AMEDD Corps History > Medical Specialist > Publication
Professional Services of Occupational Therapists, World War II
Major Wilma L. West, AMSC, USAR
Occupational therapy programs were developed in Army general, regional, station, and convalescent hospitals in the Zone of Interior during World War II and functioned under three different organizational patterns. The first pattern was that in which occupational therapy was placed either under the Surgical Service (Orthopedic Section) or the Neuropsychiatric Service. This arrangement depended upon which service generated the majority of the patient load to be treated in occupational therapy. Regardless of the placement of occupational therapy, all patients referred by any service received treatment.
The second type of organizational pattern under which occupational therapy functioned from late 1943 to 1946 was that wherein a chief of reconditioning was the administrative authority for its triad of sections--physical reconditioning, educational reconditioning, and occupational therapy. Although medical officers were assigned as chiefs of reconditioning services,1 the occupational therapists worked directly with and were professionally responsible to medical officers of other services who referred patients to them.2 Administratively, the chief of reconditioning was concerned with problems of staffing, workloads, and procurement of supplies and equipment. In one instance at Vaughan General Hospital, Hines, Ill., the Reconditioning Service operated as a section under the Chief of the Surgical Service and occupational therapy was placed under the Chief of the Orthopedic Section. In some hospitals, where the chief of the newly created Reconditioning Service had previously been responsible for the medical direction of physical therapy, this section continued under his professional supervision, for example, Lovell General Hospital, Ayer, Mass.3
The third pattern evolved in April 1946 with the establishment of the Physical Medicine Consultants Division, Surgeon General`s Office, and subsequent organization of this service in Army hospitals.4 Directed by a physiatrist, the physical medicine service comprised three professional
1This pattern of assignment continued until late 1945 when, in some instances, Medical Administrative Corps officers assumed this responsibility.
2Technical Manual (TM) 8-291, December 1944.
3Personal Communication, Sidney Licht, M.D., New Haven, Conn. Formerly Major, MC, AUS.
4War Department Circular No. 359, 28 Nov. 1946.
sections: Physical therapy, occupational therapy, and physical reconditioning.
The majority of Army hospitals established in the Zone of Interior during World War II were general hospitals in that they admitted and treated patients with a broad range of diseases and disabilities. In a few cases, exceptions to this rule were made, as in the designation of Mason General Hospital, Brentwood, Long Island, N.Y., and Darnall General Hospital, Danville, Ky., as centers organized solely for the treatment of psychiatric patients and of Old Farms Convalescent Hospital, Avon, Conn., as a center for the blind. The largest pattern of organization of general hospitals was characterized by the assignment of one or more specialties (neurosurgical, orthopedic, or psychiatric) while still retaining the general designation of each through the breadth of diagnostic conditions referred.
The occupational therapy section and the number of occupational therapy subsections established in each Army general hospital were determined by the nature of the caseload of the particular hospital in which they were organized. With the knowledge of a hospital`s designation of specialty services, the occupational therapy program in any Army general hospital during the war period can be inferred from this material.
Regional and Station Hospitals
Severe personnel shortages precluded assignment of occupational therapists to regional and station hospitals until October 1945 and February 1946, respectively.5 For this reason, there were no officially recognized or professionally staffed occupational therapy sections in these hospitals. However, this did not mean that some programs called occupational therapy did not develop. A number of these were well deserving of the name and of great value in the rehabilitation of the patient.
An indication of the types of occupational therapy carried out at regional and station hospitals can be seen in the following excerpts from accounts of two of these programs. The first account concerns the program established at the Harmony Church Annex, Fort Benning Regional Hospital, Ga.6
The plan of the whole program was to relieve the psychological malady of "hospitalitis" and to prepare the men physically and mentally for return to their own units in the quickest possible time.
In addition to regular calisthenic periods, physical exercise in the nature of
5(1) Army Service Forces Circular No. 380, 9 Oct. 1945. (2) Army Service Forces Circular No. 38, 14 Feb. 1946.
6The History of Military Training Within the Reconditioning Program, Army Service Forces Regional Hospital, Fort Benning, Ga., June 1945, p. 2.
occupational therapy was encouraged by the special atmosphere surrounding this Hospital Annex. Among the projects constructed and worked on by trainees were a chicken house and a garden which contributed not only to the health of the men participating in the construction and working in these activities, but to the menus at the Annex mess hall. In addition, a carpenter shop was operated by the trainees and equipment for the operation of the Annex, as well as visual aids to be used in the instructional program, were made in this shop by the trainees.
Another occupational therapy program was organized at a station hospital despite the initial lack of support of the commanding officer.7 To begin this program, the supervising psychiatrist levied a head tax of $5 on each member of his staff. This money was used for the purchase of supplies which were then sold to patients at cost to maintain a sort of revolving fund. However, as the program progressed, its work drew the attention of the commanding officer and soon received both his support and financial aid from the hospital fund.
The rehabilitation programs of convalescent hospitals were designed to return men to active duty quickly and to reduce the patient load in general hospitals. Occupational therapy programs in convalescent hospitals often differed from those found in general hospitals, primarily because of the differences in the degree of illness or incapacity found among patients. Patients who were sent to convalescent hospitals were classified as follows:8
a. Ambulatory convalescent medical patients not requiring general hospital care, except rheumatic fever, asthma, arthritis, tropical disease, and hepatitis cases with jaundice, which should remain in the general hospital.
b. Patients with psychoneurosis not requiring general hospital care or intensive individual treatment who * * * in the opinion of the attending medical officer will be restored to a general duty status through treatment offered at the convalescent hospital
- * * *.
c. Ambulatory convalescent surgical patients not requiring the definitive care of a general hospital.
Based on the recommendations in the circular which established the foregoing classifications, patients were divided into convalescent regiments in accordance with the three admittance groups already listed. This semi-military arrangement was an organizational tool of therapeutic value in conditioning the patient for his return to active-duty status with a Regular Army unit.
Methods and techniques of occupational therapy varied from hospital to hospital and were further influenced by the nature of the patient`s illness or disability. However, most programs had a number of common factors. First, it was established that all treatment was to be of a functional nature: These men were no longer confined to bed or the ward and were not in need of diversional craft activity. In many cases, this
7Oral description to the author by Lt. Col. Robert J. Bernucci, MC.
8Army Service Forces Circular No. 445, 14 Dec. 1945.
functional therapy was a continuation of treatment originally begun in other hospitals. Second, the direction of all occupational therapy was to rest with the medical officer who was charged with the responsibility of seeing that each patient received the specific treatment his case required.
Not all patients in any category were referred to occupational therapy, nor were those who were referred always retained in the program for their full stay in the convalescent hospital. For patients with limitations in range of motion, treatment was continued as long as further improvement was likely. For neuropsychiatric patients, occupational therapy was often a needed link in the chain of transition to the full program of the convalescent hospital.
Specialized Treatment Programs
In working with the amputee,9 it was necessary to bear in mind that both physical and psychic trauma were present. In many cases, the loss of an extremity did not produce as great a handicap to the individual as did his reaction to his loss. For this reason, retraining began soon after removal of the extremity and continued until the patient was ready for discharge. It was important to help the patient realize that the concern of all who were treating him was as great for his rehabilitation and speedy adjustment to a prosthesis as for the successful result of the operation itself.
There is neither space nor need to discuss the various types of prostheses available for patients. Generally speaking, it was found that any prosthesis was more efficient if kept simple. With the more complicated mechanisms, more time was required for adjustment and it was often difficult to keep the prosthesis in good repair. Though many changes in design and fabrication of both upper and lower extremity appliances were made throughout the war period, prostheses for the lower extremities were more satisfactory than those for the upper extremities. With the exception of disarticulation of the hip, a leg amputee was generally able to walk again provided he had opportunity for retraining and sufficient practice. In amputation of an arm above the elbow, however, no prosthesis was found which could adequately compensate for the loss of natural movement of the elbow, pronation and supination of the forearm, or the intricate capabilities of the hand and fingers.
Occupational therapy for lower extremity amputees.-Occupational therapy, usually of a diversional nature in the early stages of treatment of the lower extremity amputee, began as soon as the patient was free from fever following the operation. In accordance with physical and psychological recovery, both bed and wheelchair activities were
9Willard, Helen S., and Spackman, Clare S. (editors): Occupational Therapy. 1st edition. Philadelphia: J. B. Lippincott Co., 1947.
steadily graded in difficulty so as to provide some feeling of accomplishment for the patient. This served to stimulate interest and provide the incentive necessary in the more advanced stages of training. However, it was important that, during this early stage, the patient never be given tasks he could not accomplish.
In later stages of treatment of the leg amputee, occupational therapy had two major functions. One of these was supplementing physical therapy in prosthetic training and use. This was accomplished by operation of such equipment as four-treadle floor looms, the bicycle jigsaw, and the foot-operated printing press (fig. 76). Operation of these types of equipment required use of the prosthesis but did not add the problems of balance and weight bearing which were more intensively undertaken only after the patient had become accustomed to both the fit and function of his new appliance. The second function of occupational therapy in later phases of training for the lower extremity amputee was prevocational training. As soon as the patient had learned to use his prosthesis with a minimum of dexterity, effort was made to acquaint him with the various types of work he would ultimately be able to do or to encourage him to consider retraining for his old job. The purpose of this phase of occupational therapy was to provide the patient with information about vocational possibilities at the earliest possible stage.
Occupational therapy for upper extremity amputees.-Occupational therapy for the arm amputee was not restricted to those activities which could be done with a single hand. With the use of some types of vise or clamp, the range of activities available to these patients could be greatly increased.
The upper extremity amputee was encouraged to write, and care was taken to inform the below-elbow amputee that he would be able to write with his prosthesis and that a shift of handedness would not be necessary. Usually, the Palmer method of forming letters by motion of the arm rather than with the fingers was taught. In the patient whose dominant arm had been amputated above the elbow, it was necessary to encourage development of writing skill in the opposite hand. Inasmuch as prostheses for the upper extremity amputee were at this time not constructed to perform all necessary functions, the amputee was forced to accomplish many of his activities with the remaining hand.
Retraining of arm amputees followed one of three general approaches, largely depending on the site of amputation. First, if feasible, as in amputation at the middle or lower third of the forearm, the patient was encouraged to use the prosthesis as he would the normal limb. Secondly, as in amputation above the elbow, it was usually necessary to train the individual to use his prosthesis as an aid to the remaining hand. Finally, for high upper-arm amputations, for shoulder disarticulations and in cases of limited function in adjacent joints, emphasis was placed on increasing skill in the remaining hand. In
FIGURE 76-Preprosthetic training, lower extremity amputee. A. Use of bicycle saw to increase range and strength of right knee and hip. Extension cuff attaches to bicycle pedal.
all cases, the success of the training procedures was largely determined by the attitude of the patient and the occupational therapist had a vital role in seeing that this attitude was a healthy one.
It was found that the utility hook was the only functional terminal device on the upper extremity prosthesis. Its advantages lay in the
FIGURE 76-Continued. B. Use of potter`s wheel to increase strength of left leg. Extension cuff with rubber tip to improve purchase on flywheel.
ability to perform with it many tasks that could not be completed with the cosmetic hand. When a patient had been without an arm for a long time, it was often found necessary to prove the value of the prosthesis. This was especially true when great dexterity of one hand
had been developed. A series of activities which demonstrated the added value of the prosthesis proved helpful for this purpose.
After the patient had been fitted with a prosthesis, training in its use began immediately and continued until he was adjusted to it. Intensive training at this early stage provided the surest method of determining what adjustments needed to be made in the fit of the prosthesis. Care was taken to allow time for the skin of the patient to adjust to the necessary friction caused by the bucket which enveloped the stump and the straps which held the prosthesis in place and operated its moving parts.
The occupational therapy retraining program for upper extremity amputees generally consisted of two parts (fig. 77). One part was concentrated on activities which incorporated the use of various tools and materials in order to provide practice needed to restore ability and confidence required for subsequent vocational training. The other part of retraining provided duplication of all routine activities of the day. These included personal hygiene and care, eating, office work, and recreation. An attempt was made to provide areas adjacent to occupational therapy facilities for active indoor and outdoor sports and for driver`s training.
Various types of achievement records were helpful in the development of effective occupational therapy programs. One that was most useful contained a short list of items related to the position of the arm and the size and weight of the object to be manipulated in that position. This list was helpful in testing the fit and adjustment of the prosthesis and indicated, because of inability to use the prosthesis in certain positions, where it might be necessary to compensate for activities the patient was unable to perform.
A different type of record not only listed the activities used routinely in daily living, but provided a checklist for rating accomplishments. This had the advantage of providing initiative for self-help on the part of the patient and gave him some idea of the range of activities he could do by himself. A typical list of such activities included bathing, shaving, eating, drinking, dressing, writing, typing, and so forth.
Three Army general hospitals--Deshon General Hospital, Butler, Pa.,10 Hoff General Hospital, Santa Barbara, Calif., and Borden General Hospital, Chickasha, Okla.--were named specialty centers for treatment of the deaf, and, by 1946, approximately 9,500 patients had received the benefits of the Army`s aural rehabilitation program.
The occupational therapy program for the deafened consisted of three
10Walter Reed General Hospital was originally designated a specialized center for treatment of the deaf, but in November 1943, Deshon General Hospital was designated in its place. (Medical Department, United States Army. Surgery in World War II. Ophthalmology and Otolaryngology. Washington: U.S. Government Printing Office, 1957, p. 449.)
FIGURE 77-Retraining for the upper extremity amputee. A. Working with tools to increase ability to operate prosthesis.
major phases.11 These phases included the rechanneling and retraining of undesirable or abnormal social and psychological traits, the adjustment of the patient to various noises and distractions, and assistance in developing proficiency in lipreading, the use of hearing aids, or both. Though it might seem to be suggested, not all patients suffered from psychological or social disturbances as a result of hearing loss. When such was the case, however, prescription for the patient included treatment desired and special precautions to be noted.
In order to determine his interest and capabilities, each patient
11Brown, N. F.: Occupational Therapy in Aural Rehabilitation. Am. J. Occup. Therapy 1: 293-295, October 1947.
FIGURE 77-Continued. C. Practicing grasp and release of multishaped pieces while playing checkers. (U.S. Army photograph.)
was personally interviewed before treatment. With his medical and personal history at hand, the occupational therapist determined the activity the patient was to undertake.
Prime attention was paid to character changes which developed in the patient. In order to develop the firm personal relationship necessary for treatment of specific antisocial or depressed patients, one occupational therapist worked with a patient exclusively. Furthermore, the patient was allowed to work alone until he was prepared to join in group activities.
A second aim of therapy was to increase the patient`s power of concentration.
Since hearing losses corrected by mechanical aids usually involved some distortions of sound, the patient had to learn to block out extraneous sounds from his conscious perception. In order to accomplish this, activity was graded according to distracting noise. For example, the patient would usually begin occupational therapy by participating in some quiet type of activity such as leatherwork or carving; outdoor work such as gardening was also used during the early stages of activities. As the patient gained an ability to concentrate without fatigue, he was gradually advanced to more distracting activities such as metalwork or woodworking with power tools. Patients with hearing aids were discouraged from turning their aids off when the noise level became distracting.
Vocal communication and lipreading were encouraged, and written notes were used only when absolutely necessary, as for a newly admitted patient. Effort was made to create a normal environment for development of everyday communication skills.
General medical and surgical conditions
General medical and surgical cases made up a relatively small percentage of the total number of patients referred to occupational therapy in Army hospitals during the war years. This was because the majority of illnesses and disabilities were such as to place patients in specialty categories. However, the occupational therapy programs of most Army hospitals included some patients with cardiac pathology, arthritis, diabetes mellitus, thyroidism, kidney disturbances, communicable diseases, dermatologic conditions, hematologic disturbances, and gastrointestinal disorders.
In large measure, the occupational therapy program for these patients was psychological and supportive. Among its most important aims were aiding adjustment to hospitalization during necessary medical treatment, including promotion of relaxation and making bed rest acceptable; aiding in resocialization, as in the case of certain dermatologic conditions; and providing avocational interests to aid convalescence. Where indicated, therapeutic media were selected to provide the specific means of controlling and grading activity as prescribed by the physician in accordance with individual patient needs (fig. 78). Here, objectives included maintaining or increasing range of motion (arthritic patients), promoting relaxation (patients in acute stages of heart disease), or increasing physical tolerance (cardiac patients in convalescent stage).
Treatment for cardiac patients generally began on the ward and progressed according to improvement in the patient`s condition. Occupational therapy doctrine was carefully outlined, as follows:12
Treatment. The principle of occupational therapy for cardiac disorders is graded activity.
(1) Activity in bed involving light finger motions only.
(2) Activity in bed involving forearm and upper arm motions.
(3) Ambulatory activity, preferably off the ward.
(1) Controlled activity must be planned to combat the restlessness caused by anxiety and boredom.
(2) Correct posture during activity should be maintained.
Occupational therapy was frequently specifically prescribed for arthritic patients. Typical objectives of treatment included increasing muscle strength, extending range of joint motion, and stretching or preventing adhesions.
For other medical and surgical patients, occupational therapy was developed as prescribed by the medical officers in charge. In general,
12See footnote 2, p. 287.
FIGURE 78-Activities requiring minimal exertion for general medical and surgical patients. (Top) Clay modeling. (Bottom) Radio repairing.
it first attempted to make the patient`s stay in the hospital more acceptable through various forms of supportive therapy on the wards or in the clinics. When there could be a medical improvement brought about by supervised activity, a functional program was developed in accordance with the patient`s needs.
Inasmuch as the utilization and value of occupational therapy in the treatment of hand injuries are documented so extensively in "Hand Surgery," a volume in the professional series of the official history of the Medical Department of the U.S. Army in World War II,13 the reader is referred to that source of information for coverage of this subject.
Three major groupings of patients were common among soldiers who incurred brain injuries in the war. The first group consisted of patients with motor and sensory disturbances but no essential impairment of mental function. The rehabilitation program for these patients consisted primarily of physical therapy, vocational guidance, and the retraining necessary to condition them to their remaining defects. Occupational therapy was prescribed for increased muscle control and power, especially of the intrinsic muscles of the hand, and frequently included speech and writing lessons.
Disturbances of general physical and mental capacities were characteristic of a second major grouping of the brain-damaged patients. They were abnormally sensitive and irritable, easily fatigued, and usually demonstrated impairment of higher mental functions such as attention, interest, and capacity for abstraction. Although educational reconditioning, physical therapy, and occupational therapy were utilized in an attempt to aid in improving both physical and mental capacities, treatment of patients in this group was seldom successful.
In the third group, more or less circumscribed aphasic defects were prominent. Between 700 and 1,000 aphasic patients were admitted to Army hospitals during World War II, and in accordance with policy, they remained under Army hospital jurisdiction until it was evident that they had received maximum benefit from therapy. Criteria for determination of retention included:
1. The rate of improvement and the likelihood of further substantial improvement as a result of direct training.
2. The amount of intellectual impairment.
3. The patient`s previous educational attainment.
4. The patient`s pre-Army vocation.
13Medical Department, United States Army. Surgery in World War II. Hand Surgery. Washington: U.S. Government Printing Office, 1955.
5. The type of dependency and disposition available: self, relatives, Veterans` Administration, or transfer to another Army hospital.14
Underlying principles for treatment of the patient with aphasia were also outlined, as follows:
1. Language training, including reading and writing as well as speech, should be coordinated with general sensory and motor retraining because language training is but one aspect of a total rehabilitation program. Very often the aphasic patient has undergone modifications of personality as a sequel to brain injury, and these modifications must be considered in determining therapeutic approaches. Emphasis in therapy should be placed on the assets and the maximum use made of the unimpaired or relatively unimpaired sensory and motor avenues.
2. It is important to assist the patient as early as possible in developing a basic functional vocabulary that will meet his everyday environmental requirements, as well as his vocational and social needs.
3. It is frequently valuable to permit the direction of organized therapy to depart from and follow the patient`s spontaneous development of language.
4. Language training should be based on the past experiences of the patient. It is desirable where possible for the content of the training sessions to include material pertinent to the patient`s hobbies, occupational and school interests, and cultural background.
5. The aphasic`s condition is not static. Inconsistency in performance is characteristic. At no time should improvement be taken for granted and patients must be given repeated opportunity to practice what they have learned and encouraged to utilize this material in real situations. Efforts must always be made to build up the patient`s confidence in himself and each therapeutic session should end with a feeling of accomplishment on the part of the patient. At all costs, discouragement should be avoided.
The actual therapeutic techniques were based on the results of the Halstead Test (functional orientation) and the Head Chesher Test. Treatment for disorientation as to time, space, size, distance, objects, and the patient`s own body as indicated by the Halstead Test consisted of daily drill in various activities demanding the proper orientation. Typing was found to be of value in teaching eye-hand coordination and in the improvement of spelling.
Group work in occupational therapy supplemented training accomplished in speech programs, and, in many cases, the programs were coordinated so that each could reinforce the learning accomplished in the other. All skills that were re-learned after the injury had to be practiced regularly to establish patterns of use and communication. Since good adjustment was a necessity in treating the patient with aphasia, effort was made to select tasks of interest to him. Also, as approximately 50 percent of those patients had hemiplegia, specific treatment was given in functional occupational therapy for these conditions as well.
Psychiatric occupational therapy services were organized in general,
14See footnote 9, p. 290.
convalescent, regional, and station hospitals. In each, a separate program was developed to meet the needs of the psychiatric patient.
Both closed- and open-ward programs were conducted in most Army general hospitals which had been designated as specialty centers for the treatment of psychiatric patients. Ward assignment was determined by the degree of illness evident in the individual patient.
Closed-ward programs.-A review of the annual reports of the hospitals having psychiatric facilities indicated that nearly all of them maintained some type of occupational therapy program for closed-ward patients. It was not unusual to find the closed-ward occupational therapy program given priority over other occupational therapy programs in terms of personnel, facilities, supplies, and equipment.
The most frequent diagnoses among closed-ward patients were schizophrenia, manic depressive psychosis, and acute psychoneuroses. In smaller numbers were paranoiacs, psychopathic personalities, mental defectives, psychosomatic disorders, and hysterical paralyses.
In some instances, occupational therapy was individually prescribed by the psychiatrist. Since psychiatry was still more descriptive than dynamic, these prescriptions usually stated little more than a diagnosis or major symptomatology and, if indicated, precautions relating to suicidal or homicidal tendencies. For the most part, the occupational therapist was given only a name and a clinical label or impression.
In accordance with the doctrine in technical manuals on occupational therapy and psychiatry, some of the treatment principles used were:15
1. For the schizophrenic patient:
a. Group activities to stimulate identification and interaction (publishing a hospital newspaper).
b. Creative art for nonverbal expression (painting or music).
c. "Dirty" activities of the untidy and the "smearers" (clay modeling and finger painting).
2. For the manic patient:
a. Activities requiring gross physical motions (carpentry).
b. Work situations permitting freedom of movement without close contact (gardening).
3. For the depressed patient:
a. Simple, readily achieved, time-limited tasks (based on previous hobby interests).
b. Menial (janitorial) work for guilt atonement.
4. For the paranoid patient:
a. Individual work assignments involving responsibility (clerical).
b. Jobs permitting a high standard of performance (selected in accordance with individual interests and abilities).
5. For the psychoneurotic patient--activities selected to counteract symptoms:
a. Physically demanding for the tense and restless.
15Solomon, Harry C., and Yakovlev, Paul I. (editors): Manual of Military Neuropsychiatry. Philadelphia: W. B. Saunders Co., 1945, pp. 606-607.
b. Requiring skill and concentration for the introverted and anxious.
c. Doing something for others (family or hospital) for the discouraged and depressed.
6. For the psychopathic patient--strictly supervised and sternly disciplined activities (industrial assignments).
7. For the mental defective patient--short-term tasks within their abilities to accomplish (with constant supervision, protection from ridicule, tolerance of error, and liberal praise for achievement).
8. For the patients with psychosomatic disorders--absorbing, detailed tasks to overcome concern with complaints and motivate patient toward normal interests and recovery.
9. For the patients with neurological problems--activities incorporating principles of physical treatment with maximum psychological motivation.
Since these were programs for seriously disturbed individuals, it was necessary to have fairly close supervision of all work. However, even when this supervision was provided there was considerable freedom in the use of all available facilities by all patients.
Efforts were made to correlate the observations and experiences of the therapists with the total program of the patient. This most frequently took the form of weekly reports to the medical officer, but another occasionally used method was that of the occupational therapist`s participation in regular staff conferences (fig. 79).
Open-ward programs.-Since open-ward patients were far more numerous than closed-ward patients, there were a greater number of them referred to occupational therapy; in some instances, this ratio was as large as 3 to 1. For those hospitals reporting statistics, attendance averaged 243 patients per month in 1945.
The four basic types of military neuroses and the doctrine used in occupational therapy for treatment of these patients were:16
1. Neuroses occurring before exposure to military life. Patients such as these were often disciplinary problems and, in most cases, since prognosis was poor, they were eventually discharged from the service.
In treating these patients, it was most common to make use of the industrial therapy program. It was felt that any project of a constructive nature, particularly if of benefit to the hospital, would be advisable.
2. Neuroses caused by restrictions of military life. In these patients, prognosis was good if adjustment could be made. These patients were rarely disciplinary problems and were frequently returned to duty.
Symptoms in this group often included tenseness, loss of appetite, inability to sleep, and depression. Occupational therapists usually concentrated on shopwork activities, which would provide a physical release
16Stakel, F.: Occupational Therapy for Neuropsychiatric Patients in an Army General Hospital. Occup. Therapy 23: 225-229, October 1944.
FIGURE 79-Staff conference, neuropsychiatric occupational therapy section, Battey General Hospital, Rome, Ga.
of energy to lessen tension and anxiety as well as to induce sleep and rebuild appetites.
3. Neuroses caused by foreign service. With the precipitating factors of homesickness and poor living conditions, these patients, like the first group, had poor prognoses and were usually discharged from the service.
Although not normally antisocial in behavior, these patients needed socialization and constructive activity and thus were often worked into the industrial therapy program.
4. True war neuroses caused by actual combat. These patients were largely men who were well adjusted in civilian life and usually had a good prognosis for recovery.
Occupational therapy frequently had good results with this group. Projects such as fly tying with a high-interest level and requiring only a short-work period were often effective. The patient was urged to talk of his experiences if he felt inclined to do so and often depicted his battle experience or war dreams in various art forms. In cases where the patient was able to express himself in such a manner, occupational therapy was decidedly beneficial.
Comparing the open- and closed-ward programs, three major differences may be noted. First, many open-ward patients were assigned
to various hospital services and departments in order to provide both constructive activity and contact with normal individuals. Second, there was normally a much larger range of activities available to the patient in an open ward; these often included facilities for photography, printing, gardening, and the use of power tools. Finally, one additional type of activity--industrial therapy--was extensively used in the treatment of open-ward patients. The classical version of this type of program involved the assignment of neuropsychiatric patients to selected departments and services concerned with the maintenance and operation of the hospital (fig. 80). A variation of industrial therapy, often called commercial or work therapy, involved various experimental programs employing patients on subcontract work projects for war industries. Generally, however, the latter was not extensively used for neuropsychiatric patients.17
Specialty programs.--Two Army general hospitals in the Zone of Interior were devoted entirely to the treatment of psychiatric patients. Mason General Hospital housed more than 3,000 patients at its peakload and Darnall General Hospital provided for approximately 1,000.
At Mason General Hospital, older restrictive theories of treatment were at times reversed. One major advance was in the demonstration that neuropsychiatric patients did not have to be restricted in the use of tools appropriate to the task they were performing. So long as adequate supervision was provided and tools were periodically checked, it was discovered that no limitation was necessary. This free use of tools created a more relaxed environment and many of the evils of a restricted situation were avoided.
The occupational therapists also made an effort to concentrate on the use of self in treatment. Every attempt was made to assign the patient to the occupational therapist whose personality was best suited to working with him. Here, a conscious emphasis was placed on contact with a well person. Due to the large patient census at Mason General Hospital, the occupational therapist also played an important part in providing information about individual patients at staff conferences.
Finally, the chief occupational therapist, Miss Dagny Hoff, took two steps in administrative reorganization which resulted in recognition of occupational therapy as more of a therapeutic agent than a program concerned only with keeping patients busy. The first of these was removal of the industrial therapy program from her department on grounds that, although the use of this activity was obvious, its therapy was dubious. Secondly, occupational therapy was transferred from the jurisdiction of reconditioning to that of the chief of neuropsychiatry to permit its more definitive use in treatment of the acutely ill psychiatric patient.18
17For a more detailed discussion of industrial therapy as used with other diagnostic conditions and for its further differentiation from commercial work therapy, see sections in this chapter entitled "Industrial Therapy" and "Work Therapy."
18Personal correspondence with the author.
FIGURE 80-Industrial therapy providing socialization and constructive activity which benefits both the hospital and the patients. (Top) Mixing concrete. (Bottom) Setting a natural stone walk. (U.S. Army photographs.)
Patients with various types of orthopedic conditions formed one of the larger groups in Zone of Interior hospitals during World War II. Fractures of the extremities constituted the major group of orthopedic conditions referred to occupational therapy and equaled about one-half the total number in the only other larger group, neuropsychiatric. It was not, however, uncommon to have multiple disabilities in one patient, the most frequent combination with fracture being peripheral nerve involvement. Burns were another complication and, although far smaller in number, constituted a serious orthopedic treatment problem for occupational therapists in several Army hospitals. Internal derangements of the knee and dislocations and instabilities of the shoulder were also common, as were orthopedic conditions related to back and foot injuries. Many of the disabilities in these latter categories resulted from training accidents caused by sprains, poor physical condition, or lack of application of good body mechanics.
By April 1945, 35 general hospitals had been designated as orthopedic specialty centers19 and various others had a limited number of patients in this category. Each specialty center devised an extensive occupational therapy program especially for treatment of orthopedic injuries. As was customary, this program was both functional and diversional.
Since diversional occupational therapy varied little in its application to the treatment of different types of disabilities, the activities used for orthopedic patients were of the usual craft and hobby variety. Much of this program was carried out by volunteer members of the Arts and Skills Corps of the American National Red Cross, under the supervision of the chief occupational therapist.
The functional programs were specialized and extensive. At Vaughan General Hospital, occupational therapy was under the direct supervision of the chief of the orthopedic section. This type of organization allowed for close coordination of all aspects of treatment. The program at this hospital was described in the annual report for 1945, as follows:
The scope of the program is three-fold. It includes an orthopedic treatment program, diversional program, and a prevocational program. The purpose of Occupational Therapy in the field of orthopedics is to give medically prescribed treatment and exercise to an injured part through some purposeful activity. * * * Patients come by prescription of the Ward Officer, and the therapists supervise and guide activity programs selected to meet the patient`s physical and psychological needs. Each patient is given a scientifically graded activity program which is gradually increased until he has regained normal or near normal function of the injured part (fig. 81).
Vaughan General Hospital was credited with having a well-developed occupational therapy program and one of the most extensive in any Army hospital during the war years. In 1945, 981,750 treatments
19Smith, Clarence McKittrick: The Medical Department: Hospitalization and Evacuation, Zone of Interior. United States Army in World War II. The Technical Services. Washington: U.S. Government Printing Office, 1956, pp. 304-313.
FIGURE 81-Graded activity program for orthopedic patient with shoulder disability. A. While patient is in cast and confined to the ward, occupational therapy is prescribed for maintenance of strength and range of motion in right hand. B. Cast removed for treatment period in clinic. To eliminate pull of gravity and to protect weakened shoulder musculature, right extremity is supported by sling suspension device.
FIGURE 81-Continued. C. Final stage of graded program. Patient is exercising extremity against gravity and with added resistance of weights attached to lever of printing press.
were reported.20 This program was also enhanced by the development of special equipment for use in orthopedic cases. Among the originally designed or adapted pieces of equipment used at that hospital during World War II are mentioned in the 1945 report, as follows:
1. Extension block on coping saw for assistive motion.
2. Specially devised handles on table looms to force wrist motion.
3. Extension handles on looms to increase flexion of shoulders.
4. Large-grip sand blocks to increase spread of the palmar fascia following burn contractures.
5. Extension on lever of foot-operated printing press to increase range of hip and knee motion and strengthen quadriceps.
20It should here be noted, however, that there was little uniformity in statistical reporting systems used by occupational therapists in Army hospitals. While some reported only numbers of patients referred, others counted each visit as a treatment and still others computed treatments in terms of various time units. Thus, a patient having occupational therapy for 2 hours daily might in one instance be recorded as having 1 treatment; in another, as receiving 4 treatments of 30 minutes each. It is not known which system was in operation at Vaughan General Hospital for the period covered by the quoted figure.
Regardless of the diagnoses of patients with orthopedic conditions, the occupational therapist`s treatment problem concerned neuromuscular or musculoskeletal disabilities and, for such conditions, the then current treatment doctrine21 specified observance of the following basic principles: graded force for joint limitation and graded resistance for muscle weakness. Based on an analysis of both patient interests and the therapeutic exercise potential of available media, activities were selected to provide for each individual`s psychological and physical needs. Wherever possible, bilateral activities were used. These had the advantage of employing both extremities, on an alternating basis, in identical motions, thus enabling the patient to imitate, with the affected member, the action of the uninjured member and to profit by a normal pattern of work and rest periods for the affected arm or leg as the case might be.
Often, in the early stages of treatment, it was necessary to build up tool handles for hands with limited grasp and to use such assistive devices as suspension slings to eliminate the pull of gravity in arm and shoulder disabilities. Later, as range of joint motion or degree of muscle power increased, tool handles were decreased in size, supporting slings removed, and various techniques utilized for requiring motion not only against gravity but with resistance added. At first, such resistance was that provided by the tools and materials used; subsequently, springs and weights were added to equipment such as looms, bicycle saws, and printing presses to increase the patient`s strength as indicated. For increase in joint motion, use of various attachments to handles and pedals required effort beyond the existing range (fig. 82), as did changing the position of the patient in relation to the position of the work--high, low, or off center--as indicated for specific joint motions. The repetitive nature of the exercise also permitted the upgrading of activities in accordance with increasing function.
Peripheral nerve injuries
Up to September 1944, 26 Army general hospitals had been designated neurosurgical centers; however, a reorganization at that time centered the programs in 19 of these.22 Each developed its own occupational therapy program for the treatment of peripheral nerve injuries.
The cases referred to occupational therapy were of four major types: involvements of the median, radial, ulnar, and peroneal nerves. Patients with ulnar nerve injuries were seen most frequently and a combination of injury to the median and ulnar nerves was not unusual.
Of all the peripheral nerve injuries, 75 percent involved the upper extremity. The occupational therapist was primarily concerned with
21See footnote 2, p. 287.
22Medical Department, United States Army. Surgery in World War II. Neurosurgery. Volume I. Washington: U.S. Government Printing Office, 1958.
FIGURE 82-Following surgery, occupational therapy is prescribed to increase range of motion in affected part. (Top) Patient works to increase flexor range and strengthen left humeral flexors. Adapted handle is raised to increase arc of motion as patient`s progress indicates. (Bottom) The bicycle saw seat shaft and pedal arc can be adjusted to increase or decrease range of motion in hip and knee joints.
FIGURE 83-Peripheral nerve injury. Patient works with clay to increase coordination and strength in thumb and fingers. (U.S. Army photograph.)
those relating to the median and ulnar nerves because of their extreme importance in hand function.
Occupational therapy was generally brought into the treatment program upon the return of voluntary motion to the affected part. Its specific contribution was in the second and third stages of nerve injury management.23 In these stages, it was important to utilize as much active motion as possible in order to improve and maintain joint mobility and stimulate peripheral circulation to reduce local tissue edema.
Patients were carefully supervised through a series of activities which were graded according to amount of resistance, motion required, and length of treatment period (fig. 83). Leatherwork, weaving, woodworking, and plastics were activities that were most suitable to adaptation for treatment of these patients. In all of these activities precautions were taken to insure that the patient did not overexercise, that the resistance provided in the activity was appropriately graded, and that anesthetic areas were protected. For example, when working with plastic materials, care had to be taken that the patient with
23Medical Department, United States Army. Surgery in World War II. Neurosurgery. Volume II. Washington: U.S. Government Printing Office, 1959.
anesthetic areas did not burn himself while forming a piece of hot plastic in a mold. Since this activity was new, patients became overzealous in making lamps, bookends, and picture frames that involved the heating and molding of plastic.
Patients with peripheral nerve injuries usually required long periods of hospitalization while regeneration was occurring. Since War Department policy required the retention of patients in the hospital until maximum treatment benefit had been obtained, a major problem in management of these patients was to maintain their interest in achieving maximal function. However-
The 90-day work furlough solved this problem. Patients who exercised injured extremities grudgingly 3 or 4 hours daily in a hospital gladly exercised them 8 or 10 hours daily in a factory, while at the same time, they aided the war effort, improved their own financial status, and had the added advantage of living with their own families, which additionally improved their morale.24
By April 1945, nine general hospitals were designated as specialty centers for the treatment of injuries requiring plastic surgery.25 Each of these hospitals developed an extensive reconditioning program in which occupational therapy played an important part.
The extent of the occupational therapy program developed for patients undergoing plastic surgery at O`Reilly General Hospital, Springfield, Mo., can be seen in the fact that some 370 patients were referred for this treatment in one 6-month period. That the program for these patients was favorably received is indicated by these comments:
This dichotomous activity, consisting of functional therapy on the one hand, and diversional activity on the other, has played an important role in the reconditioning program. It would be no exaggeration to say that the integration of occupational therapy in the therapeutic regimen of patients suffering from orthopedic, neurosurgical and plastic disabilities, has accomplished much to restore the normal function of injured tissues.26
The purpose of the occupational therapy program was as already indicated, twofold. First, diversional therapy was provided for ward patients. Second, but simultaneously, a functional program was designed to restore, insofar as possible, normal motion in the affected areas. Since the extremities were often immobilized for an extended period before and after surgery, muscles were weakened and both strength and range of motion were prime objectives of the graded therapeutic activity program. As might perhaps be expected, the plastic surgery cases most commonly referred to occupational therapy were those involving the upper extremities (fig. 84).
In 1945, the occupational therapy program for plastic surgery pa-
24(1) See footnote 22, p. 310. (2) See section on work furlough in this chapter.
25See footnote 19, p. 307.
26Annual Report, O`Reilly General Hospital, 1944, p. 8.
FIGURE 84-Occupational therapy following plastic surgery. A. Woodworking. Bilateral activity needed to regain flexion in hands and fingers following application of skin grafts to dorsal surfaces.
FIGURE 84-Continued. B. Weaving is used to regain motion and strength in hands and fingers.
FIGURE 84-Continued. C. Clay modeling. Before further surgery on the thumb, patient maintains motion and strength in unaffected joints.
FIGURE 84-Continued. D. Lapidary. Partial amputation of thumb and fingers necessitates activity to increase motion, strength, dexterity, and coordination in the remaining digital portions.
tients at Newton D. Baker General Hospital, Martinsburg, W. Va., was described as follows:
Two full-time therapists are assigned to this service [the functional physical program]. All pertinent ward rounds are attended by one therapist. Patients upon referral to occupational therapy are given an initial interview when a joint or muscle test is made and a regular appointment time is given. Treatment is on an individual basis and periodic muscle and joint tests are made. The functional equipment included approximately 200 specially constructed wood tool handles, a treadle lathe, a treadle jigsaw, three bicycle saws with attachments, an adapted loom with special handles and weight attachments, three hand lever printing presses with special handles and weight attachments.27
With facilities such as those existing at Newton D. Baker General Hospital, a diversified program centered around the individual patient could be developed. As progress was made, the complexity or difficulty of the task could be increased. Here, as in other Army hospitals, a real attempt was also made to facilitate communication between occupational therapists and medical staff, in order that a total program could be designed to meet the individual needs of each patient.
Army and Navy General Hospital, Hot Springs, Ark., was designated as the Army center for treatment of poliomyelitis. The average wartime census of poliomyelitis patients at this hospital was in excess of 80. These patients were generally assigned to occupational therapy as part of the reconditioning process. The therapeutic program sought to improve muscle coordination and develop strength through interest motivating and graded activities selected in accordance with individual patient needs.28 Frequently, it was necessary to start these patients in supportive (sling-type) apparatus as muscle strength was inadequate to permit function against gravity (fig. 85).
Use was also made of industrial therapy. In selecting an assignment, the patient`s interests and physical condition were the determining factors. In a case study reported by Army and Navy General Hospital, the objectives of industrial therapy listed were:
1. To hasten maximum recovery.
2. To combat hospitalization fatigue.
3. To develop initiative.
4. To gain confidence in self and ability.
5. To overcome weakness of left leg, back, and arms by exercise.
This program was often used in countering a reluctance to participate in more conventional therapeutic activities, but its success was dependent upon appropriate selection of the assignment and adequate job supervision as well as upon an accepting attitude of the patient.
27History of Occupational Therapy Department at Newton D. Baker General Hospital, 1945, p. 3.
28Treatment doctrine was outlined in Circular Letter No. 175, Office of The Surgeon General, 20 October 1943.
FIGURE 85-Patient with poliomyelitis works to regain coordination and strength.
Rehabilitation for the newly blinded
"It was the determination of President Roosevelt * * * that no blinded servicemen of World War II would be returned to their homes without adequate training to meet the problems * * * imposed upon them by their blindness."29 This statement indicates the general approach of the U.S. Army during World War II to the solution of the problem of war-caused blindness of its personnel. It was also an indication of the extensive program which was to be carried out.
During the war, two hospitals were designated as specialty centers for treatment of the newly blinded: Valley Forge General Hospital, Phoenixville, Pa., and Dibble General Hospital, Menlo Park, Calif. In both of these, extensive occupational therapy programs were organized. Although the total number of patients treated was comparatively small, it represented a large percentage of those newly blinded who arrived at these centers. In these hospitals, occupational therapy, medically prescribed, was given as both a bedside and a workshop program. Both
29History of Old Farms Convalescent Hospital, Avon, Conn., 1947, p. 1.
Valley Forge and Dibble General Hospitals secured adequate facilities and staff following the usual initial shortages.
The overall objective of the rehabilitation of the blind was stated, as follows:30
Rehabilitation of the blind entails an educational and therapeutic service employing recognized approved techniques and methods to enable and encourage each individual to develop an emotional and practical adjustment to his handicap so that he returns to society willing and able as possible to live and thrive in it as a contributing citizen of the community.
Bedside activities of the usual scope and variety were offered. The purpose of these activities was twofold. Often started immediately upon arrival of the patient at the hospital, the first purpose was to provide some activity which would aid in passing time during the initial period of restricted activity. The second, and more important purpose, was aiding the patient to develop or improve his manual dexterity through activities requiring the use of fingers and hands. A further value was realized in convincing the patient of his ability to continue to perform various tasks for which he might previously have considered sight a necessity. This tended to have a favorable effect on patient morale.
The workshop program offered many of the same skills utilized in the bedside program but also provided a wider variety of activities (plastics, woodworking, radio repairing) because of the more elaborate facilities available in the shop areas.
For some of the blind patients, their stay was primarily a transitory period between initial hospitalization and subsequent assignment to the Old Farms Convalescent Hospital for final rehabilitation.31 At the convalescent hospital, they were taught those skills needed to carry on a normal life and simultaneously acquired the confidence with which to do so. An elaborate orientation and re-education program was developed to speed the adjustment of the patient to his new role in society. The average stay at the hospital was 3 to 4 months.
Upon arrival, each patient was assigned a counselor and given a series of psychological tests. Following these tests and an orientation period, patients were assigned to other areas. These assignments were made at a staff conference attended by heads of departments and the majority of patients were referred at that time to occupational therapy.
In planning activities for the blind patient, occupational therapists concentrated on those which would develop sense of touch, tactual perception, spatial relations, finger dexterity, and ability to follow and retain verbal directions. The usual range of activities was employed although several were particularly adaptable for use by the blind.
30Annual Report, Valley Forge General Hospital, 1944, pp. 11-12.
31(1) Medical Department, United States Army. Surgery in World War II. Ophthalmology and Otolaryngology. Washington: U.S. Government Printing Office, 1957, pp. 188-209. (2) The assignment of civilian occupational therapists to Old Farms Convalescent Hospital is not indicated in the above reference. Official records of the American Occupational Therapy Association indicate three occupational therapists assigned in 1945 and five in 1946 and 1947. (Occupational Therapy Yearbooks 1945, 1946, and 1947.)
Leatherwork utilized different types of lacing for various stages of dexterity; weaving progressed from gross to fine thread as well as in the motions required by the size of looms and from simple to complex in pattern which was braille type (made by map tacks on a strip of cardboard); metalwork included the forming of bowls on sandbags, carving of half-round silver bracelets using jigs as a guide, filing and bending twisted wire, and when very fine work was indicated, the construction of coil wire jewelry.
Occupational therapy was extended, where necessary, to training in activities of daily living, including eating, dressing, shaving, handling money, and using dial telephones and the braille watch. Performance factors observed in occupational therapy were often helpful in vocational appraisal, and further training in occupational therapy was used in developing additional skill in areas where vocational plans had already been made.
Spinal cord injuries
Twenty general hospitals were designated specialty centers for the care and treatment of spinal cord injuries among World War II patients.32 The purpose of the rehabilitation program, as stated in May 1945, was as follows:
Rehabilitation can and must establish a wheelchair life for the majority and walking with the aid of braces or crutches for many. Self-support at a sedentary occupation is the ultimate objective.
The observed progress of a fellow casualty is a powerful stimulus to continued cooperation in a long and arduous program of rehabilitation. Group care facilitates the recognition of common difficulties and methods of adaptation from patient to patient. Group care encourages group instruction, collective occupational therapy, and the institution of training * * * for self-support in sedentary jobs.33
Special emphasis was placed on adequate care and treatment for these patients.34
No type of patient is more in need of a coordinated reconditioning program than the paraplegic. * * * The physical factors inherent in the proper care of these patients demand special facilities, equipment, and trained personnel. * * * The reconditioning of paraplegics resolves itself into a coordination of all the various professional and auxiliary services that the hospital has available.
Paraplegic patients are primarily surgical service responsibility, requiring daily and constant medical, surgical, and nursing care, special exercise for the maintenance of residual muscle power, and ambulation. They are furthermore subject to "setbacks" and complications during their long period of convalescence. Little time is available daily for active physical, educational, or prevocational activities until they become ambulatory or wheelchair patients, and therefore during the bed treatment stage, bed exercise, individual counseling and guidance, and occupational therapy represent all of the reconditioning applicable, and then only on the prescription of the ward surgeon.
32See footnote 23, p. 312.
33War Department Technical Bulletin (TB MED) 162, May 1945.
34Army Service Forces Circular No. 440, 10 Dec. 1945.
FIGURE 86-Patient on Stryker frame works with plastic project to maintain functional use of upper extremities.
Occupational therapy for the bed patient had several aims. Among these were restoration of self-confidence, development of regular work habits, creation of a sense of independence, the development of hobby interests, maintenance of muscle tone and strength, and functional use of the upper extremities (fig. 86). In developing a program for these patients, psychological and morale factors were of paramount importance. These patients had been more severely traumatized than any other group. Completely independent before their injury, they were now almost totally dependent on others.
Activities ran the gamut of creative and manual skills and were often provided by members of the Red Cross Arts and Skills Corps under the general supervision of occupational therapy. Projects easily completed were best received at the start of the program, but as interest
increased, projects graded in complexity of task, motion, and strength requirements were provided.
The aims of occupational therapy for ambulatory patients were expanded to include the opportunity to explore vocational possibilities and the encouragement of avocational interests. For these patients, greater emphasis was placed on increasing independence and on the range of activities available.
It was necessary to observe several precautions in working with the paraplegic patient. These included avoidance of discouragement, fatigue, discomfort, and increase of symptoms. As the patient improved, care was taken to avoid the development of false hopes concerning full recovery.
The official Medical Department policy on occupational therapy for thoracic disorders was as follows:35
Treatment. The principle of occupational therapy for thoracic disorders is graded activity.
(1) Activity without increase of respiration. Example: Manual activity that does not involve shoulder motion, such as fly tying.
(2) Activity with increase of respiration. Example: Arm and leg activity that necessitates wide range of motion, such as the bicycle saw.
(3) Activity to increase muscle power and range of joint motion in secondarily involved areas. Example: Use of shoulder girdle against resistance, as in gardening.
Special precautions. (1) Particular attention should be paid to temperature, fatigue, drainage, and presence of substances irritable to the respiratory tract.
(2) Where joint limitations and muscle weakness occur, precautions as indicated [for these conditions] will apply.
As indicated by the foregoing doctrine, the first stage of treatment was often on the wards. Although diversional in nature, activities at this stage served as the first step for developing a therapeutic program. Close supervision, including control of materials, was needed in order to be certain that the patient did not exceed his recommended workload. Progress from one stage of activity to the next was dependent on the individual case and varied from one condition to another.
At Moore General Hospital, Swannanoa, N.C., one of the Army`s largest thoracic centers, the occupational therapy program for tuberculous patients was carried out without assistance from volunteer workers. This policy was instituted to allow for daily followups in activity that was found useful, and also, it was necessary to maintain isolation and other medical precautions on wards housing patients in active stages of the disease. These included the wearing of gown and mask while working and the requirement of chest X-rays at 3-month intervals.
35See footnote 2, p. 287.
Graded activity was closely regulated and strict efforts were made to see that no patient worked for longer periods than indicated by his classification. In order to maintain interest among long-term patients, occupational therapists were rotated quarterly and more complicated programs (such as watch repairing) were instituted.
Miss Jessie Lambert, chief occupational therapist, Moore General Hospital, throughout the war years summarized the program for ambulatory patients, as follows:36
The principles of occupational therapy as applied to the ambulatory patients centered around the continuance of graded activity in order to control fatigue, raise work tolerance, and provide greater opportunity for vocational exploration in the shops.
During the final stage of convalescence, a constant liaison was maintained between occupational therapy, the medical services, and other areas of the reconditioning program (fig. 87), in order to develop the regime best suited to the patient.
At the beginning of World War II, treatment of tropical diseases constituted a relatively unknown area of medicine in the United States. In order to conduct extensive research in all phases of this specialty, Moore General Hospital was designated as the Army`s tropical disease center.
Apathy, boredom, and anxiety were commonly found among the patients with tropical diseases. A comprehensive program of occupational therapy seemed indicated to combat these undesirable traits which develop during long periods of hospitalization. Constructive use of leisure time has long been considered a practical means of diverting a patient`s mind from thoughts of illness and helps to prevent the growth of neurotic patterns. An extensive program was therefore devised for bed and ambulatory patients.37
Activities such as craftwork, printing, typing, radio repairing, and photography were used, as were industrial therapy assignments in many different hospital areas.
The patients most frequently referred to occupational therapy were those recuperating from malaria, filariasis, schistosomiasis, amebic dysentery, polyneuritis, tropical ulcers, lichen planus, and eczematoid dermatitis. Specific occupational therapy programs were devised for patients with each type of disease.
The malaria patient generally suffered no enduring physical disability. For this reason, no restrictions were placed on his participation in the occupational therapy program. Such patients were usually given industrial therapy assignments and encouraged to maintain good work habits and good body condition.
36Lambert, J. E.: Occupational Therapy in a Tuberculosis Program. Occup. Therapy 25: 178-179, October 1946.
37Bettinger, P.: Occupational Therapy in Tropical Medicine at Moore General Hospital, Swannanoa, N.C. Occup. Therapy 25: 174-175, October 1946.
FIGURE 87-Convalescent patient gaining experience in automotive mechanics, one of the vocationally oriented courses in the reconditioning program.
Occupational therapy for filariasis was designed primarily to provide a release of tensions created by anxiety over the nature of the disease. Following acute stages, the patient was usually able to participate in more active occupational therapy programs.
For schistosomiasis and amebic dysentery, occupational therapy was directed primarily toward the improvement of morale. Because of the fatigue and weakness usually affecting these patients, a graded activity program was provided. In a number of cases, special effort had to be made to interest patients in such a program.
Occupational therapy for polyneuritis was designed to accommodate two of the three successive stages of the disease. During the first stage, activities utilized were those which would assist in maintenance of muscle tone and strength. In the second or low-level stage where partial or complete paralysis might occur, only passive exercise of the extremities by the physical therapist was indicated. Finally, as voluntary contraction of muscles returned, occupational therapy was resumed in the form of activities progressively graded to improve coordination and develop strength. Since recovery was slow and fatigue common upon overexertion, close supervision of the activity of these patients was necessary at all times.
The treatment of lichen planus, eczematoid dermatitis, and tropical ulcers necessitated the avoidance of activities which involved the use of materials irritating to the skin. As these diseases often led to depression and antisocial behavior, special emphasis was placed on activity providing social contacts.
In her article on the Moore General Hospital program, Miss (later Maj.) Pauline Bettinger concluded:
Upon analysis of the occupational therapy program for patients with tropical diseases, it will be noted that emphasis was not entirely on the diversional aspect. For this type of disability, the effect of construction activity had a measurable therapeutic value upon the morale of the patient. General physical condition of the patient was also noticeably improved through controlled activity in the acute stage and graded activity for the convalescent. Resocialization through group work and individual accomplishment improved mental attitudes. Finally, specific physical functional benefits were observed in conditions such as polyneuritis and schistosomiasis.
Inconsistent use of the term "industrial therapy" has led to some confusion concerning its meaning. As used here, the term refers to work assignments made to various hospital departments and services for therapeutic purposes. Often confused with this was work therapy, which involved the employment of hospital patients on subcontract work projects for defense industries. Further, there was the 90-day work-furlough plan which allowed patients to live in their own homes for a 3-month period while employed by industrial concerns having Government contracts for the production of war material.
During World War II, industrial therapy, usually under the general supervision of an occupational therapist, was used as a prescribed treatment for medical, surgical, and neuropsychiatric patients.
The actual administration of the industrial therapy program involved four steps. First, the available hospital jobs were carefully evaluated by the occupational therapist in relation to mental and physical demands on the patient. Second, the pertinent data concerning the patient and his needs were compiled on a prescription form. Third, accurate assignment and attendance records were maintained on each patient. Finally, periodic progress reports submitted by work supervisors were evaluated by the occupational therapist and action taken for reassignment or counseling, if indicated.
In the treatment of neuropsychiatric patients, the aims of industrial therapy were fivefold-
1. Reduction of psychosomatic symptoms.
2. Development of ego strength and a feeling of self-sufficiency.
3. Encouragement of a feeling of usefulness and provision of the means from prevocational exploration.
4. Regaining of skill in performing work tasks and building security in a work situation.
5. Provision of a semi sheltered opportunity for the improvement of social skills.
Industrial therapy programs for patients with physical injuries were maintained at a number of Army general hospitals. For this program, the job analyses determined what tasks would provide the best opportunities for the desired therapeutic effect. Job analyses done at Newton D. Baker General Hospital located the following opportunities for bed and wheelchair patients.38
Jobs for bed patients
Public Relations Office:
Preparing radio scripts.
Portable bookkeeping work.
Clerical (copying records and typing).
Detachment of Patients:
Preparing envelopes for pay checks.
Jobs for wheelchair patients
Charging out books, inventory, book repair.
Public Address System:
Selling and collecting tickets.
Typing, filing, and other clerical routines.
Bookkeeping and accounting.
Forwarding, directory, files, and clerical work.
Repairing surgical instruments.
Finance and Fiscal:
Typing war bonds.
38Knickerbocker, Barbara M.: Industrial Therapy Notebook, 18 Nov. 1945, pp. 31-33.
FIGURE 88-Work therapy program, Birmingham General Hospital, Van Nuys, Calif. A. Bed patient works on parts assembly.
Additional jobs were analyzed with reference to their therapeutic value for specific injuries and assignments made accordingly. The potential work opportunities were virtually unlimited and, in addition to the specific examples just enumerated, included a broad range of possibilities in the professional, maintenance, supply, and entertainment services of the installation. Efforts were made to encourage responsibility by liberalizing pass procedures and by requiring work uniforms rather than the normal hospital attire. Both policies tended to improve the mental attitude of the patient.
Work therapy programs were carried on in at least six Army general hospitals during World War II. The work involved such tasks as assembling, packaging, inspection of parts, payroll management, recordkeeping, use of hand machine tools, sorting, folding, wrapping, and labeling. The program was used by both bed and ambulatory patients (fig. 88) and for both mental illness and physical injuries. Some of the
FIGURE 88-Continued. B. Wheelchair patient assists in checking parts for shipment.
companies which participated in this program were the Radio Corporation of America, Northrop Aircraft Corporation, Bell and Howell, Bendix Aviation, and Lamson and Sessions.
An indication of the relative merits of work therapy may be seen in the following extracts from evaluation of the programs.
Billings General Hospital, Fort Benjamin Harrison, Ind.:39
39Report on Industrial Therapy, Billings General Hospital, World War II.
All in all, the industrial program proved valuable as a diversional activity for many bed patients and some ambulatory patients as well as therapeutic for others.
Crile General Hospital, Cleveland, Ohio:40
* * * a valuable adjunct to Reconditioning, * * * providing: a. Purposeful physical activity under the supervision of an occupational therapist. b. * * * reorientation of the mental patient to responsibility and group participation. c. Constructive use of leisure time, making patients more amenable to hospital treatment.
Percy Jones General Hospital, Battle Creek, Mich. (paraplegic patients only):41
From a medical standpoint the program was successful to the extent that it provided an activity for muscles not immobilized in this type of case. From a social standpoint the program was successful in proving to these patients that they were not useless and had a definite earning power. This factor was conducive to increased morale.
Work therapy programs were also carried out at Vaughan General Hospital and Gardiner General Hospital, Chicago, Ill. With careful job assignments and medically oriented administration, these programs provided therapeutic mental and physical effects. The later development of these explorations in factory-in-hospital programs, prevocational training, and preparation for employment of the handicapped within civilian industry would seem to confirm their value.
Ninety-Day Work Furlough
The 90-day work furlough was in use at Cushing General Hospital, Framingham, Mass., Crile General Hospital, Cleveland, Ohio, and Schick General Hospital, Clinton, Iowa. The purpose and rationale of the plan are described in description of the program at Cushing General Hospital:42
A work furlough is technically a convalescent furlough of 90 days` duration arranged so that the patient will gain the greatest possible benefit from exercising and using his injured extremity.
A work furlough creates a number of advantages for the patient in addition to a high degree of personal freedom. * * * It is to be granted only to those patients who, through their cooperation in the mobilization of their joints and in exercising their extremities, * * * have proven themselves worthy and reliable individuals.
A patient with a peripheral nerve or orthopedic injury was eligible for a work furlough provided his physical condition allowed him to perform necessary tasks and his treatment required a long period of convalescence. Work furloughs were also granted to individuals who had sustained nerve injuries which did not require surgery or which would not require it for 3 months.
Processing patients for a work furlough was an important part of the plan. Help in securing work was given by the U.S. Employment Service.
40Report on Industrial Therapy, Crile General Hospital, World War II.
41Report on Industrial Therapy, Percy Jones General Hospital, World War II, 17 Oct. 1945.
42Report on 90-Day Work Furlough, Cushing General Hospital, World War II.
The patient was rated as to his physical capacity for performing specific tasks, and it was necessary for him to secure a job before being given a work furlough. The industry for which the patient worked had to be handling war contracts for the armed services, and the employer was requested to certify that the nature of the job to which the patient was assigned would enable him to exercise his injured extremity. This plan was extended only if the condition of the patient indicated the advisability of such an assignment.
The advantages of the work furlough program as given in the Cushing General Hospital report are as follows:
Recovery from peripheral nerve injuries, spontaneous or following operative treatment is a slow process. There is no rationale in having these patients sitting about a hospital occupying much needed beds and becoming "barrack happy" during the 6 to 18 months until they * * * have attained the maximum hospital benefits which are required * * *.
There is no substitute for a well-paid job as an incentive for exercising an injured extremity. * * * The same patient is more than willing to work and to exercise his arm or leg 10 hours a day if paid 8 hours straight time and time and one-half for 2 hours overtime daily.
Furthermore, the patient was able to live with his family and become adjusted to his physical condition in a sheltered and supportive environment. At the plant, he competed with noninjured individuals and was shown that his injury would not seriously handicap him in the process of earning a living. Aside from the physical aspect of the therapy, there thus was also a psychological benefit which had a value of its own.
Personnel shortages and Medical Department policy necessarily precluded the assignment of occupational therapists to hospitals in the Communications Zone. Thus, although some hospitals secured the services of qualified occupational therapists living nearby who were available for work, there were no occupational therapy departments specifically established by the Surgeon General`s Office in the Communications Zone during the war years. There were a number of instances, however, where excellent programs of occupational therapy were developed.
A distinction should be made here between occupational therapy and the more common activity programs found in the Communications Zone. Occupational therapy was conceived as a therapeutic program conducted under medical supervision by specially trained personnel and designed to provide, through the utilization of specific tasks of a productive nature, the desired physical or psychological activity needed in each instance. Activity programs, though valuable in their own right, provided primarily diversional activity in order to allow the patient to better adjust to his period of hospitalization. Because of the lack of properly trained personnel, there was little attempt to develop a therapeutic aspect in these programs.
The philosophy of the activity program might well be summed up by an excerpt:43 "The object of the program is to achieve the desired rehabilitation by keeping both officers and men as pleasantly occupied as possible and thus make them feel that they are an integral part of the program."
Probably the best picture of both occupational therapy and activity programs conducted in Communications Zone hospitals can be provided through the presentation of several examples.
In the Neuropsychiatric Section, 9th General Hospital, Southwest Pacific Area, a type of occupational therapy was carried out by enlisted personnel trained by the chief of neuropsychiatry. Since these were neuropsychiatric patients, the main emphasis was on involvement and participation in normal activity.
At the 22d Station Hospital, Pacific Ocean Areas, in lieu of appointing an occupational therapy officer, direction of the program was assumed by the commanding officer. Craft instruction was provided by a Red Cross recreational worker and a noncommissioned officer with experience in carpentry.44 An extensive shop program was developed and some patients were assigned hospital tasks. Although the latter had all the outward appearance of industrial therapy, the actual assignment of patients to hospital jobs was not primarily designed for therapeutic value. The occupational therapy facilities operated by the 22d Station Hospital had been developed by a registered occupational therapist while the 204th General Hospital occupied the location.45
At the 4th General Hospital, Southwest Pacific Area, an activity program for neuropsychiatric patients was conducted by an Army nurse.46 It was, or so it appears from the annual reports, primarily a craft program. Some consideration was given to the needs of the individual patient, although shortage of personnel made even this difficult.
At the 51st General Hospital, Southwest Pacific Area, occupational therapy was described, as follows:47
The craft work conducted by the Convalescent Training Program was primarily diversional rather than functional. A completely equipped craft shop provided facilities for art and hobby work of all kinds. Tools and materials for wood, leather, and metal work were available and were used regularly by convalescents and other patients as well. Many attractive and useful items were made for their own use or to send home. Projects ranged from solid metal B-29 models to leather wallets. The creative talent of the patient was given full play and a qualified instructor gave him such guidance and instruction as was needed. In addition to this activity, the Convalescent Training Program provided a crafts instructor for the Occupational Therapy Department of the Neuropsychiatric Section. This department was functional in nature and was more extensively equipped than the CTP craft shop and was under the supervision of a nurse trained in occupational therapy.
43History of Convalescent Reconditioning at the 9th General Hospital, Neuropsychiatric Section, 10 July 1945.
44Report of Occupational Therapy Facilities, 22d Station Hospital, 15 Feb. 1945.
45Essential Technical Medical Data, Central Pacific Base Command, U.S. Army, for February 1945, dated 3 Mar. 1945, p. 3.
46Annual Report, Fourth General Hospital, 7 Jan. 1944.
47History of Convalescent Reconditioning at the 51st General Hospital, 10 July 1945, pp. 7-8.
In many hospitals, not even specially trained nurses, enlisted men or Red Cross personnel were available to conduct activity programs. In these cases, it devolved upon the individual medical officer to utilize such personnel and material resources as he could recruit to treat his patients (fig. 89). The following extract is from an account of how and why one medical officer attempted to make occupational therapy available to neuropsychiatric patients in the Southwest Pacific Area.48
What happens to the people of a country like the United States when they get called to fight in an Army that has been hamstrung, held-down, under-trained, poorly supplied, and ill-equipped because the people of the United States lacked the foresight and the backbone to see what was coming and back up the President when he tried to do something about it? Well, they get drafted awfully fast, they don`t get much training, and they go overseas fast as hell because if they didn`t there wouldn`t be anybody at all to handle the military situations. * * *. That`s why trained machinists, concert pianists, great authors, skilled chemists, university professors, and thousands of other specialists end up in the infantry carrying a gun instead of in a job suited to their qualifications.
And here`s what happened. A good many of those men cracked up--they got so they couldn`t stand the sound of an air raid siren, and they crawled under the bed screaming when the ack-ack started, and they got so tremulous they couldn`t write. They became so irritable you couldn`t live with them; they got recurrent, persistent headaches, dizzy spells, low back pain, functional nausea and vomiting, anxiety neuroses, full-blown conversion hysteria, and every other symptom and sign of an insoluble, unconscious, unbearable mental conflict that you can think of.
In 1942, when the Surgeon General`s Office compiled their statistics--the rate for mental disability * * * led the list among all medical causes for discharge from the Army--I think the figure was 40 percent or over. That`s too high, and the Generals said something must be done. So they sent Lt. Col. S. Alan Challman to the SWPA as Consultant in Neuropsychiatry to the Chief Surgeon, Hq. USASOS, APO 501.
* * * the Colonel decided that men with mental disabilities could be better treated, better diagnosed, and more of them sent back to duty of one sort or another if they were sent to specialized, neuropsychiatric hospitals, where the professional staff from the C.O. on down consisted of men with psychiatric experience. * * * He also decided that it would be a good idea if the patients in these hospitals had a little something to do, to keep from lying in bed all day and thinking about their symptoms, and to give them a chance to do something useful. * * * So he arranged for those hospitals to have a little extra equipment--some picks and shovels, rakes and hoes, and some seeds--so they could plant a garden and get some fresh vegetables to eat; and some hammers, saws, and planes so they could build a few trinkets, or maybe even some furniture the hospital could use. In November 1943, he told me that he wanted me to plan and direct such an Occupational Therapy program in one of the Neuropsychiatric Hospitals he was then in the process of organizing.
So I did, and I`ve learned an awful lot in the process * * *. I learned that it was hard to convince the average psychiatrist that Occupational Therapy was anything more than basket weaving. And I learned that it was hard to get the patients interested. They liked to play baseball, but they didn`t think much
48Extract, personal letter, Capt. Charles E. Test, MC, 126th Station Hospital, 7 Oct. 1944. (Recipient unknown.)
FIGURE 89-Activity programs for convalescent patients, Communications Zone. (Top) Craft program in nissen hut, 2d General Hospital, Oxon, England. (Bottom) Neuropsychiatric patients repair day room, Station Hospital, Devon, England.
of digging in the garden, and at first they didn`t think much of doing any work in the carpenter shop, until they learned that the only way they could avoid having to keep all their toilet articles on the ground was to go down to the shop and build themselves a bedside table.
I began to get some results too. One or two patients who had been given up for lost by the ward officer made apparently complete recoveries when they found something * * * suited to their abilities * * * and in the process managed to forget their troubles for a little while. As Karl Menninger puts it, they learned how to play.
Why do they like it, and how does it work? How does rebuilding a truck, running a sawmill, making a bedside table, draughting a plan for our proposed 100 student classroom and library building, planting a garden, playing baseball, constructing a 99 x 20 foot building for a machine shop--help to rehabilitate a soldier who is a nervous wreck and who couldn`t do any kind of work in his outfit?
Well, it isn`t work to them--it`s play. I keep it on that basis. They work on their own time, voluntarily, and when they get tired, or want to go out and play baseball all afternoon, they can. All the pressure and strain of ordinary military duty are eliminated. And they can do the kind of work they like best. I think they get a sense of security, of safety, of protection, from working at the same old stuff they did in civil life. Secondly, they accomplish something--they construct something--something practical and useful * * *. They can work off some of their neurotic tension through productive activity.
* * * I think that probably the biggest reason why such a rehabilitation program works is that most of our soldier mental patients aren`t as sick as we used to think they were. Their illness is due more to situational factors than to unconscious emotional conflicts. They don`t need deep or drastic psychotherapy--all they need is a chance to relax, a little understanding of their problems, something to get interested in, a goal they can reach, and a chance to start over again--a fresh start in a new job, either in or out of the Army.
Occupational therapists were available in very limited numbers in two areas of the Communications Zone. In the Africa-Middle East Theater of Operations, the program at the 38th General Hospital was described as follows:49
* * * The Occupational Therapy Department works closely with the reconditioning officer and patients are referred there by the ward officers. Occupational Therapy is directed by a professional occupational therapist and the activities offered include leather, metal, glass, and wood work, as well as arts and crafts of all kinds.
In the territory of Hawaii, a number of registered occupational therapists were available for employment. Tripler General, North Sector General, and the 26th Station Hospitals had programs conducted by qualified occupational therapists.50 The program at Tripler General Hospital included surgical, orthopedic, and neuropsychiatric services (fig. 90 A). At the 147th General Hospital, programs for general medical patients were included. At North Sector General Hospital, only neuropsy-
49Letter, Margaret Conant, Acting Supervisor of Occupational Therapy, to Miss Mary Rose Ryan, Assistant to National Director, Military and Naval Welfare Service, American Red Cross, Washington, D.C., 5 July 1945, p. 3.
50(1) Report of Occupational Therapy Facilities, Tripler General Hospital, 14 Feb. 1945. (2) Report of Occupational Therapy Facilities, 147th General Hospital, 13 Feb. 1945. (3) Report on Occupational Therapy Activities, North Sector General Hospital, 15 Feb. 1945. (4) Annual Report, 26th Station Hospital, 1946, pp. 48-49.
FIGURE 90-Occupational therapy, Communications Zone. A. Woodworking shop, Tripler General Hospital, Oahu, Hawaii, 1944.
chiatric and orthopedic patients were treated. At the 26th Station Hospital, treatment programs were conducted for patients from all of the different hospital services.
Initiated in 1946, one of the most successful programs utilizing occupational therapists in a Communications Zone was the Philippine Amputation and Prosthetic Unit (9940th Technical Service Unit, Surgeon General`s Office), whose purpose was to train Filipinos in construction of prosthetics and treatment of amputees. Two Medical Department occupational therapists, Miss (later Capt.) Mary K. Berteling and Miss (later Maj.) Elizabeth M. Nachod, were assigned to the unit (fig. 90 B). A description of the facilities and program follows:51
The unit was located in the Mandaluyong hospital center five or six miles outside of Manila adjacent to the 1st Philippine Army General Hospital where most of the amputee patients were hospitalized. * * * The buildings were constructed of corrugated metal and were nine in number. * * * the smaller buildings [housed] the supply rooms, occupational, and physical therapy.
The first patient to be fitted with an arm was a former captain in the Philippine Army * * *. Because of the country and the habits of the people of that country were entirely new to the therapists * * * there would have to be some changes made in the types of achievements to be attained by the patient
51Nachod, E.: Occupational Therapy With Filipino Amputees. Am. J. Occup. Therapy 1: 92-95, April 1947.
FIGURE 90-Continued. B. Occupational therapists, Philippine Amputation and Prosthetic Unit, 1946. Left to right: Elizabeth M. Nachod, Filipino patient, and Mary K. Berteling.
from the types of achievements used in the States, so that they would fit into the mode of living of the Filipino. The captain * * * was able to make a few helpful suggestions as to what might be superfluous and what might be added.
* * * * * * *
There was, of course, a language difficulty between patient and therapist. * * * Photographs were an excellent medium for explaining the purpose of the program to these patients * * *.
* * * * * * *
The program was carried on in much the same way as it was in the States. Patients reported to the shop whether or not they had been fitted with a prosthesis. Pre-prosthetic treatment was emphasized but was found to be less valuable to the Filipino patient * * * due to the fact that most of them had received their injuries [years ago] * * *. To summarize treatment of the Filipino pre-prosthetic patient, it can be said that the benefits were principally diversional with a gratifying psychological response from many of them.
* * * Manual labor using woodworking tools, garden tools, lifting heavy objects, etc., was stressed for most patients * * *. Craft activities were continued after the patient received his prosthesis as an aid to increase the patient`s skill.
After the program for the arm amputees was running smoothly, one for the leg amputees was started. The purpose of occupational therapy for these patients was to give them an additional activity such as operating the bicycle jib saw, treadle sander or loom, to help increase skill in the use of the prosthesis.
During the time the two occupational therapists were assigned to the unit, they trained two Filipinos in the occupational therapy amputation program.
That a need existed for occupational therapy and activity programs in the Communications Zone is well illustrated by reports from the hand centers in the European Theater of Operations, U.S. Army.52 Conclusions drawn on the specialized care of hand injuries included:
Physical and occupational therapy, which are of paramount importance in the treatment and rehabilitation of injured hands, should be on or near the wards set aside for a hand center.
* * * * * * *
Hand centers should be as near the front as circumstances will permit and evacuation of the wounded to them should be accomplished within 2 to 3 days after wounding.
52Seventeen hospitals were designated for the specialized treatment of hand injuries in the European Theater of Operations. Of these, 10 were in the United Kingdom and 7 were on the Continent. (See footnote 13, p. 300.)