SECTION II
IN THE AMERICAN EXPEDITIONARY FORCES
ORGANIZATION
Reconstruction in the American Expeditionary Forces did not become highly organized as it did in the military hospitals of the United States, nor was it intended that it should. It is true, however, that certain phases of it were to have been utilized to the fullest extent possible, and early in the organization of the American Expeditionary Forces. In the plan for the organization and development of the orthopedic department in the Surgeon General's Office, which was submitted to the Surgeon General on August 14, 1917,1 provisions were included for the immediate formation of an orthopedic hospital of 1,000 beds for service abroad. This hospital was to be fully equipped with all facilities for physiotherapy and was to include a curative workshop. Within a few months, however, the idea of providing special hospitals for orthopedic cases was given up; thereafter, each hospital unit destined for overseas was to have an orthopedic section, with its curative workshop.2 Furthermore, it was planned to provide sets of equipment to enable bedfast patients to keep employed and to ship these sets for such overseas hospitals as would have patients confined to bed for relatively long periods.3 One teacher was to be provided for each such hospital, with the expectation that the teacher would instruct wounded men for duty as assistants. For certain hospitals a part of the standard equipment was to consist of splint shops, carpenter shops, forges, etc., in which convalescent patients could be kept employed and at the same time make articles that would be of use in the upkeep of the hospitals.3 As will be seen below, however, even these modified plans were not consumated.
The majority of the patients in the American Expeditionary Forces requiring physiotherapy or occupational therapy were orthopedic cases. Reconstruction work, consisting principally of occupational therapy and physiotherapy, therefore devolved largely upon the orthopedic service. It was not practicable to provide for our hospitals in France curative workshops that could compare in number or quality with those shops furnished the military hospitals in the United States. There were two reasons for this--the restriction necessarily applied to ocean tonnage and the special classification of patients in the American Expeditionary Forces. Restrictions on overseas transportation, imposed by the limited tonnage available, also necessitated utilizing all personnel in the American Expeditionary Forces to the fullest possible extent. To this end instructions were issued in March, 1918, to convene disability boards, to classify all officers and soldiers coming before them in accordance with their degree of uesfulness overseas, as follows:4 Class A, physically fit for combat duty; class B, temporarily unfit for combat duty but fit for other duty and expected to become class A within six months; class C, permanently unfit for combat duty but fit for other duty overseas; class D, unfit for any duty overseas, to be evacuated to hospitals at base ports for return to the United States.
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This utilization of individuals not wholly physically fit in a limited service capacity and the return of the wholly unfit to the United States had a direct bearing on the overseas reconstruction problem, for, while it tended to reduce the load by evacuating to the United States the permanently disabled, this was counterbalanced by retaining in hospitals for months those who would become fit for limited service within a reasonable period. Furthermore, it afforded opportunity to retain overseas disabled men who would be of value as instructors in occupational therapy.
The first instructions covering a special class of cases requiring reconstruction concerned amputation cases and were issued early in April, 1918.5 These instructions required that all such cases be transferred to Base Hospital No. 9, American Expeditionary Forces, pending the establishment of the special orthopedic hospital, Base Hospital No. 114, at Beau Desert.
Reconstruction work was carried on also by other surgical services, the whole being correlated and coordinated through the chief consultant, surgical services.6 In the spring of 1918 the Surgeon General expressed the desire to send to France, to assume charge of the reconstruction work, a medical officer who had gained experience in this line by duty in the reconstruction division of the Surgeon General's Office.6 This plan was not approved by the chief surgeon, American Expeditionary Forces, as the organization there was considered to be satisfactory, and it was felt that better results would be obtained by continuing the work under the direct supervision of the individual heads of the departments concerned 6 rather than by instituting a new division for this purpose in his office.
On May 3, 1918, the Surgeon General authorized the chief medical officer of each army or separate auxiliary force to appoint head aides not to exceed two to each hospital from among the reconstruction aides serving overseas.7 It was under this arrangement that the reconstruction service, American Expeditionary Forces, operated. There were no chief head aides, but there was one head aide who was in charge of the reconstruction aides in each hospital. There was a supervisor of reconstruction aides who, until January, 1919, was located at the Savenay Hospital Center.8 In January, 1919, she joined the chief surgeon's office at Tours and was affiliated with the office of the director of Nursing Service, American Expeditionary Forces.9
For the greater part of the fall of 1918 conditions in the American Expeditionary Forces not only caused a setback as regards the organization of the reconstruction service there but also made it practically impossible for the aides to carry on any of their work. The frequent arrival of convoys of troops from the United States during the fall of 1918, each transport having many cases of influenza on board, threw such a great burden on the hospitals near the base ports that the services of every available and suitable person were demanded for the care of the sick.10 Consequently, occupational work was practically abandoned during this time of stress and the reconstruction aides were called upon to act as assistants to the nurses. This was a valuable experience for the aides and promoted harmonious relations between the two organizations. In November, however, the need for such services declining, the aides were enabled to devote their whole time to reconstruction work.10
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Efforts were made by the supervisor of reconstruction aides to so standardize the occupational therapy that uniform crafts could be used for all cases of the same type. It was felt that the work should be as simple as possible and that progressive interest could be maintained by the use of increasingly difficult designs rather than by introducing different varieties of work.11
PERSONNEL
It was estimated by the chief of the orthopedic division of the Surgeon General's Office in the fall of 1917 that 400 reconstruction aides would be needed in our overseas hospitals for the first 1,000,000 troops actively engaged and 200 would be needed for each additional 1,000,000 men.'2 It was not contemplated at this time that any occupational therapy aides would be sent overseas, since it was believed such aides could be obtained from our overseas enlisted personnel.
The first aides to reach France were 22 physiotherapy aides attached to Base Hospital No. 114, which had been organized primarily as an orthopedic hospital unit.13 During the same month, however, arrangements were made by the War Department to send 28 additional reconstruction aides to the American Expeditionary Forces.13
The first occupational therapy aides to reach France from the United States numbered 13 and arrived there August 13, 1918.14 They were sent to Base Hospital No. 9, at Chateauroux, seven of them subsequently to be transferred (September 15, 1918) to Base Hospital No. 114, Beau Desert.14
In August, 1918, General Pershing recommended to the War Department that 20 reconstruction aides (10 physiotherapy aides and 10 occupational therapy aides) accompany each base hospital sent overseas, the aides to be reassigned for duty upon arrival.15 This recommendation followed a statement made by the chief consultant in orthopedic surgery, American Expeditionary Forces, that though there were then in France sufficient aides for massage, electrotherapy, and hydrotherapy for the needs at that time, there was needed a large number for bedside occupations.16 The neuropsychiatric division also expressed a decided preference at that time for aides trained in bedside occupational work with neuropsychiatric patients.17
A revised list of reconstruction personnel for each orthopedic hospital was formed in September, 1918, as follows: 18
Aides in physiotherapy | 26 |
Masseuses | 20 |
Electrotherapeutists | 6 |
Aides in bedside occupations | 20 |
Hydrotherapeutists (men) | 4 |
Physical trainers | 5 |
Shop instructors (men) | 10 |
The sending of reconstruction aides to the American Expeditionary Forces continued during the fall of 1918, and by the end of December, 1918, there were 200 aides there,10 distributed among 20 base hospitals.
Many invalided soldiers had been returned to the United States by February, 1919, and the orthopedic work was largely concentrated at Bordeaux and Savenay, thus permitting the return of a number of aides to the United States.11
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Seventy-one physiotherapy aides and 22 occupational therapy aides were serving in France at the end of February, 1919, with the hospitals at Angers, Bordeaux, Brest, Nantes, Savenay, and Vichy.19 The evacuation to the United States of patients who were in good condition caused a change in the proportion of the two classes of aides after February, there being in the American Expeditionary Forces on May 1, 1919, 54 aides in physiotherapy and 55 in occupational therapy; 13 of the former and 17 of the latter were in Germany with the Third Army.20 The need for work in both departments was rapidly lessening, and aides were being transferred to Germany and to the United States. Thirty-two aides were on duty with the Third Army in May, 1919, at Treves, Neuenahr, and Coblenz, their work being principally with accident cases.21 The supervisor of reconstruction aides for the American Expeditionary Forces rendered her final report at the end of the month,21 and the last group of aides in France sailed for the United States late in May, 1919.22
SUPPLIES
Special kinds of easily workable wood were at first supplied the hospitals for use in the curative workshops, but this was discontinued during the summer of 1918 owing to the demand for space in overseas transportation.23 No provision had been made prior to the year 1919 for the general supply of materials for use in the wards and shops, so it was necessary to call on the American Red Cross to furnish such material as was available and to salvage and utilize such waste material as wooden boxes and tin cans.10 The American Red Cross also furnished much equipment, and the aides themselves financed the work to a considerable extent.10
PHYSIOTHERAPY
Since physiotherapy, as practiced at Savenay hospital center, is representative of the work done at its best elsewhere in the hospitals of the American Expeditionary Forces, the following account of that branch of reconstruction is reproduced:
DEPARTMENT OF PHYSIOTHERAPY
SAVENAY HOSPITAL CENTER
Reconstruction aides did not become a part of Savenay hospital center until October, 1918.24 At this time a group of four aides was transferred from Base Hospital No. 116 to Base Hospital No. 8, at Savenay. To the last detail things were in a state of great activity; the wards were full; the staff was not large and was working to its limit. Plans were being made to enlarge the facilities for caring for the wounded. Just then everything was centered upon the influenza epidemic, for large convoys of influenza patients were arriving from the transports.
Notwithstanding all these pressing claims upon the attention of those at the head of the physiotherapy unit, time was taken to welcome the new group of workers and to assure them of hearty cooperation which has not failed. It was not possible to start work right away, so for many days the physiotherapy aides were employed at different occupations to lighten a little the heavy work of the nurses.24
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Gradually a system was worked out; a small clinic was obtained and work was begun with classes for ambulatory patients in the clinic and individual work upon those in the wards.24 In hospitals which were already developing rapidly it soon became evident that four reconstruction aides could not begin to cover the work; therefore a group was obtained from Base Hospital No. 9, at Chateauroux, and in November another group came from the United States.24 From this time on an average number of 30 physiotherapists was maintained at Base Hospital No. 8.24
In December a new clinic was opened-a large, well-ventilated room with all equipment necessary for caring for the patients. 24 Patients who could walk came to the clinic for treatments. These were classified as follows: (1) Patients with median, musculospiral, and ulnar nerve injuries; (2) patients with knee joint injury for thigh or leg massage; (3) patients with sciatic, external popliteal, or other nerve injuries of the lower extremities; (4) patients with elbow injuries for forearm, hand, or finger exercises. Where practicable, patients were grouped for curative exercises.
Under the direct supervision of the center consultant in orthopedic surgery, the cases were carefully diagnosed, a plan of treatment for each patient was worked out and changed from day to day as the patient's condition progressed, manipulation and exercise forming the basis of the work.24
In the wards the work was supervised by the ward surgeon; the cases were classified as follows:24 (1) Gunshot wounds involving joints; (2) gunshot wounds with fracture; (3) gunshot wounds with resulting nerve injury; (4) amputation; (5) head injury; (6) soft-part wounds; (7) closed fracture; (8) gunshot wound with loss of bone substance; (9) trench foot; (10) face.
Especially good results were obtained from this ward work, particularly on the hypothesis that "an ounce of prevention is worth a pound of cure." Previous to the war the general tendency in physiotherapy had been never to touch an injured member while there was any inflammation present. It has been found, however, that careful manipulation around a draining wound instead of checking actually hastens the recovery. In the case of fractured femurs where the limbs were practically covered with bandages and tape work around the patella and foot made a great difference in mobilizing the patient's limb when the splint came to be discarded. Of secondary importance to final results, but of primary importance to the patients, is the comfort and relief that follows a little massage given to men who have lain, strapped and tied, for months in
most uncomfortable positions.
The following data, representing treatments given, show the increase in the physiotherapy work at the Savenay hospital center after such work was instituted: 24 October, 1918, 1,426; November, 1918, 3,440; December, 1918, 5,251; January, 1919, 6,568; February, 1919, 6,528; March, 1919, 4,333; April, 1919, 4,218.
During the winter of 1918-19 a course of lectures was arranged for the reconstruction aides.24 These lectures were given by the various surgeons at the center and embraced subjects which would give the aides information and advice for the cases under their care. The program was as follows:24 (1) The pathology of contracture deformity; (2) the surgical correction of contractures;
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(3) the correction of contractures by massage and nonsurgical methods; (4) deformity of upper extremities due to soft-part wounds, including amputations; (5) deformities of upper extremities due to bone and joint injuries; (6) the use of splints and plaster of Paris in injuries and deformities of the upper extremities; (7) deformities of the lower extremities due to soft-part wounds, including amputations; (8) deformities of the lower extremities due to bone and joint injuries; (9) the use of splints and plaster of Paris in injuries and deformities of the lower extremities; (10) massage treatment of arm and hand wounds before and after operation; (11) the massage treatment of thigh and leg wounds before and after operation; (12) mechanical treatment of joint injuries.
The progress of physiotherapy at this center was not contrary to that of other lines of work; 24 it was retarded here and there by unforeseen events and helped along by other circumstances. Despite changes in personnel and organization, the work continued steadily until the discontinuance of the center.
OCCUPATIONAL THERAPY
AT BASE HOSPITAL NO. 9 25
The first unit of occupational therapy aides to be sent to France arrived at Base Hospital No. 9, Chateauroux, August 14, 1918. No arrangements had been made for the reception of the unit, so that it was not possible to begin reconstruction work at once. For this reason, the members of the unit did nurses' aide work for about three weeks. At the end of this time the chief consultant in orthopedic surgery, American Expeditionary Forces, showed a personal interest in the work, and the aides were permitted to begin occupational therapy. They were first allowed to do ward work. The chief difficulty here lay in the lack of proper materials, as this unit had been sent to France without any equipment and without funds to carry on the work; however, the aides themselves supported it out of their own pockets for a few months until they were able to get the work on a self-supporting basis.
Each day the unit, comprising 1 head aide, 1 aide in charge of tin-shop work, 1 in charge of woodwork, and 4 ward workers, reported at 8.30 a. m., had until 9.30 to prepare work; went on duty in the wards at 9.30 and stayed until 11.30. They then worked until lunch time on preparation. At 1.30 p. m. they returned to the wards, stayed until 4, and then spent from 40 to 50 minutes on preparation. At 5 o 'clock they were released for the remainder of the day. They did not work on Sunday except when put on nurses' aide duty. The aides were allowed one afternoon each week free. That afternoon was largely spent in shopping for the patients, the town of Chateauroux offering very little in the way of amusement.
The first space allotted to the aides was the corner of a small room.25 This was for the storage of supplies and the preparation of work. At first the equipment consisted of one claw hammer and one old fancy French plane; the materials were pasteboard boxes and empty tin cans. The aides made their own looms, rakes for knitting, and in fact everything that was used, until one day it was discovered by them that there was a reconstruction shop at the station. The shop was fully equipped and helped to advance the work. Men were allowed to work in the shop, and they helped in a great many ways, planing boards and getting the rough material ready.
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The work had to be stopped when large convoys of patients arrived and the shop was used to house some of the patients for whom there was not room elsewhere in the hospital.25 The aides helped in caring for them.
Finally a medical officer was placed in charge of the reconstruction aides, and the patients were sent to a small shop which had been constructed in a corridor of the hospital. Here two types of work were done--tin work and woodwork. The patients at this time were what were termed hand cases-that is, they were men with gunshot wounds of the arm, forearm, or hand. Patients were sent to the shop as soon after operation as possible and were assigned some simple form of work which required practically no muscular effort, but enough motion to keep the small muscles in tone and to prevent the hand and arm from becoming stiff and atrophied.
The curative side of the work was started as soon as the men were able to work in the ward and then was continued in the small shop until they were able to go to the regular curative workshop, the work done in the small shop being of a very light kind.
Some time in October, 1918, the curative shop, formerly in charge of enlisted men, was turned over to the occupational therapy aides. In operating this shop the policy of the aides was always to give each patient a definite time at the prescribed work; the rest of the period of the day was given over to making up into some definite article the material upon which he had been working. Thus the interest of the man was kept up. The officer in charge would send all patients to the aides and then visit the patients twice a day to examine them and suggest the kind of work that was best for them to do.
In the American Expeditionary Forces hospitals there was no educational department, and the aides were directly under the orthopedic surgeons and worked under their direction. The curative work in Base Hospital No. 9 was the side that had most stress laid on it. In leg injuries it was a mere matter of occupational therapy and not of curative therapy. The leg cases in the shop were taken care of mostly by the use of the jig saw, lathe, and a grindstone. Two jig saws were used for ankle work, one which flexed the knee, and the lathe which acted both on the ankle and the knee. The arm and hand cases were put on light work-the use of pliers and hammer, wood carving, and general carpentry.
In right-arm amputation cases the left hand was trained from the very beginning by clamping a piece of work on a bed tray. First the patient would start with simple painting, when it was a question of merely holding the brush, and following a line. From that he advanced with the work so that when he was able to leave the bed he had acquired a degree of skill with his left hand. In a case of double amputation of the hand the man would first be taught to feed himself by means of a spoon and fork inserted in straps on his forearms. Then an appliance made of wire with a nob at the end was inserted in place of the eating utensils so he could use the typewriter. He also was taught to write by inserting a pencil in the strap.
When the patients made articles in the shops an arrangement was made with them to duplicate the articles. One of these they could keep; the other was for the shop. In this way the shop was kept supplied with articles which could
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be sold. If a patient became very ill or was going to leave the hospital before he could finish the second article he had the privilege of buying the first one at cost.
WARD WORK
KNITTING
Occupational therapy aides considered rake knitting the lowest form of work that an injured man could do, and they always tried at once to get a man to do some higher grade of work. However, this occupation proved particularly useful in empyema and heart cases and for men who had very low vitality or were weak. Nearly every patient knitted a cap for himself.
SIMPLE WEAVING
The weaving done was of the simplest type and most of it was done on handmade looms.
BLOCK PRINTING
Much of this work was done by bed patients. The men themselves cut the blocks of wood and made many postal cards of the scenes in the little town of Chateauroux-the small, low houses with the red roofs, the odd little donkey carts, and the usual town square with the church. In addition to the postal cards the patients printed material used for books, table covers, and children 's bibs. It was an interesting process and one that kept a man busy for quite a while, because cutting the block itself took considerable time. Block printing was used to a great extent in cases of wrist-drop, for it required the man to stand up and press with his fingers many times to each impression.25
BEAD WORK
Quantities of bead chains were made by the men. Bead chain making was used chiefly with cases of gunshot wound of the hand or arm. It required great concentration and coordination of the small muscles in the hand which so easily atrophy from disuse. If a man felt he could not use his hand or arm at all he was given bead work, which had to be watched so closely that soon he forgot he was using his hand and thus gained valuable exercise. It required no muscular effort and was not injurious to open wounds.
WOOD CARVING
Wood carving required very little muscular effort, especially if the work was clamped down. At the same time it required a variety of motions. The men made many trays, picture frames, boxes, book ends, bag handles, and pin trays.
LEATHER WORK
From leather the patients made traveling cases, musette bags, and, after the finding of some pieces of gray suede, some pocket books. The men in the shops made metal handles in order to complete the bags. This work was done by practically all patients and was especially helpful for wrist-drop, as a certain amount of pressure is necessary to do the work.
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EMBROIDERY
The men did a great deal of embroidering, and it proved that the more severely a man was injured the more he liked to embroider. Cross-stitching was given to men who had lost one arm. The work was clamped down with thumb tacks to a wooden frame or a bed tray. In this way a patient could get both sides of the work with one hand.
PLAQUES
Plaques were made containing little French scenes. The scene was outlined with a very fine carving tool and then it was painted in flat color. This kind of work became very popular, for all the men enjoyed painting.
TILES
Red French tiles were procured and decorated; they were then varnished and used for tea tiles.
WORSTED AND RAFFIA WORK ON CANVAS
Some very attractive bags were made of worsted and raffia on canvas.
BEADING
Sealing-wax beads were made in large quantities and used as ornaments for bags.
SHOP WORK
TIN WORK
In the beginning of occupational therapy work at Base Hospital No. 9 the only tin that could be secured was empty tin cans from the kitchen and commissary. From these empty tins the patients made dustpans, which could not be bought in France and of which the hospital had none. The patients also made ash trays, match holders, and all kinds of toys, such as automobiles and fire engines. Finally one of the patients succeeded in getting an old copper tank from a friend in the Aviation Corps. From this the patients made bag ends, desk sets, paper knives, etc. Rubber tubing was used as tires for automobiles, and whistles on steam engines were made of cartridge shells and the bulbs from atomizers.
BRASS WORK
A small piece of thin brass was procured and it was fashioned into brass flowers. The flowers were used as ornaments on metal bowls.
WOOD CARVING
Much wood carving was done; trays, book ends, penholders, workboxes, tool boxes, picture frames, desks, chairs, and cabinets were made. Such things as tool handles, electric lamp standards, candlesticks, and wooden tools were turned out on the lathe. Sets of toys and small theaters were made; they were cut out on the jig saw and then taken to the wards to be sandpapered and painted by patients confined to bed.
Seventy-five millimeter shells were made use of for candlesticks, vases, and ash trays; 1-pound shells for candlesticks, table bells, and dinner gongs;
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155-millimeter shells were fashioned into jardineres, large ash trays, the foundation for large, five-branch candlesticks, and handles of riding crops. Rifle bullets were used for the handles and tongues of bells. It was found that the hammering of the metal gave exercise to stiff wrists and required hours of work; in cases where flexion and extension were most needed this was assigned
Attractive bag ends were made from the shells which were flattened out and then hammered into shape from the wrong side.
A large part of the brass secured was used in making brass handles for wooden trays, handles for bags that were made in the wards, also brass blotter corners.
MACHINES
Certain machines in the curative shop were used for leg cases. These machines comprised an old wooden lathe and three foot jig saws, two of which exercised the ankle and one the knee. There was also a large grindstone which was made adjustable and used for knee work. On this the men sharpened the bread knives, meat knives, axes, etc., for the hospital.
The shop also contained a large adjustable hand drill which was used for shoulder and elbow cases, the handles being put up or down according to the degree of motion desired. There were hand drills that were used to improve the grip. In instances where men were unable to grip their hands were covered with gloves and then tied to the hand drills. In this way the muscles would work unconsciously in the beginning.
The emery wheel, which was ball-bearing and required very little exertion, was used for men who were very weak and had practically no grip.
Sawing, especially of firewood, was recommended in shoulder cases. The men never liked it very much as it was too much like real work; however, it was one of the best exercises that could be recommended.
AT SAVENAY HOSPITAL CENTER
The following account of occupational therapy, as conducted at the hospital center, Savenay, is taken from the history of that center: 24
When the aides arrived in Savenay they found the hospital extremely busy and needing assistance in many lines. The management of the making of plaster bandages was put in charge of one aide and the gauze-dressing room was given to another. For the first few weeks, until more nurses arrived, we did nurses' aide work for two hours in the morning, and, in emergency, helped make and apply splints and plaster bandages. For occupational therapy work we were given a corner of a room, a chest of tools, and later a box to put materials in. With materials salvaged from all departments of the center and a few things bought with our own money we started the work. From this small beginning the work increased until in January we had a small room for the aides to prepare work, and a large shop, formerly the post office of Base Hospital No. 8, where curative work was done.
The purpose of the work in occupation is twofold: (1) To divert the mind from suffering and occupy the patient and bring back a more normal attitude; (2) to work with physical disabilities in cooperation with the physical therapy aides, giving definite work for improving injured hands, stiff wrists, elbows, shoulders, ankles, or knees. The leg disabilities, of course, can only be treated in the shop.
The following crafts have been used in the wards or in the shop: Metal work in tin, lead, copper, brass, wire gauze, etching of shells, woodworking, rough carpentry, boxes and book racks, wood carving, chip carving and low relief, block printing, designing, cutting blocking paper and cloth, painting, water-color card, oil panels and types, lathing, rake knitting,
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macreum cross-stitch, embroidery, weaving, tapestry, basketry, reed, rush, raffia, leather work, tooled, painted, cut, toy making, metal and wood, bust work, string work, bookbinding. When in good running order 300 men on the average were kept busy every day.
FINANCING THE DEPARTMENT
* * * * * *
We, like all the other occupational aides, arrived in France minus all tools and materials except the few treasured ones each brought with her and minus the means of procuring them unless we bought them ourselves out of our salaries.
Added to that was the general lack of knowledge regarding us and our work. It was new and therefore unnecessary, perhaps even frivolous. Therefore, we were tucked away in odd corners-- some of them very odd-to sleep, and put to work on the wards, making beds, giving baths, and being generally useful.
Savenay was no exception. We were nurse's aides in the morning and reconstruction aides in the afternoon, leading a rather strenuous life. One aide was placed permanently in the surgical dressing room, one to oversee the making of plaster bandages, and a third as assistant in the department for putting on and adjusting casts and splints. The latter was relieved after three weeks and became assistant in the curative workshop. The other two were not so fortunate. After about a month the occupational work was recognized and the aides were allowed to devote all their time to it. The sale, given after two weeks' work, was quite remarkable, as most of the materials were salvaged. They were extremely pretty, too. There were candlesticks made by soldering the tin spool for adhesive plaster onto the cover of a plaster can and giving a cheerful coat of paint. There was a loving cup, shown by close inspection to be an inverted ether can on a candy-box cover. There were shopping bags of unusual wrapping paper, with rope handles; toys from cigar boxes and carved wood from Quaker Oatmeal boxes. Our "official rustler" was known all over the hospital, from the supply house to the dump. Every corner yielded a treasure. An empty can was a future rowboat; discarded floor tiles made wonderful palettes, and many a painting was made on them. Silver paper from chocolates was melted into lead soldiers, the end of a crutch became a lighthouse.
More men began to work and the need for money became desperate. We appealed to the American Red Cross for 250 francs, and with their usual generosity in emergency they made it 750.
That first real money loomed as big as a fortune. Only once afterwards did we feel so overwhelmingly wealthy, and that was after an auction which the American Red Cross managed for us and which netted about 2,000 francs.
A sink appeared and was installed by a plumber. One of the 17th Engineers, a private, helped us day after day and week after week till our path became easy. One after another he supplied every necessity, making many unusual tools-making even a soldering stove and irons. We never could have built up the shop in so short a time without him.
Well, there came a day when the one little room could hold us no longer, and we begged for more space and more money. It was a wonderful day when the colonel said he would see that we got both. He moved the post office and the fire warden, and through a hole in the partition of beaver board our excited eyes saw empty space, clear to the end of the barracks. It seemed as if we never could fill the space.
They built us more carpenter benches, more stools, put up more vises, and with the American Red Cross definitely behind us, paying whatever bills we were unable to meet (for the work was, of course, never self-supporting), we finally became well equipped with tools and well stocked with materials.
A fine assortment of whitewood and gumwood, requisitioned in the United States six months before and given to us, filled the last need. We could leave behind us the days of tin cans and Quaker Oat boxes and turn out work that was really fine and artistic-carving, block printing, embroidery, painting, work in wool and raffia, and beads and velvet.
Every week now the "official rustler" could go to Nantes and shop all day, bringing home hundreds of francs worth of paints, knives, needles, embroidery cottons for knitted bags, straw baskets to decorate in fact, everything that 300 people a day could use in,
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it seemed to her, as many different crafts. Her list usually contained one or two nerve-wearing articles, like asphaltum varnish or butter of antimony, or jig-saw blades, or a bullhead stake.
Toward the end of the work a carload of brass ammunition shells came, given us by the Red Cross, and a supply of copper and leather from the orthopedic departments.
I have said that we were not self-supporting. Of course, the first few months of any business are bound to be all expenditure and not return till the equipment equals the demand, and, of course, our work is not to make money-it is to help mentally and physically. Nevertheless, for the last few weeks we have needed practically no help, and if it were not for the number of very valuable articles which we are obliged to keep and send to the International Exhibition at Rome we should be well ahead financially.
At present we have nearly $200 in the treasury. We have never had but the one auction, lest we acquire the reputation of being commercial. Since then there have been sales as often as convenient, sometimes for officers and nurses, sometimes for the patients, and sometimes for everyone.
Our method is this: For every article a patient makes for himself he makes one of equal value for the shop. He pays nothing for his own, and we sell the other for enough, if possible, to cover the cost of both.
If he has only time to make one, he pays for the materials. If he wants both, and is going home, he pays a little more than the material costs. Other shops have used other methods. Some have paid the patients for their labor, some have shared the profits, some have allowed the patients to make and sell what they chose. But we felt that the exchange of money was rather to be avoided, considering the purpose for which we are here. And to give them materials and the use of the shop for nothing is demoralizing.
TATTING AND BEAD WORK
I was rather dubious about the place of tatting in a hospital for wounded soldiers, but when I found men on my ward who had use of their hands but who could not raise even their heads from the pillow I made the experiment. The first man I approached with a tatting machine was (I learned later) a plumber, steam fitter, and coal miner in civil life, and I would not have been surprised if he had told me politely but in unmistakable terms that he would see me further before he would learn tatting. I had one of the surprises which one comes to expect in ward work, the kind of surprise that encourages adventure in new paths. My plumber took kindly to the tatting shuttle, and during his stay on the ward made yards and yards of tatting which was used to finish bags and scarfs made by other men on a hand ward. I sometimes feared that he would tire of endless tatting for other men's bags, but I need not have worried. Several times I tried him on other work which I thought might prove more interesting, but each time he quietly returned to his shuttle at the first opportunity.
After this I tried tatting vwith several other men, and I have never seen a man refuse to learn.
I never had the opportunity to use tatting with a hand case, but I do not see why it might not be valuable as a wrist and hand movement in helping to gain flexibility. For bed patients it has the advantage of being light and easily handled, and while it causes no mental effort it carries with it the sense of having mastered something intricate and the satisfaction of using one's fingers in a deft fashion.
In my ward there was a Greco-American, a candy maker, named Sam. He told me he could make me a thousand pounds of candy if I wished, but he couldn't do the work the other patients in the ward were doing. Bead jobs attracted him, but he didn't want to make one. I threaded a loom and left beads, loom, and a pattern at his bedside, but he only laughed at me for expecting him to do the work. The loom stood around conspicuously untouched for a day. The following day I placed the loom on Sam's bed when he was out, but it was not until the day after that I heard from Sam. He asked me to thread him a needle and I knew the work had started. After Sam finished his first job he asked for beads for another, and it was while he was working on this that I heard him say, "It's funny what a fellow will do in the Army."
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COLOR WORK
The inborn love of color that is in almost everyone seems to make painting appeal to a surprisingly large number of patients. It offers an especial diversion to men having but one arm to use, and that a left one. The necessity to keep within certain bounds of the design, the constant study of tone values, and the control of the light brush make the occupation a thoughtful one.
Such men as miners and farmers, who have never had an opportunity to paint before, take pleasure in expressing themselves by certain assemblings of color.
The city boy paints bricks into his houses; the Italian arches the windows and doors; the country lad makes his into a barn; the Mexican sees his of pink and yellow plaster.
The choice of designs, of cards, tends toward figures and houses and scenes of natural healthy life. After the first card the patient begins to realize that skies are not always blue, that buildings are not always brown. He finds that, from the same design, he can produce a night scene or a day in spring. Then his imagination begins to play-eked out by his observation and social inheritance.
Nature means much more after he has tried to imitate her. The same colors that vibrate in the rainbow are echoed in a Coney Island crowd. A man who for some weeks has been unconsciously absorbing colors, masses, lines, and shapes will see new beauty in the details of his everyday life. The greatest value of the work is the patient's heightened perception.
J. A. was a Spanish miner from Socarro, Mexico. He had received no letters from his wife since arriving in France and carried a picture of his only little child that had died.
J.'s foot had been badly wounded, which obliged him to lie on his back for many weeks. Painting of a small card was the first occupation given to him, and pleased him so well he never wished to do anything else but paint. At Christmas time he did consent to make many Jacob's ladders for the ward tree, but resumed painting immediately afterwards and painted up to the day of his departure for the United States.
J. had an unerring sense of color and an innate feeling for design. He had never painted before, but stored within his mind was a wonderful collection of images and a childlike imagination. Simple designs were given to him, mere cutting of spaces; to them he added strange rich flowers and an embroidery of delicate leaves. Large block-printed cards he made into panels of beauty, with his personal touches of flower vases, fruit trees, window panes, and spotted dresses on the ladies. He liked to have a new thing to paint and smiled with delight at animal designs. The reconstruction aide on his ward was kept busy thinking up patterns. No matter how bizarre her ideas appeared to outsiders, J. always understood and interpreted them. One day he painted a delightful tile of an animal. One half of the tile represented the antelope, in his summer coat, grazing on yellow flowers; the other half showing him in his winter coat, feeding on scant herbage.
Another tile had many small animals on it. J. thoughtfully painted each one as he saw it, making a fox into a skunk, a kangaroo into a coyote. In one tile he put a Spanish vase, two pitchers and flowers, all in the Mexican glowing colors of red and yellow and orange.
He always changed a thing to better it, and constantly his brush would wander into new bypaths of fine color. He painted book ends, cards, tiles, tin boxes, candles, toys, wool bobbins, and never failed. He used water colors, oils, and enamel paints, never messed his palette nor spilt his colors, but painted in a fastidious manner, using a small pointed brush.
He said he intended to have a box of colors of his own to paint some pictures on the walls of his Mexican home.
K. termed himself the worst-tempered man in the American Expeditionary Forces, but that was a pose. He became interested in the bead chain belonging to the man in the next bed and wanted to make one also; so he was started on a chain of his own and worked faithfully, but rather ungraciously, until the chain was almost completed, when he lost the beads necessary to finish the job. I tried to impress on him the fact that he should have taken better care of the materials intrusted to him, but with little apparent effect. Later in the day the surgeon on the ward noticed K.'s woe-begone look and went over to cheer him up-laying his blue look to the pressure pads on two fractured femurs. He discovered
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however, K.'s gloom was due to the loss of the beads. Later the beads were found, and that was the first of three chains made by K. The third chain went along to be finished on the homeward trip.
B. was disconsolate. The doctors hurt him when they dressed his wounds and he was in a great big frame with all kinds of ropes around him (a Balkan frame). Life was very hard on him, and he did not care to talk to anyone.
H., in the next bed, was about as badly off, but he was making some knots around a. board, which he worked at everlastingly. It finally turned out that the knotted thing was to be a bag. H. was delighted with it and it had a lovely lining. H. also said it made him feel better to be moving his hands and thinking of something besides his troubles.
I persuaded B., after many rebuffs, also to try something, with the understanding that he could stop at any time he got tired. I gave him some weaving with pretty colored thread, and ever after B. was a changed man. He still was in pain and the doctor still hurt him, but the bag progressed. It had an attractive little border, and in his eyes was much prettier than H.'s.
B. worked with and for me for six months afterwards. He made many bags of wool and raffia. He did block printing, also knitting, and made a great variety of things. He enjoyed his work and did not like to be without something to occupy his mind while he was in the hospital.
M. was a carpenter. He was all roped in bed when I asked him if he wished to make something. He laughed and said he did not know what he could make. I suggested several things, which immediately aroused his interest, and the next day he was busily engaged with a knife and some soft pieces of wood, whittling, although flat on his back. It was very difficult to keep the shavings out of his neck, but he never complained. He used to sing as he worked, although the pain was very intense at times. He made letter cases at first. Later, when he could sit up a little, he made a windmill. He had two operations. after he did his first piece of work, but as soon as he could possibly do it he had a knife in his hand again, dodging his ropes, his bed covered with shavings, and a smile on his face. He used a fret saw also and constructed some of my best toys. He tried mechanical drawing and made some very good letters, also drawings of different joints. He wrote me a nice letter about the value of occupational therapy before he left for the United States.
B. came to us as an "up patient," having had his right hand amputated. He had been in the ward only two days when he followed me to my source of supplies and asked for some cord. I gave him a ball, and half an hour later he had his bed covered with twisted cords and tassels, or "pompoms," as he called them, of various sizes and designs. It was wonderful to see him work, using his stump, his mouth, and his left hand. The other patients were fascinated with his performance. He seemed to like the feel of wool especially, and when he had made draw strings and pompoms for everybody who could possibly need one I gave him some embroidery to be done in wool. He managed to hold the frame with his stump and showed great dexterity in the use of his left hand. He refused all assistance, threading all his needles and correcting his own mistakes. His work was perfectly done, and he added to my design some little touches that seemed characteristic of his Greek ancestry. He seemed delighted to handle material, and expects to return to his work as a maker of cords and tassels.
REFERENCES
(1) Letter from Maj. E. G. Brackett and Maj. J. E. Goldthwait to Major General Gorgas, August 14, 1917. Subject: Plan of organization and development of orthopedic department. On file, Record Room, S. G. O., 024-14 (Orthopedic Division).
(2) Report on orthopedic surgery and the war, by Maj. David Silver, M. R. C., November 30, 1917. On file, Historical Division, S. G. O.
(3) Memorandum from Maj. Edgar King, M. C., for Colonel Birmingham, September 13, 1917. On file, Record Room, S. G. O., 321.62
(4) General Order No. 41, General Headquarters, American ExpeditionaryForces, March 14, 1918 .
(5) Circular letter from chief surgeon, American Expeditionary Forces, to commanding officers of base hospitals, April 5, 1918. Subject: Treatment of amputation cases. On file, Record Room, S. G. O.
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(6) Letter from the Surgeon General of the Army to the chief surgeon, American Expeditionary Forces, France, May 13, 1918. Subject: A director of physical reconstruction for the American Overseas Force, and attached papers. On file, Record Room, S. G. O., 356 (General).
(7) Memorandum from the Surgeon General of the Army to the supply division, Surgeon General's Office, May 3, 1918. Subject: Approval of letter of appointment for reconstruction aides. On file, Historical Division, S. G. O.
(8) Memorandum from the commanding general, American Expeditionary Forces, to the chief surgeon, American Expeditionary Forces, November 4, 1918. Subject: Contract and oath of office taken by reconstruction aides. On file, A. G. O., World War Division, chief surgeon's files (231.238).
(9) Report from Julia C. Stimson, Resident Army Nurse Corps, director of nursing service. American Expeditionary Forces, to the Surgeon General, United States Army, May 31, 1919. Subject: Nursing activities, American Expeditionary Forces, on the Western Front, from May 8,1917, to May 31, 1919. On file, Historical Division, S. G. O.
(10) Report of the work of reconstruction aides, hospital center, Savenay, December 29, 1918. On file, Record Room, S. G. O., 231.238.
(11) Letter from Marguerite Sanderson, supervisor of reconstruction aides, American Expeditionary Forces, to Col. E. G. Brackett, February 8, 1919. On file, Record Room, S. G. O., 231 (Reconstruction aides, A. E. F., France), Y.
(12) Letter from division of orthopedic surgery to the Surgeon General, October 27, 1917. Subject: Weekly report, and attached papers. On file, Historical Division, S. G. O.
(13) Letter from Joel E. Goldthwait to Miss Sanderson, July 1, 1918. On file, Record Room, S. G. O., 231 (Reconstruction aides, A. E. F., France), Y.
(14) Report of the activities of the occupational therapy department, Base Hospital No. 9, American Expeditionary Forces, by Miss Susan Hills, head aide. On file, Historical Division, S. G. O.
(15) Cablegram from General Pershing, Headquarters American Expeditionary Forces, to The Adjutant General, Washington, August 1, 1918. On file, Record Room, S. G. O., 231 (reconstruction aides, A. E. F.), Y.
(16) Memorandum from Lieut. Col. David Silver, M. C., for Lieutenant Colonel King, August 16, 1918. Subject: Medical aides. On file, Historical Division, S. G. O.
(17) Memorandum from Frankwood E. Williams, major, M. C., United States Army, for Major Haggerty, August 20, 1918. On file, Record Room, S. G. O., 231 (Reconstruction aides, A. E. F.), Y.
(18) Memorandum from Lieut. Col. David Silver, M. C., for Lieutenant Colonel King and Lieutenant Colonel Hart, September 5, 1918. Subject: Aides, etc., for overseas orthopedic hospitals. On file, Record Room, S. G. O., 231 (Reconstruction aides, A. E. F.), Y.
(19) Letter from supervisor, reconstruction aides, American Expeditionary Forces, to chief surgeon, American Expeditionary Forces, March 15, 1919. Subject: Report of reconstruction for the month of February, 1919. On file, Record Room, S. G. O., 231.238.
(20) Letter from supervisor, reconstruction aides, American Expeditionary Forces, to chief surgeon, American Expeditionary Forces, May 1, 1919. Subject: Report of reconstruction aides for the month of April, 1919. On file, Record Room, S. G. O., 231.238.
(21) Letter from the supervisor, reconstruction aides, American Expeditionary Forces, to chief surgeon, American Expeditionary Forces, June 3, 1919. Subject: Last report of reconstruction aides for the month of May. On file, Record Room, S. G. O., 231.238.
(22) Letter from Marguerite Sanderson, supervisor, reconstruction aides, American Expeditionary Forces, to Col. Frank Billings, the Surgeon General's Office, Washington, D. C., May 23, 1919. On file, Record Room, S. G. O., 314.7-2 (A. E. F., France).
(23) Memorandum from Col. E. G. Brackett, M. C., for Colonel Darnall, October 22, 1918. On file, Record Room, S. G. O., Colonel Darnall.
(24) History of the Savenay hospital center, American Expeditionary Forces, undated, prepared under the direction of the commanding officer. On file, Historical Division, S. G. O.
(25) Report of the activities of the reconstruction service, Base Hospital No. 9, Chateauroux, by Miss Susan Hills, head aide. On file, Historical Division, S. G. O.
