CHAPTER VIII
IN HOSPITALS CARING FOR THE TUBERCULOUS
The treatment of cases of tuberculosis is radically different from that of other types of disease or injury, in that all exertion not absolutely necessary must be avoided during the febrile stage and for a period thereafter; furthermore, exertion, when finally allowed, must be increased very gradually and be under constant medical supervision. This fact made necessary a decided difference between the reconstruction work in hospitals for the tuberculous and that in other hospitals, and was a factor in the determination to segregate all such cases in hospitals designated for their care alone. Therefore, the shopwork in tuberculosis hospitals was not used, except as a test of the patient's ability to withstand exertion and as a hardening process before discharge.
In fact, reconstruction for tuberculous cases was a new field and many medical officers doubted its availability, the chiefs of medical service in several hospitals going so far as actively to oppose its adoption after it had been ordered by the Surgeon General. One chief of service thought that tuberculous cases should not be permitted to take exercise in any form,1 another considered that mental work was deleterious, 2 while a third could see no good features inany variety of reconstruction activity.3 Although the introduction of reconstruction work into every tuberculosis hospital was mandatory, it was necessary in one, in initiating occupational therapy, for the aides to persuade one ward surgeon to let them see what they could do with a few of his patients.4 However, reconstruction was developed, carefully and gradually, in the tuberculosis hospitals, converting to its acceptance officers whose minds were open to reason and removing to other fields the purely obstinate ones who happened to be in positions of authority.
Nine of these special hospitals eventually were established, 5 the choice of sites being governed both by regional necessity and by favorable climatic conditions.
Though reconstruction was instituted in several of these hospitals as early as the summer of 1918, 6 the work was not well under way as a whole until about the first of the ensuing year, for most of them were war-time establishments not yet equipped to give this service, and those already functioning were so overcrowded as to leave no room available for the offices, classrooms, shops, etc., of the educational service.7
MORALE WORK
The success of the reconstruction work of a hospital, particularly of a tuberculosis hospital, was so dependent on the morale that often the offices of morale officer and chief of the psychological service were combined. The following example indicates the measures used to maintain morale :8 At General Hospital, Fort Bayard, N. Mex., the program first emphasized the importance of improving physical conditions, mess, physical environment, etc., wherever
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possible. Sick men were likely to be dissatisfied with the mess, however good, and the morale and mess officers went into the wards to talk with the men, partly for the purpose of letting the men know that these officers had a personal interest in them. This was productive of good results. It was planned to control the thought, attitude, and conversation of patients so far as possible by means of personal talks and pamphlets and by building up in them some cheerful philosophy of life. A campaign against talking about troubles and death and for wholesome conversation was planned. The writing and publication of pamphlets to be distributed to the patients was supervised by the commanding officer. School and shop work were advertised by posters and pamphlets and by personal talks of teachers and special workers. Special assistants were appointed to help obtain information as to the morale, conversation, attitude, etc., of the men. Special personal talks were arranged for, to be made by the morale officer, one of the chaplains, or anyone else who might be specially fitted to deal with the case. With the help of the librarian, teachers, posters, etc., attempts were made to extend the use of the American Library Association books for the purpose of building up morale. The teachers and aides helped to stimulate the men to appreciate the school and shop work, to look ahead and make plans for the future, and to avail themselves of all the helps that were at their disposal. Letters were written to relatives and friends asking them to write the helpful kind of letters to the patients. Letters received which concerned patients, their discharge, etc., were turned over to the morale officer by the commanding officer, with instructions that he communicate directly with the writers. It was arranged to have clubs for officers and enlisted men, with an officer to take charge of this phase of the work. A practical, cheerful philosophy of life was outlined to help stabilize and comfort the minds of patients who had no philosophy of life or who were floundering, not knowing what to think, or who were at odds with the world. In a series of lectures for teachers the morale officer made suggestions for the development of morale. Entertainments, recreation, etc., were furnished by the American Red Cross.
Hospital newspapers were active morale agents, considerable thought being devoted to suggestive titles, as "Ward Healer," "The Come Back," and "Carry On," and to contents which would be encouraging, stimulating, and attractive. On the other hand, nothing lowered morale more quickly than poor food. Several of the tuberculosis hospitals suffered from difficulties in the messes at some time, due to various causes, such as inefficiency, the high cost of suitable food, at General Hospital No. 19,9 and isolation at Fort Bayard, N. Mex.10 Inadequate provision of quarters for aides was said to be an important factor tending to lower morale at Fort Bayard, N. Mex. 11
PSYCHOLOGICAL SURVEYS
At Fort Bayard, N. Mex., psychological studies were made of series of patients in order to present information to them concerning opportunities which they would encounter in shop and school, and to obtain information for the morale officer concerning the impressions and influences playing on the patient's minds.12 The obvious benefits to be derived from such studies were the compilations which would indicate the general trend of mental influences
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and attitudes in the wards. These generalizations gave composite pictures of conditions, weaknesses, and opportunities which aided in making plans for the groups concerned. The psychology also of the tuberculous patients was revealed more definitely, for example, by the positive optimism of 91 percent of the patients, while 8 of the remaining 9 per cent were doubtful rather than definitely pessimistic. The chief values of such surveys consisted not in the generalizations afforded but in concrete situations dealt with on behalf of individual patients. The interview in itself had an immediate benefit in giving the patient information of interest to him, and his cheerfulness was increased by giving him a confessor, as it were, to whom he could unload his thoughts. In addition to this, each patient's record sheet was examined carefully, and the various items indicating their individual needs and the various channels through which they could be approached were turned over to the proper reconstruction agent, whether teacher, librarian, shopman, aide, ward worker, morale officer, psychologist, chaplain, or vocational director. Thus the way was opened for a full contact with each patient's need with a minimum of wasted time.
General studies of 407 cases and psychological studies of 132 cases were made with the following general results: 12
Race, percentage.- White, 92.1; Negro, 7.4; Indian 0.49.
Occupational, percentage.- Farmer, 31.9; mechanic, 17.6; clerk, 11; laborer, 9.9; engi- neer, 3.4; salesman, 3.2; carpenter, 2.7; merchant, 2.7; miner, 1.2; soldier, 0.98; and various others below 2 per cent.
Schooling, percentage.- None, 5.1; 1 to 4 years, 12.2; 5 to 8 years, 53.8; incomplete high school, 13.5; high school, 9.5; college, 6.1.
Arm of service, percentage.- Infantry, 35.6; Depot Brigade, 16.9; Artillery, 12.5; Aviation, 10.3; Medical Department, 9.8; Quartermaster's Department, 4.9; Engineers, 3.9, Cavalry, 3.7; Motor Transport, 1.4; Ordnance, 0.73.
Nativity, percentage.- United States, 93.2; Germany, 1.7; Italy, 1.7; Scandanavia, 1.4; and others below 1 percent.
Mental attitude of 32 colored patients, mostly bed patients in an advanced stage.- Average length of stay in hospital was three and one-half months; average schooling, five years; reading, correspondence, and occupational therapy provided most of their interest; they were less inclined to worry than were white patients, and were more fatalistic; their interest in religion was more apparent than among the white patients. On the whole, the mental attitudes of the negroes ran parallel to that of the whites, their ideas and emotions being perhaps more simple and open to view.
Mental attitude of 100 white tubercular patients.- Average length of stay in hospital, four and three-fourths months. The summaries of the various tables give the best idea of the results.
Chief impressions from present environment.- The reconstruction work occupied fifth place among the leading topics of conversation. The need was shown for increased stimulation in the direction of such healthy activities as were offered by the curative-work shop schedule in order to replace the prevailing discussions about discharges from the Army tuberculosis, restrictions, etc.
Impressions concerning their own cases.- These were chiefly encouraging. Added to the natural optimism of tuberculous patients (10 per cent still believed that they had no tuberculosis) was the distinct encouragement which one-half of them had received from their physicians and one-third from relatives at home.
Immediate interests.- The chief one was reading, which might profitably have been broadened by outlining reading courses for bed patients. Objective and healthy interests greatly outweighed the introspective and morbid. These could have been more profitably directed by expanding the scope of work in occupational therapy, which would have been possible when additional aides arrived.
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Future interests.- The patients looked forward principally to resuming their former occupations at home or else simply to being discharged. Prospective school work held a gratifying interest, but they seemed to regard the shopwork as less attainable. The opportunities for consultation with and training under the Federal Board for Vocational Education had not been appreciated as they should have been, and should have been presented more vigorously.
Worries, fears, and causes of discontent.- The snails source of complaint was the food served. A number were chafing under the rules and restrictions in force. There was some apprehension, more or less morbid, regarding the high altitude. There was often a need for some one to take up home difficulties, especially the failure of allotments to arrive.
Social instincts expressed.- Ninety per cent showed a friendliness to the interviewers and58 per cent expressed a wish for more visitors or a feeling of loneliness or homesickness. More systematic visiting was evidently needed; with the arrival of the additional aides which had been requested much of this loneliness and craving for visitors could be dealt with.
Temperament.- Many weeks of confinement did not appear to have shaken the optimistic attitude.
DEVELOPMENT OF THE CURATIVE WORKSHOP SCHEDULE
The curative workshop schedule in tuberculosis hospitals consisted mainlyof ward occupations, academic and commercial classroom work, and graduated exercise in the form of walks.
The earlier ideas of reconstruction for tuberculous cases were that the courses would run largely along practical vocational lines, but experience led rather to ward occupations and general schooling; 13 when patients were physically able to take the shop courses they were very liable to demand discharge.14 Agriculture in some form was at first looked upon as the ideal pursuit for an arrested case, as it provided an outdoor life with varying degrees of strenuosity. While its theoretical advantages were evident and its practical advantages were demonstrated, the great majority of the patients did not look upon the pursuit with favor, and the enrollment in that course fell far below what had been hoped for.15 It was difficult to interest officer patients in courses other than ward occupations, owing to their relatively superior education, but many pursued advanced correspondence courses under the guidance of the educational service.16
Certain hospital activities which ordinarily were included in the curative-workshop schedule were not considered to be proper occupations for tuberculous cases to follow from the standpoint of the best interests of both the patients and others. The physical conditions of this class and the necessary treatments and examinations imposed upon them rather short and irregular working hours. Such activities as the print shop were called upon to deliver work with regularity and within a time limit, and some hospitals felt that the lowering of the efficiency of these various activities necessary for the maintenance of the hospital by the employment of irregular workers was not justified. Further-more, if the sick and the well were so associated, there would be competition, and the sick men would become discouraged at the greater progress made by the well men. Those not sick would also run a certain risk of infection. These conditions would demand a duplication of plants if the two requirements of efficiency and instruction of the inexperienced were to be attained simultaneously, rather than one set of curative workshops for the conjoint use of the hospital and the reconstruction service. In other activities of the hospital, such as the laundry, bakery, and kitchen, the danger of infection of others
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was always a possibility, and the occupations were too confining for tuberculous cases. It was considered to be extremely doubtful if any tuberculous cases should be allowed to engage in painting, plumbing, or printing on account of the possibility of lead poisoning.
EQUIPMENT
Equipment of the shops was quite complete for the class of cases considered and could supply instruction in all lines which their physical condition warranted. In one hospital (General Hospital No. 20) the machine shop was equipped with an engine lathe, drill press, shaper, drill grinder, power hack saw, and a full line of vises, wrenches, workbenches, and small hand tools. 16 The auto shop used the machine-shop equipment, and obtained from the Motor Transport Corps, for demonstration purposes, unserviceable motor vehicles--an Overland motor car, a Studebaker six-cylinder car, a Republic truck, and an Indian motor cycle with side car. The Overland car and the motorcycle were in such condition that they could be used for driving instruction within short distances, although it was frequently necessary to tow them back to the shops. The carpenter shop was equipped with a wood speed lathe, mortising machine, small jointer, circular saw, and workbenches, with a complete assortment of hand carpenter tools. In addition, a small Avery 5-10 tractor was purchased for the use of the shops, and a 10-ton artillery tractor was obtained from the Ordnance Department. Several sets of small field equipment for prospecting for minerals and courses in simple mineral tests were also available.16
The agricultural section had two 50-egg incubators, a brooder, sanitary rabbit hutches, and a small henhouse.16
COURSES GIVEN
The courses which made up the curative workshop schedule at General Hospital No. 20 will serve to illustrate such courses in other tuberculosis hospitals: 16
(1) Academic.- Algebra, trigonometry, civics, Spanish, penmanship, English for begin-ners, English for foreigners, journalism, vocational arithmetic.
(2) Commercial.- Commercial English, commercial arithmetic, stenography, typewriting bookkeeping, business law, elements of filing systems.
(3) Art craft.- Cartooning and illustrating, basket making, leather work, weaving, toy making.
(4) Technical.- Astronomy, meteorology, ore testing, elementary physics, telegraphy, motion-picture operating, photography, mechanical drawing, machine drawing.
(5) Shop.- House wiring, sign painting, carpentry, furniture repair, machine shop, automobile repair and construction, auto-ignition systems, tractor operation, tractor construction, tractor repair.
(6) Recreational.- Piano playing, mandolin playing, orchestral instruction.
(7) Agricultural.- Poultry raising, rabbit breeding, farm management, cold frames as a factor in growing vegetables, alfalfa culture, corn culture, onion culture, barley culture, dairy husbandry, swine husbandry, sheep husbandry, vegetable gardening, beekeeping.
(8) Correspondence courses (courses offered through the courtesy of the Agricultural College of the University of California).- Milk-goat raising, pear culture, plum and prune culture, walnut culture, almond culture, grape growing, citrus fruits, olive growing, fig culture, canning and preserving, date culture, certain semitropical fruits, avocado culture, lumber and its uses, the business aspects of California agriculture.
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SELECTION OF COURSES FOR INDIVIDUALS
All of the tuberculosis hospitals employed a system of classifying patients in three main divisions, based on their physical conditions, in order to facilitate assignment to reconstruction work.17 The arrangement varied in the different hospitals but, in general, bed patients were febrile cases and took very little work; ambulatory patients were permitted mild exertion with prescribed rest periods; the inactive patients gradually were brought to a full day's work. The most complete classification coordinated both the assignment of curative work and the location of the wards with the physical condition, as follows: 18, 19
Tuberculous patients were divided into four classes, the wards into four corresponding groups, and reconstruction work was assigned to patients according to their classification as given below. Each patient, except those critically ill, was to be given something to do, and his day planned for him in a rather definite regime. Patients were taught that the treatment of their cases was a progressive affair, and that the aim of the entire staff was to help them to progress through the successive classes to that consisting of the healed and inactive lesions, and to "graduate " from the hospital by discharge from this "graduating"class and from the hospital. Exercise was a part of the treatment. A brief of a patient's clinical history was presented to the chief of the medical service before prescribing the exercise, and the kind, amount, and results of the exercise performed were entered in a book kept in each ward. The exercise itself was conducted by the reconstruction division, but the responsibility, so far as concerned the patient, rested with the ward surgeon who prescribed the exercise and observed its effects.
Class D comprised patients with a persistent temperature above 99 0,extensive active lesions, hemorrhage, progressive lesions, or any other condition requiring confinement to bed. These patients were assigned to a group of wards having closed connecting corridors leading to the mess hall, surgical pavilion, and laboratory. Knitting, embroidery, crocheting, and raffia weaving were the varieties of reconstruction work assigned to them.
Class C patients were those showing a persistently rapid pulse, excessive cough, loss of weight, dyspnea, or extensive inactive lesions. They were permitted to take a little exercise, and were located in a group of wards near the main mess hall. The same handicrafts as for class D were prescribed, but with longer hours. Classes in commercial and academic courses and light games were also allowed.
Cases showing little or no activity and requiring an open-air life with plenty of rest and regular hours, and without too much or too violent exercise, were classified as B and located in a group of wards one-fourth mile from the mess hall. These were given such courses as carpentry, gardening, wood carving, automobile repairing, plumbing, agriculture, animal husbandry, light games, and graduated drill in the school of the soldier.
Class A patients were those showing no evidence of active pulmonary dis-ease who were being hardened preparatory to return to duty. They were housed in a group of wards three-fourths of a mile from the main buildings, were gradually put on a schedule of full work, including one or two hours drill daily, and
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were not required to observe the usual rest hours. They wore brassards to identify them as belonging to the "graduating class."
Patients in the febrile stage of the disease, and therefore taking the "rest cure," were inclined to become very restless and discontented. The ward handicrafts, the simpler academic studies, and reading, were particularly adapted for this class of patients, requiring a minimum amount of exertion and concentration, could be laid aside at any time, and served to quiet the patient's restlessness and reawaken his desire and hope for recovery. Some care in the selection of handicrafts was necessary in order to avoid those which might have provoked a man into a too strenuous effort through complexity or absorbing interest of the problem. Rake knitting, mat weaving, weaving on small looms, beadwork, basketry, clay modeling, block printing, and simple studies fulfilled the requirements at this stage.
For patients confined to the ward but not confined to bed the porches were equipped as workshops where reed and willow basketry, bookbinding, loom weaving, and wood carving were carried on. Patients who were classed as "ambulant" were given graduated walks, with prescribed periods for walking and for resting, and were under close medical observation at all times. These walks were graduated from 1 to 4 miles, and patients who completed this course successfully were then given light work in the workshops, in animal husbandry, or in agriculture.20 At Fort Bayard, N. Mex., a period of physical exercise and manual labor was considered to be necessary as a test for a false arrest of the tuberculous process, for a number of patients had suffered are lapse when subjected to real work after discharge.21 The types of work pre-scribed varied in the different hospitals-graduated walks, agriculture, animal husbandry, auto mechanics, and a system of graduated exercises. However, at General Hospital No. 21 no such test was used during the earlier stages of its operation, for at that time the chief of the medical service believed that no form of exercise was beneficial for tuberculous cases; nevertheless, 96 per cent of the patients discharged were recorded as being without any disability, although there had been no test to ascertain whether or not they were able to perform physical labor without a relapse.22
The careful selection of recreations was necessary in order to avoid over-exertion or too much excitement, and they were confined principally to such games as checkers, chess, cribbage, quoits, to automobile rides, and entertainments of various kinds. At general hospital, Fort Bayard, N. Mex., special effort was made to get entertainment into the wards where the patients were too sick to get out to the entertainments furnished for ambulant patients.11
One of the functions of the wardworkers was to recruit entertainment material from among the patients in thewards where the patients were well enough to help entertain and have them helpentertain in the wards of bed patients. The ward workers themselves were notbed patients. It was very difficult to keep the group of ward workers recruitedup to full strength-i. e., one for each ward, owing to frequent loss bytransfers, etc. An entertainment committee representing the American Red Cross,Young Men's Christian Association, and the Knights of Columbus cooperated tohave entertainments in the wards where the bed patients were. This committeeused patients for entertainers as much
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as possible and reported to the morale officer. The work of this committee was coordinated by him. The recreational officer was required to teach patients to entertain themselves. 11
At Fort Bayard, N. Mex., academic and commercial subjects were assigned to patients whose physical condition permitted, but here also the necessity for watchful supervision in the character and duration of the work was evident. 11 The necessity for shorter daily periods available for instruction than was customary in other hospitals required a relatively larger teaching force. As in other hospitals, the Americanization courses proved to be among the most popular and most valuable of all the courses offered.
CURATIVE WORKSHOP SCHEDULE, GENERAL HOSPITAL NO. 8, OTISVILLE, N. Y.
The records of General Hospital No. 8, Otisville, N. Y., provide material for the following account of the functioning of the curative workshop schedule: 23
BEDSIDE HANDICRAFTS
Bedside handicrafts became the line of work which occupied the time of the greatest number of patients. Ward surgeons who were skeptical about the work at the start became converted to belief in this type of work and many expressed themselves strongly in favor of it. Indeed, for many weeks the chief educational officer was overwhelmed with a demand for aides at a time when no aides were to be had. Before the first aide came to the post both the chief educational officer and his assistant entertained a lively prejudice against the work of the reconstruction aides. They felt that handicraft work was a form of activity which kept men from doing something more worth while, and had noted this to be the case in some other hospitals. This difficulty did not appear at General Hospital No. 8, however, due in part to the fact that the head aide realized the importance of urging men to do the most virile work possible. A factor of even greater importance was the classification of wards, by which patients who are able to do physical work were assigned to wards where they were required to take exercise under the supervision of the reconstruction department, where the aides did not go.
BEDSIDE ACADEMIC INSTRUCTION
Though some men in the wards considered that handicraft work was beneath them, to many of them bedside academic instruction came as a welcome diversion. Some few subjects, such as modern languages, could hardly be taught successfully, and the attempt to give instruction in them could be justified only as a therapeutic measure. In many other subjects, however, notably in arithmetic, English, free-hand and mechanical drawing, patients could work successfully in bed. The method used was a modification of the correspondence-school method. Patients worked by themselves as little or as much as they would. Instructors visited them daily for 10 or 15 minutes, went over their work with them, and gave them encouragement. The best proof of the success of this work was that the enrollment increased steadily from its beginning. As one ward surgeon expressed it, the patients were quiet, busy, satisfied,
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and rested better during the rest period. Those who were ambitious looked forward to the time when they would make use of the knowledge they had gained.
CLASS WORK
The success of voluntary class work had been subject to serious limitations. Most patients had been eager to leave the hospital as soon as possible and had felt that if they were in condition to do serious work they ought to be allowed to go home. Hence, they often protested against reconstruction work on the ground that their thoughts were elsewhere or that they would not be there long enough to make it worth while to take up the work. When they had been persuaded to take up work on therapeutic grounds their objections soon were driven from their minds. It was quite possible for one to get in a substantial addition to his attainments in bookkeeping, poultry and beekeeping, penmanship, typewriting, and English. In these subjects satisfactory results were obtained, either by means of individual instruction or by the use of unit courses covering a small part of a subject in a few days' time. English for foreigners has been especially successful, partly because of the eagerness of the students and partly because of the time allowed daily-twice as much as in the case of any other subjects in which class instruction was given. Even in salesmanship, stenography, Spanish, telegraphy, and wireless men laid a good foundation for future study. Here, as elsewhere, an enthusiastic instructor could do much for students, even in subjects where, apparently, a long period of study was necessary to get any results. Class work seemed to be especially successful in cases involving large numbers of men of moderate attainments who desired instruction in elementary subjects.
THERAPEUTIC WALKS
The graded therapeutic walks prescribed by the Medical Service was an important part of the reconstruction work. Due to the close supervision of these walks and the careful grading of the patients, there was a steady and progressive physical upbuild. All patients before undertaking any of the outside-the-ward occupations must have passed through the four lengths of walks. Ward surgeons praised these walks as a means of testing the patient's endurance; patients looked upon them as a means of developing their strength after a long time in bed.
SHOP AND FARM WORK
After they had finished the course of graded walks patients were required to take up therapeutic work either in the auto or carpenter shops or on the farm. They made their choice of the one to which they should be assigned. Shop and farm work proved quite practical for tuberculous men whose physical condition had been carefully tested before they were allowed to take either up. During a period of many months' observation no patient was obliged to quit any of the outside work because of increased tuberculous activity.
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CARPENTER SHOP
Though the activities of the woodworking shop were under the head of carpentry, the actual projects completed and work done embraced carpentry, cabinetmaking, pattern making, and general millwork. Nothing but real jobs were handled. The men in the drafting room were instructed first along the lines of theory, that they might be equipped to turn out complete working drawings and blue prints necessary for the work in the shop. This type of course promoted great interest, proving the real value of the relation of shop mathematics, strength of materials, and bills of stock in connection with the finished product.
As the men were received for the woodworking shop they were graded in accordance with their physical condition, working through from the lighter bench work to the more active operation with the circular saw and power mortiser. Along with the therapeutic value of the work the men gained an opportunity to enlarge their experience along the lines thay had chosen, which added great interest to their activities, in many cases developing initiative with an actual business end in view. This specializing project was not lost sight of. One patient drafted plans for a home which he hoped to build soon; another patented a machine for cleaning chicle and made large patterns from which his castings were to be prepared. In these and similar cases the shop work proved of great value from the standpoint of both instruction and morale.
There were three points in favor of shopwork--the physical value to the patient, the vocational instruction received, and the value of ways and means in production both to the patient and the hospital. The physical condition of the patient improved by graded exercise, which many times had been taken unknowingly. Due to the fact of the interest developed by vocationalizing the work, combined with factory production, one of the first examples of the methods used to obtain this end was through the production of four styles of footstools in which many bench and machine operations were contained; 250 of these stools were built, to be caned and seated in various ways by the bed patients, greatly expediting that side of the work by furnishing an attractive and practical project at low cost. Of the men assigned to this grade of work it was invariably true that they desired long assignments and more work in the attempt to reach a definite end.
AUTOMOBILE SHOP
Especial interest was shown in the automobile shop, where many men learned some of the fundamentals of auto mechanics and repairs. Many patients were prone to elect auto mechanics because of its pleasurable aspect and its dynamic character, but experience proved that because of lack of consistency and continuous work the therapeutic value of the assignment was not of the highest grade. The danger of the periodic overexertion so often called for in an emergency was also a point of apprehension. With this in view, only men who were especially qualified physically and who had mechanical tendencies were permitted to take up the work.
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FARM WORK
The men who elected farm instruction continued the therapeutic work which they had begun on the walks. The work undertaken by the agricultural department was divided into two parts-academic and occupational. In the academic group courses were conducted mostly during the winter months--poultry care, beekeeping, farm management, milk bacteriology, animal husbandry, and general agriculture. When possible, these courses were supplemented with laboratory work, such as in poultry care, the practical running of an incubator, and in milk bacteriology the use of the clinical laboratory. The other agricultural courses were strictly academic, standard textbooks being used. Again, in poultry care, trips were made to near-by poultry farms for study and criticism.
In the occupational work a far more diversified program was followed. A 75-acre farm was rented early in the fall and the work of construction of numerous farm projects was begun immediately. First a modem piggery was built, consisting of a 50-foot feed house and a series of small colony houses. Through loan, 14 excellent sows and 1 boar were obtained from the New York City Sanitarium for breeding purposes. Breeding began early in the fall and the results were seen and realized in litters of baby pigs. The small pigs, after weaning, would be kept for use and the sows returned. The work in this swine project assumed not only a therapeutic angle but also became exceedingly vocational. Hospital garbage was converted by thorough cooking into the bulk of feed stock for the pigs.
Together with this project, that of market gardening was perhaps the largest and most extensive. Here the patients were divided into distinct groups for unit courses when feasible. Such units were hotbed construction, the making of flats, sowing seeds, transplanting, the use of farm implements, problems in farm management, etc. With a farm of 75 acres at their disposal, it was planned to produce a large portion of the market stuff for the hospital consumption. The crops were planned with a view of eliminating the more difficult and tedious farm operations, so that light, easy work would always be available for the patients. The heavier operations of the farm, such as plowing and hauling, were performed by a limited number of corpsmen. Plans were under way for a poultry project which would take up the construction of modern poultry houses and an opportunity for poultry management. It was hoped to obtain a collection of some of the best and most practical breeds of poultry, together with flocks of ducks, geese, guinea hens, and, possibly, pheasants. The aim of the department was to accomplish three distinct things in the order of importance; namely, occupational therapy, vocational instruction, and the greatest production of food stuff possible for the use of the hospital.
The interest of the patients in farm work was encouraging. After being restricted in physical activity for many weeks, the ambition of the convalescent patient was to find some channel as an exit to his youthful energies. He welcomed the out-of-door farm occupation, and more difficulty was experienced in restricting his work than in supplying it. Furthermore, he fully realized that before being sent from the hospital as an arrested case, he must demon-
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strate that he was able to do a moderate amount of work without displaying fatigue. Coupling his own innate propensity to once again use his restless muscles with the knowledge that to get a discharge he must prove his measure of resistance, the success of reconstruction through agricultural projects resolved itself simply into organizing the work.
SALE OF FINISHED PRODUCTS
Any immediate financial aspects of reconstruction work in the hospitals for general cases was minimized in the belief that such an appeal was rather stultifying to the high purpose of the reconstruction program and detrimental to the individual. With tuberculous cases, on the contrary, it was found that the production of articles which possessed a commercial value tended to restore a man's confidence in his ability to become a self-supporting producer and had a pronounced morale value, and thereby a therapeutic value, not only in removing a great source of worry but also in increasing his optimism as to the probability of recovery.
PHYSIOTHERAPY
The use of physiotherapy was so limited as to be almost negligible, for two reasons: The patients being nearly all cases of disease rather than injury, its use was less often indicated; tuberculous cases do not react in a beneficial manner to most varieties of this form of treatment.
SEGREGATION OF RACES
The segregation of tuberculous patients, white and colored, in separate hospitals was ordered for the East and South in July, 1919,24 but the hospitals in the other sections of the United States received both classes, segregating them in wards. Though there were exceptions, as a rule there was not sufficient interest in classes manifested by colored students to warrant their continuance.2
REDUCTION IN NUMBER OF TUBERCULOSIS HOSPITALS AFTER THE ARMISTICE WAS SIGNED
The status of the tuberculosis question in the Army having become more or less stationary by the spring of 1919, the Surgeon General was in a position to recommend to the War Department which of the tuberculosis hospitals might profitably be abandoned and which might be retained as permanent institutions. Of the three general hospitals in the West and the three in the East then operating for the care of tuberculosis cases all but two were to be closed as rapidly as their sick could be cured, returned to duty, or otherwise disposed of. 25 The excellent railroad connections, geographical location, type and character of buildings, to say nothing of the amount of money previously expended ($3,250,000) at General Hospital No. 21, Denver, Colo., practically committed the Army to its retention as a permanent institution. As regards a hospital for the East, it appeared to be to the best interests of the Government
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and the Army for the latter to operate a tuberculosis hospital in the East, not only to avoid the long transportation of many soldiers from the Eastern States to hospitals in the West but to avoid the depression often found in tuberculous patients separated from their families by great distances over a protracted period of illness. Accordingly, the Surgeon General recommended that General Hospital No. 19, at Oteen, N. C., be retained as the permanent institution in the East.25 The Surgeon General's reason for desiring to abandon the general hospital at Fort Bayard, N. Mex., was based upon the comparative inaccessibility of that place, thus not only making difficult the transfer of patients thereto but also furnishing supplies to the place. Furthermore, fully two-thirds of the buildings there were in a poor state of repair.
Definite approval of these views of the Surgeon General was made by the War Department on April 2, 1919, thus preventing the subsequent abandonment of the other tuberculosis hospitals when need of them no longer existed.25
PATIENTS DISCHARGED AFTER ONE YEAR OF TREATMENT
A new policy regarding hospital cases of long standing was promulgated by the War Department in November, 1919,26 the provisions of which applied particularly to tuberculous cases. Under this policy patients who had been in a military hospital in the United States for a year were to be discharged, with some exceptions, those requiring further treatment to receive such from other governmental sources. This was later so modified as to permit those tuberculous cases who had had treatment for a year, who had active lesions but were making satisfactory progress and would recover within a reasonable length of time, and who so desired, to be retained in Army hospitals for further treatment. This "reasonable length of time" was given a maximum of six months, and no such patient was to be discharged until he had been given a sufficient interval to arrange his affairs-ordinarily about two weeks but with a maximum of six weeks.27 Commanding officers of tuberculosis hospitals were authorized to correspond directly with regional directors of the War Risk Insurance Bureau concerning the cases which were to be transferred to the hospitals of that bureau. 28
PERCENTAGE OF ENROLLMENT
The percentage of patients enrolled in the curative workshop schedule varied widely in the different tuberculosis hospitals and at different periods in the same hospital. The figures varied from 20 to 90, with an average of approximately 60. In four hospitals-General Hospitals Nos. 19, 20, 21, and Fort Bayard-the average percentage of patients enrolled in the educational work during five months of the year 1919 was 57.8; 47 percent of all enrollments were in ward handicrafts, 10.8 percent in ward academic courses, 21 percent in technical courses in the workshop, and 9 percent participated in various recreational activities.28 Table 2 gives certain data on the educational work in the tuberculosis hospitals.
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TABLE 2.- Educational work in special hospitals for the care of the tuberculous, as of the end of the month a
GENERAL VALUE
It is difficult properly to evaluate reconstruction work in tuberculous cases, since the psychologic side is so predominant; however, the consensus of opinion of the commanding officers of the tuberculosis hospitals, the ward surgeons, the educational personnel, and the patients was to the effect that curative work in the wards, schools, shops, gardens, and fields was of great psychological and material value in the treatment of pulmonary tuberculosis. 29 The commanding officer General Hospital No. 19 stated that he considered the work of physical reconstruction the greatest modern advance in the treatment of tuberculosis, and that he felt strongly that the type of curative work needed was that which was capable of developing interest in the vocation which the patient would later pursue, rather than any considerable quantity of undertakings of the so-called kindergarten varieties. 30
REFERENCES
(1) Letter from Maj. Arthur Davis Dean, S. C., to the Surgeon General of the Army, March15, 1919. Subject: Reconstruction at United States Army General Hospital No. 21, Denver, Colo. (and attached documents). On file, Historical Division, S. G. O.
(2) Letter from chief educational officer, United States Army General Hospital No. 8, Otisville, N. Y., to the Surgeon General, United States Army, Washington, D. C., November 16, 1919. Subject: Historical sketch of reconstruction work (and attached documents). On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 8), K.
(3): Report of reconstruction work at United States Army General Hospital, Fort Bayard, N. Mex., undated. On file, Record Room, S. G. O., 353.91-1 (General Hospital, Fort Bayard), K.
(4) Letter from chief educational officer, United States Army General Hospital No. 21, Denver, Colo., to the Surgeon General United States Army, Washington, D. C., April 23, 1919. Subject: Brief historical sketch of reconstruction activities. On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 21), K.
(5) Based on data compiled from plans for general hospitals. Plans on file, Hospital Division, Surgeon General's Office; also Annual Report of the Surgeon General, United States Army, 1919, Vol. II, 1164-1167.
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(6) Report from Maj. S. M. Rinehart, M. C., to the Surgeon General of the Army, August 17, 1918. Subject: Reconstruction in United States Army General Hospital, Fort Bayard, N. Mex. On file, Record Room, S. G. O., 356 (Reconstruction, Fort Bayard), K.
(7) Letter from Capt. John A. Sexson to Maj. A. C. Monahan, September 22, 1918. On file, Record Room, S. G. O., 353.91-1 (Fort Bayard General Hospital), K.
(8) Letter from the morale officer, United States Army General Hospital, Fort Bayard, N. Mex., to the Surgeon General of the United States Army, January 2, 1919. Subject: Monthly report. On file, Record Room, S. G. O., 353.91-1) General Hospital, Fort Bayard), K.
(9) Letter from Col. W. J. L. Lyster, M. C., United States Army General Hospital No. 19, Oteen, N. C., to Col. Roger Brooke, Surgeon General's Office, Washington, D. C., July 5, 1919. On file, Record Room, S. G. O., 323.7-5 (General Hospital No. 19), K.
(10) Letter from the commanding officer United States Army General Hospital, Fort Bayard, N. Mex., to Col. E. R. Schreiner, M. C., sanitary inspector, June 7, 1919. Subject: S. G. 0. 721 (Base Hospital, Camps)-Sanitary inspections (and attached documents). On file, Record Room, S. G. O., 721-1 (General Hospital, Fort Bayard), K.
(11) Letter from the Surgeon General United States Army to the commanding officer United States General Hospital, Fort Bayard, N. Mex., January 15, 1919. Subject: Report of chief educational officer (and attached documents). On file, Record Room, S. G. O., 356 (General Hospital, Fort Bayard), K
(12) Letter from chief of educational service, United States Army General Hospital, Fort Bayard, N. Mex., o the Surgeon General of the United States Army, Washington, D. C., March 10, 1919. Subject: Psychological research (and attached documents). On file, Record Room, S. G. O., 353.91-1 (General Hospital, Fort Bayard), K.
(13) Letter from chief of reconstruction service, United States Army General Hospital No. 16, New Haven, Conn., to the Surgeon General, United States Army, August 15, 1919. Subject: Historical sketch (and attached documents). On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 16), K.
(14) Letter from Maj. John R. McDill, M. C., U. S. A., to the Surgeon General United States Army, Washington, D. C., March 15, 1919. Subject: Reconstruction function at Whipple Barracks (and attached documents). On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 20), K.
(15) Letter from chief of educational service, Fort Bayard, N. Mex., to the Surgeon General of the United States Army, Washington, D. C., June 4, 1919. On file, Record Room, S. G. O., 353.91-1 (General Hospital, Fort Bayard), K.
(16) History of reconstruction service, United States Army General Hospital No. 20, Whipple Barracks, Ariz., October 25, 1918, to February 15, 1920, unsigned. On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 20), K.
(17) Memorandum from Maj. John A, Sexson, S. C., U. S. A., chief educational officer,
United States Army General Hospital, Fort Bayard, N. Mex., for the Surgeon General's Office, division of reconstruction, March 14, 1919. Subject: Questions for consultants to discuss with head aides. On file, Record Room, S. G. O., 353.91-1 (General Hospital, Fort Bayard), K.
(18) Letter from Maj. S. M. Rinehart, M. C., U. S. A., to the Surgeon General, United States Army, August 30, 1918. Subject: Reconstruction in United States Army General Hospital No. 19, Oteen, N. C. (and attached documents). On file, Record Room, S. G. O., 356 (General Hospital No. 19), K.
(19) Letter from commanding officer, United States Army General Hospital No. 19, Oteen, N. C., to the Surgeon General, United States Army, Washington, D. C., February 15, 1919. Subject: Report of hospital for the year 1918 (and attached documents).On file, Historical Division, S. G. O.
(20) Letter from Samuel M. North, chief, reconstruction service, United States Army General Hospital No. 19, Oteen, N. C., to the Surgeon General, United States Army, May 15,1919. Subject: Reply to paragraph 2, S. G. 0. 356, dated April 14, 1919. On file, Record Room, S. G. O., 353.91-1 (General Hospital, No. 19), K.
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(21) Letter from Maj. Allen R. Cullimore, S. C., United States Army, to the Surgeon General, United States Army, undated. Subject: Educational work at General Hospital, For Bayard. On file, Record Room, S. G. O., 353.91-1 (General Hospital, Fort Bayard), K.
(22) Letters from Maj. A. D. Dean, S. C., United States Army, to the Surgeon General, United States Army, March 17, 1919. Subject: Report on reconstruction service, United States Army General Hospital No. 21. On file, Record Room, S. G. O., 353.91-1 (General Hospital No. 21), K.
(23) Letter from chief educational officer, United States Army General Hospital No. 8, Otisville, N. Y., to the Surgeon General, United
(24) Letter from the Surgeon General, United States Army, to surgeon, port of embarkation,. Hoboken, N. J., July 29, 1919. Subject: Transfer of tuberculous patients. On file, Record Room, S. G. O., 705-1.
(25) Letter from commanding officer, United States Army General Hospital No. 19, Oteen, N. C., to The Adjutant General of the Army, Washington, D. C., March 5, 1920. Subject: Status of this station (and attached documents). On file, Record Room, S. G. O., 323.7-5 (General Hospital No. 19), K.
(26) Circular Letter No. 345, Surgeon General's Office, November 10, 1919.
(27) Letter from the Surgeon General, United States Army, to the commanding officer, United States Army General Hospital No. 20, Whipple Barracks, Ariz., December 10, 1919. Subject: Discharge of disabled military personnel. On file, Record Room, S. G. O., 701-1 (General Hospital No. 20), K.
(28) Statistics of educational service in tuberculosis hospitals on May 31, 1919, prepared in the reconstruction division, Surgeon General's Office. On file, Historical Division, S. G. O.
(29) Billings, F.: Physical reconstruction applied in the treatment of tuberculosis. Journal of the American Medical Association, Chicago, 1919, lxxiii, 1033-1035.
(30) Letter from Maj. Charles L. Greene, M. C., to the Surgeon General, United States Army, December 6, 1918. Subject: Report on visit to (General Hospital No. 19)K,
