever necessary. The men were quick to realize the value of the treaments and were remarkably punctual and regular in meeting their assignments.
At the same time an increasingly larger number of patients was assigned to the physiotherapy clinic. Electrical apparatus, consisting of a Bergonié chair, sinusoidal, high-frequency, faradic, and galvanic machines, had been installed and a hydrotherapy room had been thoroughly equipped.
Still a third branch of the work in physiotherapy was carried on in the gymnasium in Ward D. Quite an adequate set of apparatus had been furnished and about 100 patients were sent to this room daily for exercises. Two, and
FIG. 42.- In the woodworking shop-grasping exercise for stiffened joints of the hand
later three, aides in physiotherapy were sent to this gymnasium for duty. They gave massage treatmnents there and directed the reinedial exercises.
Three definite and distinct agencies were struggling along by January, 1919, attempting to accomplish for the patients that which physiotherapy claimed to do. These three were the physiotherapy clinic, the gymnasium, and the physiotherapy aides in the wards.
At this juncture, however, the sensible and logical step for the progress of physiotherapy was taken. These three branchies-the clinic, the gymnasium, and the organization of aides-were consolidated under capable leadership. Thanks to the power of organization and to the ability and personality of the officer in charge, the work of physiotherapy, long a puzzle to the personnel of the post, very soon began to have a definite meaning. It came to stand for
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massage, electrical treatment, hydrotherapy, and remedial exercises-all of which brought hope and an interest in life to many whose faith in ever again being able to use their bodies in a normal way had nearly disappeared.
The electrical and hydrotherapy treatments at the clinic were coordinated with the treatments in massage and remedial exercises given by the aides. The massage work itself was left to the direction of the chief head aide. The work of the officer in charge was to examine the patients given the aides for massage and determine the further electrical and remedial treatment needed. The
schedule was so arranged that the patients after receiving physiotherapy treatment in their own wards were sent to the clinic for electricity or to the gymnasium for remedial work.
As time went on more and more aides were called upon to give electrical treatments. Their field increased to high frequency, slow sinusoidal, Alpine lamp, and vibration.
About the 1st of January, 1919, an important step was taken in the progress of the physiotherapy work in this hospital, when the chief of the surgical service asked for physiotherapy aides to give treatment to his nerve cases, and at this time no one fully realized how much this meant for the neurosurgical
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department. However, when after two months this department had increased from a few scattered cases in two wards to four full wards, the importance of the recognition of the need of physiotherapy for these patients was readily seen. At first the preoperative cases only were intrusted to the aides. Very shortly, however, the aides were given postoperative eases of 10 days 'or 2 weeks' standing. In a short time the personnel of the neurosurgical department realized
that massage, exercise, and electricity were vital assets in the recovery of peripheral nerve injuries.
The personnel of the staff in the clinic was also changed. Prior to this time the officer in charge had supervised the work but had corps men only as assistants. Although these men were willing, their ignorance of anatomy and their lack of tact and painstaking care caused much of the work to be more or less ineffective. Early in March the service of six of the physiotherapy aides was requested for half of each day in the clinic to give interrupted galvanic electricity and faradic electricity to nerve injuries of the arm. Shortly after three more were requested to be in the clinic each morning to give the same treatments to nerve injuries of the leg.
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FIG. 45.- Commercial course, typewriting
FIG. 46.- Commercial course, class in penmanship
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FIG. 47.- Commercial course, posters by practical art class
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FIG. 49.- Practical agriculture
FIG. 50.- A simple milk-testing outfit in the agricultural course
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FIG. 51.- Testing milk in a completely equipped dairying plant
REFERENCES
(1) Annual report of the Surgeon General, United States Army, 1918, 402.
(2) Letter from the Surgeon General, United States Army, to commanding officers United States general hospitals, December 31, 1918. Subject: Use of available room for certain workshops and physiotherapy. On file, Record Roonti, S. G. O., Miscellaneous Letters, D-176.
(3) Letter from the Surgeon General, United States Army, to commanding officers of hospitals, undated. Physical reconstruction. On file, Record Room, S. G. O., 365, General.
(4) Letter from the Surgeon General, United States Army to commanding officers of base hospitals, May 21, 1918. Subject: Transfer of patients for physical reconstruction. On file, Record Room, S. G. O., Miscellaneous Letters, A-893.
(5) Memorandum on occupational therapy-ward occupations, June 25, 1918, division of physical reconstruction, Surgeon General's Office. On file, Record Room, S. G. O., 356 (Occupational therapy).
(6) Letter from the Acting Surgeon General to commanding officers of hospitals, September 27, 1918. Subject: Classification of reconstruction aides in occupational therapy.On file, Record Room, S. G. O., Miscellaneous Letters, C-735.
(7) Letter from the Acting Surgeon General to commanding officers of hospitals, September 25, 1918. Subject: Cooperation with the Federal Board for Vocational Education in the reeducation of disabled soldiers. On file, Record Room, S. G. O., Miscellaneous Letters, C-379.
(8) Report on curative workshop schedule and other educational work in hospitals, division of physical reconstruction, Surgeon General's Office, undated. On file, Record Room, S. G. O., 353.91-1.
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(9) Memorandum from Col. Frank Billings, M. C., United States Army, for the Surgeon General, November 29, 1918, and attached papers. On file, Medical Department at Large, S. G. O.
(10) Memorandum for conference, division of physical reconstruction, Surgeon General's Office, June 5, 1918, and attached documents. On file, Medical Department at Large, S. G. O.
(11) Memorandum on physical reconstruction, October 8, 1918, division of physical reconstruction, Surgeon General's Office. On file, Record Room, S. G. O., 353.91-1.
(12) Statistical summary, education service reports for November, 1918. On file, Record Room, S. G. O., 353.91-1.
(13) Annual report, Walter Reed General Hospital, for the year 1918. Copy on file, Historical Division, S. G. O.
(14) Report on the functional treatment in orthopedic cases, undated and unsigned. Made to the chief of the reconstruction division, Surgeon General's Office. On file, Historical Division, S. G. O.
(15) Circular Letter No. 80, Surgeon General's Office, February 10, 1919.
(16) Circular Letter No. 216, Surgeon General's Office, May 20, 1919.
(17) Circular Letter No. 263, Surgeon General's Office, July 17, 1919.
(18) Baldwin, B. T.: The Functions of Psychology in the Rehabilitation of Disabled Soldiers. Psychological Bulletin, N. Y., 1919, xvi, 267-290.
(19) Letter from superintendent, Army Nurse Corps, to National Headquarters, American Red Cross, Washington, D. C., January 24, 1919, and attached documents. On file, Record Room, S. G. O., 353.8-1.
(20) Crane, A. G., Ph. D.: Education for the Disabled in War and Industry. Teachers College, Columbia University Contribution to Education, No. 110.
(21) Based on education service reports. On file, Record Room, S. G. O., 353.91-1.
(22) History of reconstruction, General Hospital No. 3, Colonia, N. J., undated, prepared under the direction of the commanding officer. On file, Historical Division, S. G. O.
(23) History of section of physiotherapy in the Surgeon General's Office, undated, by Maj. F. B. Granger, M. C., director of physiotherapy service. On file, Historical Division, S. G. O.
(24) Report of physiotherapy department, General Hospital No. 6, Fort McPherson, Ga., 1920, by Capt. Charles L. Ireland, M. C. On file, Historical Division, S. G. O.
