UC-NRLF M71 GIFT OF DOCUMENTS DEFT. 65TH CONGRESS \ o-c-w A TV ( DOCUMENT SENATE ] No. 167 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY FOR THE REHABILITATION OF DISABLED SOLDIERS AND SAILORS LETTER FROM THE US, FEDERAL BOARD FOR VOCATIONAL EDUCATION TRANSMITTING, IN RESPONSE TO A SENATE RESOLUTION OF JANUARY 27, REPORT ON A STUDY OF THE FEDERAL BOARD ENTITLED "REHABILITATION OF DISABLED SOLDIERS AND SAILORS AND TEACHER TRAINING FOR OCCUPATIONAL THERAPY" JANUARY 30, 1918 Referred to the Committee on Education and Labor and ordered to be printed WASHINGTON GOVERNMENT PRINTING OFFICE 1918 FEDERAL BOARD FOR VOCATIONAL EDUCATION. MEMBERS. DAVID F. HOUSTON, Chairman, P. P. CLAXTON, Secretary of Agriculture. Commissioner of Education. WILLIAM C. REDFIELD, JAMES P. MUNROE, Secretary of Commerce. Manufacture and Commerce. WILLIAM B. WILSON, CHARLES A. GREATHOUSE, Agriculture. Secretary of Labor. ARTHUR E. HOLDER, Labor. EXECUTIVE STAFF. C. A. PBOSSER, Director. LAYTON S. HAWKINS, JOSEPHINE T. BERRY, Assistant Director for Assistant Director for Agricultural Education. Home Economics Education. LEWIS H. CARRIS, CHARLES H. WINSLOW, Assistant Director for Assistant Director for Research. Industrial Education. CHEESMAN A. HERRICK, Special Agent for Commercial Education. 2 UB557 ' DEPT. S. RES. 189. IX THE SEXATE OF THE UNITED STATES. JANUARY 28, 1918. Mr- SMITH of Georgia submitted the following resolution ; which was consid- ered and agreed to. RESOLUTION. 1 Resolved, That the Federal Board for Vocational Educa- 2 tion be directed to furnish to the Senate such information as it 3 may have or can readily obtain on the rehabilitation and voca- 4 tional reeducation of crippled soldiers and sailors. 3 371847 LETTER OF TEANSMITTAL. FEDERAL BOARD FOR VOCATIONAL EDUCATION, Washington, January 29, 1918. SIR : The Federal Board for Vocational Education is in receipt of the following resolution of the Senate of January 28, 1918 : Resolved, That tlie Federal Board for Vocational Education be directed to furnish to the Senate such information as it may have or can readily obtain on the rehabilitation and vocational reeducation of crippled soldiers and sailors. Pursuant thereto there is herewith transmitted a study by the Federal board entitled " The rehabilitation of disabled soldiers and sailors, and teacher training for occupational therapy." Respectfully, JAMES P. MUNROE, Vice Chairman. Hon. THOMAS E. MARSHALL, President United States Senate, Washington, D. C. CONTENTS. Page. Foreword 9 Introduction 11 PART I. The problem of training teachers 15 Problems in teaching the war invalids 15 Readjustment to civil life 18 Classification of disabled men according to impairment of working capacity . 20 (a) Men not able to compete under any conditions 20 (6) Men not able to compete after completion of medical treatment. . . 20 (c) Men able to compete after completion of medical treatment 20 Chart showing stages of occupational treatment in hospitals and teacher training 22 Organization 23 Selection of instructors for invalid occupations 24 Selection of instructors for occupational therapy 24 Course of study 25 I The problem of rehabilitation 25 II Study of occupational therapy in convalescent cases of internal diseases, injuries, and post-surgical treatment (not orthopedic). . 25 III Study of occupational therapy in relation to orthopedic treatment. 25 IV Study of occupational therapy in mental and nervous disorders. . 26 V Technique of occupational therapy 26 VI Study of occupations in relation to occupational therapy 26 VII Methods of teaching 26 VIII The curative workshop 27 Qualifications of teachers for directing occupational therapy . 27 Qualifications of teachers for vocational education " 31 Equipment. 32 (a) Invalid occupations 32 (&) Occupational therapy 33 PART II. Functions of occupational therapy 35 Psychological functions 35 Physiological functions 37 Internal diseases, injuries and post-surgical treatment (not orthopedic) . 39 Orthopedic surgery 41 Occupational therapy and the war invalid 42 Mental and nervous disorders 43 Internal diseases, injuries, and post-surgical treatment (not orthopedic) . 45 Orthopedic surgery 46 The need for immediate occupation 48 The present field of occupational therapy, and its possibilities of development. 48 PART III. Social and economic aspects of occupational therapy 52 Advisability of practical work 52 Remuneration of men in workshops 55 Marketable products 56 Overlapping of stages of rehabilitation 57 Contributions of vocational expert 58 (a) Occupational direction 60 (6) Classification of duties of vocational expert 61 7 8 CONTEXTS. Social and economic aspects of occupational therapy Continued. Page. Control of men during reeducation . .; 61 Permanent provision for disabled men 65 Demobilization . P 66 Value of civilian strength and vitality 66 (a) Rehabilitation of the "undesirable '' 66 (6) Rehabilitation of the "unfit" 66 (c) Rehabilitation of the industrially handicapped 67 Necessity for occupational therapy at all times 67 Value of the handicapped 69 Letters from rehabilitated soldiers 69 Suggested registration and record blanks for charting progress of patients. . 72 Hospital registration Curative workshop weekly record Hospital discharge 75 Vocational school weekl v record r 76 REHABILITATION OF DISABLED SOLDIERS AND SAILORS TEACHER TRAINING FOR OCCUPATIONAL THERAPY. FOREWORD. Not the least of the war problems in the field of vocational educa- tion is the industrial rehabilitation of the disabled soldier and sailor. Kealizing that if the United States was to avoid the serious mistakes made by several of the belligerent nations in their early attempts to solve this problem, the Federal Board for Vocational Education, on August 16, 1917, authorized its research division to investigate thor- oughly and at the earliest possible moment the entire question of the rehabilitation of war cripples. A preliminary survey of the experience of the European nations since the beginning of the great war had convinced the board that it was necessary to develop facts from every source for the formulation of a broad and comprehensive plan for the restoration of men, handicapped as a direct outcome of their military employment, to useful industrial employment. This study aims, therefore, to build upon such information as was available before the war, to enrich and complete it with the abundant foreign experience gained since the war. and to anticipate the problems of demobilization which will far outlast the war itself and which will conserve in handicapped labor a resource of great economic value. Rehabilitation, whether of the war or of industrial cripples, de- pends to a large extent on the practice of occupational therapy dur- ing convalescence. In the present moment of preparation the United States discovers at once the great need for occupational therapeutists and an equally great shortage in the supply. It is the principal pur- pose of the study presented in this document to attempt to meet this situation, to show what methods Europe, after costly experiment, has found to be the best, to outline courses for the emergency training of teachers, and to map out the essentials of a complete national pro- gram of rehabilitation. This study was made by Elizabeth G. Upham, under the direction of Charles H. Winslow, Assistant Director for Research. Acknowl- edgment for valuable suggestions is made to Dr. William Rush Dun- ton, jr., President of the National Society for the Promotion of Oc- cupational Therapy and Instructor of Psychiatry, Johns Hopkins University, Baltimore ; to Dr. J. Madison Taylor, Associate Professor of Nonpharmaceutic Therapeutics in the Medical Department of Temple University, Philadelphia; to Dr. Frankwood E. Williams. Vice Chairman of the Mental Hygiene War Work Committee of the National Committee for Mental Hygiene; to Dr. Shepherd Ivory Franz, Chairman of the Committee on Rehabilitation of Maimed and Crippled of the Council of National Defense ; to T. B. Kidner, Voca- tional Secretary of the Canadian Military Hospitals Commission, and to officers of the Surgeon General's Staff of the War Department. C. A. PROSSER, Director. INTRODUCTION. Disabled soldiers and sailors are now returning to the United States from the theater of war, and the situation created by their return is one that calls for immediate action by the Federal Gov- ernment. The purely emergency problems involved in the ques- tion of the industrial rehabilitation of these men, great as they are, are only a part of the ever-present problem arising from the fact that a much larger number of men are annually crippled and handicapped V in the ordinary course of industry. The present study attempts to * analyze broadly the fundamentals of these problems, emphasizing particularly, however, the more pressing military aspects. It is to be hoped that whatever program may be adopted will serve not for the period of the war alone, to be discarded at its close, but also for the solution of the rehabilitation of the industrially handicapped. Between the time when the disabled soldier or sailor enters the hospital and his final placement in industry, commerce, agriculture, or less frequently in the special workshop or home, there lies a long period of reeducation and adaptation. In this period such terms as " invalid or bedside occupations," " occupational therapy," " curative workshop," and "vocational education" are commonly used. Each of these terms refers to some process of the rehabilitation. The dis- tinct function of each, however, their overlapping and interdepend- ence are but vaguely understood, and therefore require definition. 1 The different disabilities, physical and mental complications, the capabilities and experiences of the disabled soldier or sailor, are such that the problem of his rehabilitation is in each case an individual problem, and complete standardization of either medical or occupa- tional treatment is impossible. In the main, however, the average program for a man incapacitated for further military service over- seas may be described as follows : First, a period of acute illness or surgical care ; second, a period of convalescence, frequently of long duration ; third, vocational reedu- cation. These stages may merge imperceptibly into one another or they may be separate and distinct. In many instances one or two of the stages may be altogether omitted. J A confusion exists between invalid or bedside occupations and occupational therapy. Institutions offering instruction to teachers in occupational therapy are giving identical courses with those offering instruction in invalid occupations. Invalid or bedside occupa- tions may be used interchangeably, as they cover the same field It has been expedient in this study to draw the distinction between invalid occupations and occupational therapy, reserving for occupational therapy work of a serious and educative type. The thera- peutic value of invalid or bedside occupations is, however, fully appreciated. It is impos- sible to give a complete list of all the institutions and hospitals in this country offering courses in " invalid occupations." Notable among them are : The Experimental Station of Invalid Occupation, conducted by Miss Susan E. Tracy, Jamaica Plains, Mass. Dr. Wm. Rush Dunton, jr., course for nurses at the Sheppard and Enoch Pratt Hospitals, Towson, Md. Columbia University, department of nursing and health. The Red Cross class conducted by Mrs. Eleanor Clarke Slagle in Chicago. The Chicago School of Civics and Philanthropy, in cooperation with the Henry B. Pavllle School of Occupations, is offering a course for institutional workers. The Henry B. Faville School of Occupations of the Illinois Society for Mental Hygiene offers a course in training teachers for invalid occupations and occupational therapy. It gives instruction in occupational therapy to the extent that many of the materials han- dled are the raw materials of industry and the patients learn machine processes and the use of lathes. 12 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. As a rule the acute condition will occur overseas unless complica- tions or surgical operation take place after the patient has been trans- ported to the United States. Patients who are permanently dis- abled for further military service will be brought to this country as soon as their condition permits, thus relieving hospital congestion in France. In this country, furthermore, not only are supplies, care, and the elaborate equipment needed for many types of recovery accessible, but the technical schools and shops for vocational training are or will be at hand. As the patient recovers from the first acute convalescing, he may be given "invalid or bedside occupations." Occupational therapy and the curative workshop are invaluable in the period of convalescence, while vocational education follows physical recovery, and is the final stage in rehabilitation. The three stages are necessarily distinct in their function, and call for distinct methods of teacher training and different kinds of equipment. They respond by improved conditions." * During the close of the first, or acute, stage of illness invalid occu- pations is sometimes the treatment. This is desirable in cases when the patient's disability necessitates his staying in bed for a consider- able length of time. Not only w 7 ill the time pass more quickly for the patient so employed but his mental outlook w T ill be improved, and even in severely restricted positions certain activities w r ill prove a physical benefit. The period of invalid occupations is perhaps the least important of the three stages in rehabilitation, since it usually covers the shortest period and marks the interim when the patient is contending against the greatest number of limitations. The spe- cial object of invalid occupations is to help the wounded man feel that he is not wasting time and to save him from self-pity and a brooding condition of mind. Even those who accept their condition with heroism and philosophy become depressed as a result of the long waiting to get well. Depression, inertia, and worry aggravate physical conditions, and the chief duty of the instructor of invalid occupations is to shorten the period of unproductiveness and worry, and if he can " prove to the patient who chafes against his limita- tions that there is really a broad highway of usefulness opening be- fore him of which he knew not, the mental friction is diminished and satisfaction steals in, while the whole physical organism prepares to respond by improved conditions." * While the occupations given in this early stage of recovery may have a therapeutic effect, they can not always be of practical value to the patient's economic future inasmuch as the field of invalid occupa- tions is limited to the bed patient or to the patient unable to attend classes in the curative workshop. They should not be confused with occupational therapy, which is more comprehensive and belongs properly in the second or convalescing stage of rehabilitation. 9 1 Studies in Invalid Occupations, by Susan E. Tracy. 2 The first stage was not considered in the resolution passed at the interallied con- ference held in Paris, May 8-12, 1917. The following two stages wore considered and differentiated as provided by resolution No. 43 : " The reeducation of the wounded falls into two period's : " 3. That of functional restoration by work, the object of which is to euro the wounded, prepare them for instruction, and encourage them to work. " 2. That of technical reeducation, which begins as soon as the injuries are honied and is intended to restore morally, intellectually, and practically those who have limbs." TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 13 Occupational therapy is the science of healing by occupation, and the curative workshop is the shop where the convalescing patients are given occupational treatment. Occupational therapy is designed to cover the long and tedious periods of convalescence when the pa- tient is able to be about, when medical treatment occupies only a part of his day, but when it is necessary for him to be under the strictest medical supervision. Long convalescence is characteristic of many of the disabilities of the disabled soldier or sailor, such as general debility, heart trouble, nerve disorders, tuberculosis, rheumatism, in- juries requiring orthopedic treatment, etc. Vocational training takes place on the completion of convalescence or when the patient has sufficiently recovered to be permitted to. follow a prescribed course of study. Upon vocational training de- pends the employability of the man and his value as a producing agent. Important as is this final stage in rehabilitation, its success de- pends upon what has been accomplished by occupational therapy in the curative workshop. What is done during the convalescent stage forms the vital link between medical treatment and vocational educa- tion or economic adjustment. It is the critical and most important of the three stages. During this period, ambition, the desire for self-support and economic usefulness may be fostered, replacing the despair, apathy, and dependence often experienced. This is, more- over, the period when the patient regains the functional use of his body. The extent to which he becomes reeducated and the purpose and end to which that reeducation is directed make not only pos- sible vocational education but industrial rehabilitation as well. While many of the patients will have the opportunity to complete the training begun in the curative workshop in the vocational school, many others will be able to go directly into wage-earning occupa- tions. The period of occupational therapy must, therefore, be used to prepare and adjust many patients to civilian life. Occupational therapy has suddenly received world-wide recogni- tion as a factor indispensable in the rehabilitation of wounded sol- diers and sailors. The participation of the United States in the war and the establishment of an elaborate system of reconstruction hos- pitals designed to rehabilitate the disabled, necessitate the erection of curative workshops and the training of teachers of occupational therapy. It is timely, therefore, that serious attention be given to the study of occupational therapy in order to determine the qualifi- cations of its teachers, to ascertain its function, its effect upon war invalids, and its social and economic aspects. PARTL THE PROBLEM OF TRAINING TEACHERS. The problem of training instructors to meet the war need, for teachers capable of directing occupational treatment, must be studied first from the point of view of the number involved and the prob- able number of teachers required; second, special problems en- countered in dealing with war invalids ; third, qualifications of the instructors; and fourth, course of training for teachers. Canadian experience, upon which the figures for this country may be based, estimates that 10 per cent of the men sent overseas are re- turned unfit for service. Thirty per cent of these are in the hos- pitals at one time. This means that for every 1,000,000 men sent over- seas, 100,000 will come back permanently disabled for further mili- tary service and approximately 30,000 will be in the hospitals at one time. The majority of these will be convalescent patients. Four instructors are estimated in Canada to every 100 convalescent patients. Canada is endeavoring to increase the number of in- structors. In Canada the men go to the shops in relays, and the classes run from 16 to 20 men, often, however, considerably less. Allowing 4 teachers to every 100 men, 1,200 occupational therapeutists would be needed for every million men overseas. If the United States maintains an over-seas army of 5,000,000, 6,000 instructors will be required. For the best results there should be a higher percentage than 4 instructors for every 100 men. The war invalid presents a problem that is distinct from that of the civilian patient or the industrially handicapped. The indus- trially handicapped person is more frequently alone and unaided. The war invalid, on the contrary, has served his country, and the Nation stands ready to help him. At his service are a multitude of resources and agencies. In case of serious injury, the pension re- lieves him from apprehension as to the future. Th^e training during convalescence comes at a time when mentally and physically he is most responsive, provided he is stimulated; and the military au- thority which it is possible to exercise over him, but not over a civilian patient, has the advantage of controlling the stubborn and willful patient for his own advantage. PROBLEMS IN TEACHING THE WAR INVALIDS. The records reveal that a few of the patients take the attitude that they have done their part and that others may look out for them in the future. The majority of the men, however, have self-respect 15 16 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. and confidence; they have made good in the face of danger, and return handicapped but determined to make the best of their con- dition. The care, guidance, and patriotic attitude of the public, together with the consciousness on the part of the patient that he has served his country, help to simplify the problem of the returned soldier or sailor. The instructor who understands how to approach the sick, who has sympathy and understanding not only with the subnormal but with the peculiar mental attitude of the war in- valid, and who knows how to talk his own language to him, will find the disabled man a responsible and willing student. There are, however, certain difficulties in teaching the war invalid which do not exist to the same ^ extent in the case of the civilian patient. The physical handicap is likely to be serious, and in many oases constitutes a permanent disability. The instructor must there- fore take his past into consideration, aiming to reduce the per- manent handicap to the minimum and to increase to the maximum the remaining faculties of the patient. In addition to the physical disability, the mental and nervous conditions brought on by the strain of trench warfare complicate the problem. In the case of men whose mental and nervous condition appears quite normal there will be found to be a mental sluggishness, a lack of concentration, and a nervous fatigue which is the logical outcome of the experience of modern warfare. Although many of the men are young enough to be teachable, the instructor, to be successful, must understand the psychological condition of the disabled soldier or sailor. Many of the common disabilities involve either amputations or inability to use a member. Cheer and helpfulness are needed in the exercise of a stump or in teaching a man to be skillful with his left hand. 1 In many cases there is no amputation, but the limb has ankylosed or remained inactive over a long period, and here again time, patience, and encouragement are constantly needed in order to develop the first feeble muscular exertions into forceful and produc- tive movements. The fatigue and debility suffered by many of the patients prevent long-continued activity, and the instructor must understand the therapeutic value of the occupation to these patients, realizing that this value can not be measured in. the shop by the tangible results possible to obtain in some cases. ^ The administering of occupational treatment in the cases of shell shock, w r ar neuroses, and ps} r choses requires the most expert skill and understanding of the delicate balance and relation of motor functions to the central nervous system. The totally blind and deaf are fortunately few. Sudden blindness or deafness coming to an adult renders the victim far more helpless than would be the case with a child who has never had these senses, or with an adult w r ho has developed a certain adjustment through their gradual loss. 1 The method devised by M. Tamenne, a Belgian refugee, who has educated his left hand most proficiently and teaches handwriting, shorthand, and typewriting to those who have lost the use of their right hands at the Ecole Professionelle de Blesses at Montpellier, is described in the Lancet for Apr. 7, 1917. M. Tamenne emphasizes the psychological value of having the pupil write as nearly like his former hand as possible. Thus he has an unconscious means of comparison, and when he has imitated his normal handwriting he no longer feels disabled. M. Tamenne also notes the necessity of giving the patients confidence, and of teaching them to consider their loss not a disability, but an inconvenience which, may be overcome. TKAIX1XG OF TEACHERS FOR OCCUPATIONAL THERAPY. 17 The blind 1 must be "taught to be blind," to accept their lot as an inconvenience, not as a disability. Intelligent sympathy, not pity, will assist them in becoming independent. Blindness imposes a se- vere nervous strain which must be safeguarded. The method of teaching typewriting and Braille to the blind soldier or sailor is the same as teaching any victim of blindness. It must not be sup- posed, however, as is popularly understood, that the sudden loss of a sense develops a corresponding sudden acuteness of the other senses. The sudden loss of sight is in itself a paralyzing experience, for in addition the hearing has often been dulled by the bursting of shells and exposure, and the manual and rough work of army life has calloused the hands so that many patients do not possess a sensitive 1 ouch. The blind soldier or sailor requires a specially trained teacher for the blind, and, in addition, one with great patience and apprecia- tion of the particular handicap of the war invalid. 2 Under the head of deafness should be included both the dull of hearing and the totally deaf. A resolution passed May 11, 1917, at the interallied conference held in Paris states that " lip reading should be regarded as the only useful method of reeducating those who are totally deaf." Trained teachers of the deaf are the only ones who should be intrusted with the difficult task of teaching lip reading. After first learning the lip picture of a few written words, the patient is taught to read forms of speech of the first and second articulation point and is then instructed how to distinguish different sounds at the same site of articulation. Enthusiasm must be main- tained, though the difficulties of lip reading for the adult patients must not be minimized. As the patient learns to read lips, simple, interesting sentences and stories must be recited, preferably those relating to experiences with which he is familiar. 3 The patient should be taught from objects, motions, and concrete examples. This treatment applies to the totally deaf whose condition is organic. There is also a group of extremely deaf war invalids whose difficulty is mainly functional. Such cases respond to the occupational treat- ment of war neuroses. For such patients " a course of soothing and fortifying treatment with the judicious application of psycho- therapeutic methods and organized work may produce unexpectedly brilliant results." 4 Although the concussions, head injuries, and vicissitudes of the war do not cause total deafness in many cases, they often result in de- fective hearing. The returns from 12 English military hospitals 1 Resolution 87a, passed May 11, 1917, at the interallied conference, provides that " The creation of small workshops near ophthalmic centers and ophthalmic departments in hospitals should be made compulsory." 2 The great success of Sir Arthur Pearson's work with the blind at St. Dunstan's, England, and the rapidity with which the men learn, has been attributed to the fact that he favors blind teachers as instructors. He himself is blind. The men are encour- aged and stimulated to learn from one who has experienced the same disability. The following is an extract from a letter written by Helen Keller to the American-British- French-Belgian permanent blind relief war fund : " In order really to console and help the blind, we must take into account their par- ticular needs, their peculiar difficulties, their individual capabilities. * * * Their lot is so horrible " (the maimed as well as blinded) " that any effort to break through their isolation and cheer them must be precious beyond our powers of comprehension. * * * If we have the will and courage to face the dark, a gentle warmth steals into our fearful hearts. * * * We are so constituted that we can adapt ourselves to almost any condition if only a friendly hand is reached out to us, if we only hold fast to our faith in the conquering might of the spirit." 3 The method of Director Kroiss, of Wurzburg, is described in Recalled to Life, June, 1917 *A memorandum prepared by Sir Alfred Keogh, G. C. B., director general, army med- ical service for the AngJo-Belgian committee. 42298 S. Doc. 167. 65-2 2 18 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. show that 1.4 per cent of the patients suffered from some form of deafness. Two German Army corps showed a percentage of disease or injury to the ear as high as 7.5 in a year. Many of these cases are capable of improvement, and total deafness may be prevented. While lip reading is desirable for many of these cases, it is important that the patients use and exercise what hearing they have and take ad- vantage of all mechanical appliances for the deaf. It is a character- istic of the deaf to be depressed and expect favors on account of their deafness. Since deafness does not prohibit men from entrance into many gainful occupations, it is necessary that the instructor be not only versed in the technique of instructing the deaf, but that he also know how to use and develpo any fragments of hearing left and overcome any natural unfavorable tendencies of temperament occa- sioned by the deafness likely to handicap a man in securing employ- ment. READJUSTMENT TO CIVIL LIFE. The instructor of disabled men has an ambitious purpose to accom- plish in the curative workshop. The military discipline to which the men have long been accustomed renders difficult the adjustment to civilian life. This period may be made less trying if the instructor develops individual thinking and initiative in the patients. The recourse to military discipline in the curative workshops should be rare. Control of the war invalids should lie in the instructor's ability to interest them, to teach them, and to develop in them regular habits of work, habits which are self-disciplinary and which will render the men valuable members of civil communities. French experience has established very clearly that the .selection of the right type of teacher is vital to the success of any scheme of training. The ordinary technical instructor who understands his subject but not his pupils is quite useless. Teaching the physically defective is not perhaps so difficult as teaching the mentally defective, but it requires much the same qualities, the game inexhaustible patience, the same blending of sympathy and firmness, and, above all, the power of appreciating the idiosyncrasies of the different pupils. The ideal instructor must know his men as well as his trade. He must study their peculiarities and be able to vary his methods so as to get the best out of each man. 1 The fact that the majority of the war invalids will partly, if not wholly, recover makes the task of instruction hopeful. Inasmuch, however, as their economic independence depends to a large extent upon the occupational therapy of the convalescent period, there is imposed upon the instructor a heavy responsibility not only to help the patient to get hold of himself and thus to facilitate his recovery, but to furnish him with that accurate knowledge which will be his vocational equipment. Canadian figures show that 80 per cent of the disabled men are able to return to their former industry without vocational training, that 10 per cent need complete vocational reeducation, and 10 per- cent partial reeducation. It therefore follows that 80 per cent of the men receive no further instruction after leaving the curative workshop and that 20 per cent receive varying degrees of vocational reeducation. The last opportunity which the Federal Government 1 L. G. Brock, in American Journal of Care for Cripples, Vol. IV, No. 1. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 10 will hare to assist these 80,000 x men who need no further vocational education in the task of adjusting themselves to civilian life and to the demands of industry will be during the period of convalescence in the curative workshop. The problem of the curative workshop is, then, twofold first, to provide those occupations which may facilitate the patient's recovery from a therapeutic point of view; and, second, to make those occupations so far as possible of such a practical type that the patients may add to their industrial equip- ment. Intelligence and skill is the workingman's capital. The fact that these men are returned unfit for further military service indi- cates that they are subnormal in some slight measure, if not seriously and permanently handicapped. In addition to those men who will become employable on hospital discharge, there are 20 per cent who can only become so after par- tial or complete vocational rehabilitation. Since many of these men must spend a long convalescence in the curative workshop before they are able to take up vocational education, it will save time and expense to make the course of instruction in the hospital workshop prevocational to the course which the patient will subsequently fol- low. If such a course can not present the exact processes, either be- cause of lack of equipment or inability on the patient's part to per- form such work at this period of his recovery, it may at least con- tain allied and academic subjects which will form a valuable back- ground to technical training. In the hospital workshop there will be a few men who will never be able to compete in industry and for whom provision will have to be made in special workshops. A special workshop should have a rest' room with a nurse or doc- tor in constant attendance. It should have as many comforts as possible in the way of special devices, foot and back rests, etc. The hours will have to be adjusted to each patient. Attendance should be as regular as possible and discipline should be consistent with the patient's physical condition. There should be classes in connection with the shop, so that the patients may increase their skill and so that other handicapped persons may improve their time while out of employment. Every effort should be made by those in authority in the special workshop to secure employment for the patients out- side the shop whenever it is possible to do so. The patients should receive a small return for their work, and the character of the work should be distinctly commercial and should compete fairly with nor- mal prices. In all probability these shops can not be self-supporting, since labor is necessarily dependent upon the irregularity and uncer- tainty of men so seriously incapacitated that they can secure employ- ment in no other way. The deficit incurred by such an establishment may well be borne by the Federal Government and regarded as an economy in comparison with the older methods of caring for such cases in soldiers' and sailors' homes, where the men are maintained in idleness and subject to mental and moral deterioration. The cases for the special workshops are fortunately so rare after the modern method of hospital treatment that they are negligible in number. 1 On the basis of a million men overseas, Canadian figures give 10 per cent, or 100.000 men, returned unfit for further military service ; SO per cent of them, or 80,000, are able to return to industry without vocational education. 20 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. The Lord Roberts Memorial Workshops, established in London, are special workshops for this class of men. In the first year a profit of 900 was made after meeting all expenses and after paying 16.000 in wages to the men and their dependents. There will be a few paralytics and bedridden patients who will never be able to attend even special workshops for the handicapped. Bedside and invalid occupations may pass the time and be a pallia- tive measure for this last group. CLASSIFICATION OF DISABLED MEN ACCORDING TO IMPAIRMENT OF WORK- ING CAPACITY. The following classification of the three groups of patients in the curative workshop shows the degrees of disabilities in relation to impairment of earning capacity and clarifies the purpose and func- tion of occupational treatment in relation to each group. (a) Men not able to compete in normal occupations under any con- ditions. Men sufficiently disabled to prevent competition in any normal occupation so that they will be employable only in special workshops upon hospital discharge. For this group invalid occupa- tions and even occupational therapy can be both a palliative measure and an economic policy within limited restrictions. It can pass the time, keep the patient contented, and later, under supervision in special workshops, enable him to be partially self-supporting. (b) Men not able to compete after completion of medical treat- ment. Men not able to return to former occupations on completion of medical treatment but able to become self-supporting in new voca- tions. Occupational therapy is of the greatest value to this class. Not only may it accelerate their recovery, but the training received in convalescence may be made a part of the preparation for their new vocations. The economy, efficiency, and success of training lie in making the therapeutic requirements for mind and body in con- valescence coincide with preparation for vocational education, if not the actual vocational training itself. (It is, of course, under- stood that the physical condition of patients in the curative work- shop prevents them from attending regular vocational schools.) (c) Men able to compete after completion of medical treatment. Men able to, return to former vocations on the completion of medical treatment. Regulated activity and wholesome habit of work, is designed chiefly to facilitate recovery. Whenever it is possible, gen- eral education classes and practice in the workshop should increase the patient's economic equipment by greater knowledge of the occu- pation with which he is already familiar, and to which he intends to return when cured. While many of the patients will be learning to perform their old occupations better, many others must go through the torturous period of strict reeducation, not in the sense of learning a new occupation, but in learning to perform an already familiar one under severe limitations. It is now clear that there are three different kinds of classes in the curative workshops at the same time. Moreover the length of time each patient may work, the extent to which he may exert himself, and the kind of exercise prescribed must be determined in each case by the individual. Mr. T. B. Kidner, vocational secretary of the Military Hospitals Commission of Canada, has pointed out the desir- TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 21 ability of having the classes separated not only according to subject, but according to the earnestness with which the men may work. Men who are capable of applying themselves to serious vocational study, although still in the curative workshop, should not be mixed with those who are taking training merely for its therapeutic value or with those who are incapable of making even a fair degree of progress. For instance, many of the men may not be able to apply themselves seriously during convalescence, whereas a few may be able to work fairly hard and receive great benefit from a vocational course leading directly to a trade. Such patients must not be held back or they will develop lazy habits of w r ork and cost the Government unnecessary expense by lengthening the period of training. The curative workshop must be a departmental institution in which there are many occupations affording a wealth of choice both from the medical and economic points of view. This is necessitated by the different interests, possibilities and handicaps of the men. In many cases a rudimentary or even a higher education is advisable. In other cases there should be classes in commercial education, printing, drafting, salesmanship, agricultural pursuits, motor mechanics, and skilled trades. While the instruction must be individual and the con- dition and fatigue of the patient must form the basis of the teaching in each case, those men should be grouped together of whom the same relative degree of progress can be expected. It is therefore evident that the director must be familiar with the instruction of these groups and with a wide range of subjects. He must necessarily possess the qualifications of the manual-training teacher. The scheme of training of the men should be organized so as to train large groups of people at one place rather than small and scattered groups at many places. This will make pos- sible effective use of the coterie of teachers who are specialists in their lines. The common practice of schools with schemes of recita- tions and assignment of work can be followed on the basis of what- the different teachers are able to contribute. The chart on page 22 indicates the stages of occupational treatment and teacher training in relation to each group of men. It shows the present resources for training each group, the sources from which teachers may be recruited and the practical experience necessary for each group." TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 9 '3.-. a o 3$ III SI* tsti *^fl . SsT 2 II II <3 ff ^ x< C3 ?? C - c-2 ^2- +J a a 2 1 a p ? 9 03 o a 8 - -E- P "is 8 . 3 * 2 8 III I V^ci co II m i in i ii 23 C3 l| gag TRAINING OF TEACHERS FOE OCCUPATIONAL THERAPY, 23 ORGANIZATION. This country is confronted with the task of preparing teachers for each group of disabled men. Aside from invalid occupations, little attention has been given in the United States to the various phases of this great problem. Not only are few teachers available to start the work in the first hospitals, but there are few people experienced in the preparation of such teachers. Some hospitals have the begin- nings of equipment for invalid occupations but few are provided with curative workshops. Furthermore, this country has no back- ground of experience for dealing with the subject, and for this reason it will be necessary at the outset to resort to Canadian hospitals for observation and practice work. The knowledge of the allies was gained from actual experience with the problem, which has been costly in time, money, and wasted human efficiency. Such a comprehensive plan as is demanded by the present emer- gency can only be met by the Federal Government. In no other way can a uniform standard of qualification of teachers be secured. Private institutions, with their inadequate hospital facilities, school equipment, and lack of teaching staff, are incapable of meeting the situation. Moreover, since these institutions will be under the direc- tion of some agency of the Federal Government yet to be determined, it is imperative that the classes preparing teachers of disabled men should be controlled, directed, and supported by those directing their future work. In order to meet the difficulty of preparing people for occupations that are not at the present time followed in this country, the principle should be asserted that these people will be trained to follow a voca- tion, and that that vocation is the teaching of the handicapped. Every principle already set up in this country such as, for example, those established under the Smith-Hughes Act with regard to train- ing for vocations holds true for the training of teachers of disabled men. These principles of vocational education are: (1) Effective preparation for a vocation requires, first, practice; second, experience, with proper theory. (2) In order to determine what shall be taught persons preparing for any vocation, including teaching, the demands of the occupation are the first consideration. The organization of the work, the course of study, and methods employed should be constantly determined and shaped by this consideration. Only in this way can training be made direct and effective. (3) In any scheme of training for a vocation every requirement of the occupation should be dealt with in the course. This may be accomplished either by setting up entrance requirements of such a character as* to insure that the student already possesses a certain amount of training. This means, for example, that if it be deter- mined that instructors of disabled men must have a certain amount of manual, industrial, trade, or technical skill and knowledge, hos- pital observation and experience, or practical experience in invalid occupations or curative workshop ; or else experience in the vocational education of disabled men, together with an elementary knowledge of the medical, mental, economic, and sociological problems involved ; 24 TRAINING OF TEACHERS FOE OCCUPATIONAL THERAPY. then this training must either be given in the course or as much of it required before entrance as is practicable. In order to accomplish results, courses which are short must necessarily have high entrance requirements. (4) It is a well-founded law of psychology that a teacher can not successfully confer on others that which he himself has never ex- perienced. Vocational education the world over has come to rec- ognize that instructors of vocations must themselves be experienced in the vocation which they teach. This principle has been written into the Federal law. It is recognized by every agricultural and mechanical college in America, and by every private and public trade, technical, and engineering school. Not to observe it would be to violate a quarter of a century of experience in vocational educa- tion gained on both sides of the Atlantic. Applied to the teachers of disabled men, this means that they must be persons of experience in the subjects which they teach, and in addition possess special preparation qualifying them to meet the particular problem of the handicapped men. The first task confront- ing the United States at this time is to select and train the teachers of teachers of disabled men, and allow them practical experience in Canadian hospitals. SELECTION OF INSTRUCTORS FOR INVALID OCCUPATIONS. The first instructors to be trained should be carefully selected from the standpoint of their education, previous experience, and occupa- tional or technical knowledge. They should be chosen with the idea that they are to become directors of other training centers established by the Federal Government. They should meet as far as possible the different entrance requirements for teaching the various groups of men as outlined in the chart on page 22. Teachers of invalid occupations and simple occupations may be found who- have had theoretical training and practical experience. Technical and skilled instruction is not so much needed in teaching invalid occupations, though the instruction so far as it goes should be correct, as is tact, resourcefulness, patience, contact with the sick and a knowledge of the medical problems involved. Before such teachers will be permitted to direct the work of invalid occupations and simple occupations in the first Government hospitals for the dis- abled, or to train other teachers for teaching the disabled, they must qualify in a short intensive course of not more than four weeks offered by the Federal Government. SELECTION OF INSTRUCTORS FOR OCCUPATIONAL THERAPY. The teachers of academic subjects of an elementary nature will be found in the ranks of educated men and women, especially those who have had teaching experience. A course of four weeks' study of the medical and social problems involved in teaching the dis- abled soldiers, together with practical experience in teaching the subnormal, will serve as preparation for this group. Teachers of prevocational and vocational subjects in the curative workshops may be recruited from manual training teachers, from men who have had technical knowledge in the teaching profession, TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 25 and from the ranks of skilled workmen, foremen, and superin- tendents who are quick to learn and have developed teaching ability by helping their fellows. Such a group of picked men 1 will be able to take an emergency course. The course of study should include five lectures each week, a written test on the lectures and correlated reading on some phase of the problem of rehabilitation. The lecture period should be fol- lowed by classroom recitation or an informal discussion of the sub- ject, including the reference reading. The student should be required to keep a notebook of both lectures and reading. Each student should have a weekly conference with the instructor and should understand thoroughly the corrections on the written test. The final examination, weekly tests, notebooks, and recitations should form the basis for marking. The following course of study is divided into weeks according to the subjects covered. It will be followed by practical experience in Canadian military hospitals. COURSE OF STUDY. I. The problem of rehabilitation. 1. Survey of problem of rehabilitation from the wounding in the trench to placement in industry. 2. The three stages of rehabilitation : Invalid occupations, occu- pational therapy, and vocational education. Function and scope of each. -). Medical, social, and economic problems to be encountered in rehabilitation. 4. Psychology of the disabled soldier. Discussion and reading should develop the point of view neces- sary for the instructor. The reading should include accounts of rehabilitation in foreign countries, selected chapters from One Thou- sand Homeless Men, by Solonberger; Social Service in Hospitals, by Ida Cannon; and The Work of Our Hands, by Herbert J. Hall. II. Study of occupational therapy in convalescent cases of inters nal diseases, injuries, and postsurgical treatment (not orthopedic). 1. Physiological effect of muscular activity on the heart, lungs, circulation, digestion, etc. 2. Important points in the medical treatment of heart trouble, tuberculosis, and common diseases. 3. Relation of occupation to each of the above disabilities. 4. Relation of work and fatigue and indications of fatigue. Reading should include references from Fatigue, by Mosso, re- searches by Prof. Amar. and medical authorities on various diseases, etc. III. Study of occupational therapy in relation to orthopedic treat- ment. 1. Physiology and anatomy of bones, tendons, muscles, ligaments, and peripheral nerves. 2. Relation of occupational therapy to orthopedic surger}^ physio- therapy, mechano-therapeutics. and massage. Danger of wrong ex- ercise or strain. 1 " Men " is used in its generic sensr. 26 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 3. Occupational therapy in cases of amputations, exercise of stumps, study of Amar and other tests, etc. 4. Value of exercise in reeducating disused and stiffened parts. 5. Exercise in spite of permanent ankylosis-, and in relation to prosthetic appliances. Reading: References from the American Journal of Care for Cripples, from Prof. Amars researches, and selections from medical journals. IV. Study of occupational therapy in mental and nervous dis- orders. 1. Study of the central nervous system. 2. Pathology of neuroses and psychoses. 3. St udy of motor functions in relation to nervous system. 4. Effect of occupation, fixing the attention, interesting the patient, directing channels of thought, observing methods of work and ways of cooperating with the physician. Reading: References from Mental Hygiene, and writings of Drs. J. Madison Taylor, William R. Dunton, jr., Herbert J. Hall, Thomas AY. Salmon, etc. V. Technique of occupational therapy. 1. How to relax, stimulate, and coordinate the brain; how to con- centrate the mind; how to restore self-confidence and overcome de- pression, indifference, and excitability, 2. General exercises, exercise of certain parts, and kinesiology. In addition to reading from selected medical authorities, the student must prepare a list of processes from agricultural or com- mercial or industrial pursuits which may be suitable for relaxing, stimulating, coordinating, or concentrating the mind, and which may be used to restore self-confidence, overcome depression, indiffer- ence, and excitability. The student must select processes from one of the a^ove pursuits which will serve for general exercise and for exercise of special parts. VI. Study of occupations in relation to occupational therapy. 1. Analysis of industrial, commercial, and agricultural occupa- tions in terms of therapeutic values. 2. Modification of processes,, special devices and tools for special needs and fatigue prevention. The student must list common occupations in agricultural, com- mercial, and industrial pursuits, with reference to those occupations particularly suitable for various disabilities and combinations of dis- abilities, with possible machine devices and tool modifications for handicaps. VII. Methods of teaching. 1. Principles involved in teaching handicapped persons and dis- abled soldiers. 2. Methods of presenting processes and occupations. 3. Discipline and control of patients in curative workshops. The student should be given imaginary cases of disabilities with physician's instruction for treatment and the description of the patient's education and experience, From this he must present a plan for occupational treatment, following the physician's instruc- tion, and developing the patient toward the vocation suggested by the vocational expert. The student must show not only the patient's TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 27 -4 occupation in the curative workshop but the method of presentation and development of instruction. These should furnish subjects for class discussion. VIII. The curative workshop. 1. Equipment, upkeep, management, record keeping, and account- ing. 2. Physiological value of occupational therapy. 3. Psychological value of occupational therapy. The student should list equipment for different curative workshops and show diagrams of arrangement and prepare sample work charts, As the continued flow of returning men necessitates additional instructors they may be recruited from the ranks of the disabled men themselves. There will be among the patients men with previous technical experience who have shown marked capacity in the curative workshop and who possess teaching ability. These will make the ablest instructors, provided they fulfill the "requirements of teachers of occupational therapy. They understand more clearly than a civilian instructor the point of view of the returned man. The ex- ample, moreover, of one who has himself successfully passed through the experience of war and has overcome a handicap is a constant source of encouragement to the student patients. It has been said that no one better than a inutile can train a mutile. While a handi- cap overcome is a definite asset to a teacher of disabled men, and while many of the handicapped will undobutedly become teachers, a handicap must not be regarded as an asset offsetting other indispen- sable qualifications for an efficient teacher and leader of men. The French method of using the reconstruction hospitals as train- ing centers for instructors may be adopted with profit. The emer- gency course as outlined for the first instructors for returned soldiers may " be modified in the new training centers and many theoretical points abandoned for actual practice teaching. Before competently trained people will engage in this profession, and especially in the present war emergency, they must be assured adequate remuneration. Mr. L. G. Brock, in telling of the importance of adequate teachers for the convalescent hospitals of France, says : It follows, of course, that if great demands are to be made on the instructors they must be carefully selected and adequately paid. The best possible men must be secured without regard to cost, and those who fail to develop the requi- site qualities must be vigorously weeded out. QUALIFICATIONS OF TEACHERS FOR DIRECTING OCCUPA- TIONAL THERAPY. The courses of training as outlined are emergency courses only, de- signed to relieve the shortage of occupational teachers for the men who will return disabled from the front. The courses do not attempt to meet the problem of providing occupational therapy for civilian handicapped persons, who will in all probability outnumber the war victims by a large majority. Such training can best be provided in institutions offering long and thorough courses. Since occupational therapy dovetails in many cases with medical treatment and either vocational training or employment, it is funda- mentally necessary for the occupational therapeutist to have a back- ground of both medicine and industry besides the actual knowledge 28 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. and technique of the profession. Many of the failures of occupational therapy in the past may be attributed to the fact that it has been attempted by those equipped with a background of only medicine or industry. This accounts for the lack of shop management and prac- tical training when occupational therapy is directed by doctor or nurse; and equally for the lack of the patient's interest or therapeutic results when directed by a technical expert. The medical aspect of the problem is skillfully manipulated in the hands of the doctor or nurse, but they are usually ignorant of the variety of industrial proc- esses, the demands of competition, and the economic conditions to which the patient must adjust him,self. The shop boss or tech- nician, on the other hand, fails to understand the connection between physical debility and impaired capacity. However well his shop may be organized or however expert his skill, he will fail utterly with the handicapped unless he has a medical and social background, an intelligent sympathy, and an understanding of the psychology of the handicapped. An economic background is as essential for the occupational thera- peutist as a medical and industrial background. He must know the relative value of commodities, how to effect economies in purchasing, the danger of an over-stimulated market, what markets are de- pendent upon fads, or the fickleness of the public. The danger of turning men away from real vocations by successful but .superficial results in the curative workships may be thus avoided. The director of occupational therapy must know something of several occupations so that he may have a variety of resources with which to attract the patient's attention. He must have a first-hand and thorough acquaintance with at least one industrial occupation and a general knowledge of several others, so that he, if the unit is sufficiently large, or his assistants will be able to hold the patient's interest and develop him in practical lines over a considerable period of time. He must know how to restore self-confidence in the dis-, couraged, how to awaken ambition in the disheartened, and how to develop perseverance in the restless. Quick results are necessary for the encouragement of some, painstaking accuracy for the progress of others. The therapeutic value of a process is gone for some pa- tients the moment they master it, and recovery is measured by the systematic change from process to process, each demanding more initiative or concentration. Continued practice, long after the mas- tery of the process, gives to other patients just that assurance and self-reliance necessary for recovery. The occupational therapeutist must know the functions of muscles, how they may be exercised, how the brain may be stimulated or relaxed, and how the coordination of body and mind may be produced. The faculty for learning among the mature handicapped is slow; here infinite patience is required. Overexertion is particularly to be guarded against, and only the medical authorities should de- termine at what point it is safe to stimulate and force the patient. The best medical treatment may be nullified by strain or by failure to take proper exercise. It is, therefore, of the utmost necessity that occupational therapy be in the hands of one specially trained to understand these conditions and to carry out intelligently the doc- tor's instructions. Each disability has its particular limitations, possibilities, and methods of adjustment. The occupational thera- TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 29 peutist must be familiar with these as well us with the types of work which the patients will be able to perform on discharge, and the conditions under which it is advisable that they work. The cardiacs, for instance, must not be subjected to sudden muscular ex- ertion, nor the tubercular to dust and fumes. The patients must bo, trained for those vocations in which their disabilities will IDG re- duced to a minimum and their faculties increased to the maximum. There is at present no standard course of training or qualifications for directors of occupational therapy. Several institutions give courses, but none are complete or adequate as training centers. Dr. William Rush Dunton, jr., president of the National Society for the Promotion of Occupational Therapy, has gathered together the opin- ions of those best qualified to speak in an article entitled " Training of occupational teachers and directors," published in the Maryland Psychiatric Quarterly for July, 1917. The consensus of opinion is that personality is the first qualification of a teacher or ^director of occupational therapy. The peculiar problems involved in working with the handicapped necessitate force, resourcefulness, tact, sym- pathy, and courage, and these can not be acquired in any course of training, however elaborate. Miss Gunderson, of the Bloomingdale Hospital, has said: "The successful occupation teacher or director owes more to her tact and personality than to her skill in crafts." While personality is a foremost consideration in the selection of a teacher or director, it can not compensate for either lack of training or technique. Since occupational therapy is more and more becoming a part of hospital equipment, it is opening a new profession, and one for which the most careful training is necessary. The following course is suggested for the training of directors. A high-school course is prerequisite. The course requires four years, the equivalent of two years of college and two years of dis- tinctly technical study. The time of the first two years is equally divided between^ academic and technical subjects. The purpose of the academic subjects is to give the proper background for the more technical work. These subjects include chemistry, physiology, anatomy, English, and eco- nomics. Physics and geometry must be elected, if not offered for col- lege entrance. The technical subjects include mechanical drawing, design, and crafts. The course in design must be of the standard re- quired for training professional designers. Xot less than six hours a week for tw r o years is required in design, of which one hour is a lec- ture on theory, three hours' practice in abstract designing, and two hours in practical designing. Six hours a week for two years is re- quired for crafts. The first year includes the ^principles of several crafts weaving, willow T .and raffia work, stenciling, block printing, leather work, and metal work. The second year includes a detailed study of metal work. Metal work is selected because it holds the greatest number of possibilities in the use of tools and processes, and is more closely connected than other crafts with actual mechanical operations. The work includes complicated and intricate problems, so that the student may acquire skill, touch, and technique, and the general principles of hard and soft soldering, casting, contraction, expansion, and annealing of metals, forging, and electric wiring. On the completion of the first two years the student has a back- ground and a technical knowledge of design and craft. The purpose 30 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. of the following two years is to provide special training for directing occupational therapy. One semester of the junior year should be spent either as a volunteer worker under a competent factory inspec- tor, or, better still, on the pay roll doing factory work itself. No part of the student's training is more valuable than actual knowledge of lathes, machinery, quantity and quality of output, and industrial demands. The principles of the woodworking, metal, and building and electrical trades should be studied both in theory and practice. The academic subjects required for the remaining semester include psychology and sociology, together with a carefully selected list of medical reading relating to cause and effect, diagnosis, prognosis, and the special treatment of the most frequent disabilities with which the student will come in contact. It is assumed that the student has already mastered the principles of design and is ready in the junior semester for a course in com- mercial design. The emphasis in the crafts is upon the making of a marketable product, the study of costs, overhead expense, economy of purchases, shop management, and utilization of waste products. The principles involved in commercial education are surveyed and re- ord and bookkeeping are also studied in detail. One or two half days weekly in the semester are spent as a volunteer worker in the social-service department of a city hospital. The student receives his first contact with hospital patients under direction, and he becomes acquainted with their problems and methods of solution. It is desir- able that he find employment for some of these patients, so that he may have the experience of approaching employers, encountering the difficulties of placing these people, and learning the tact and com- mon sense necessary in the " follow work." At the close of the third year the student's theoretical and practical background is complete. He has an economic perspective, a first- hand knowledge of industry, a medical understanding of the relation between pathological conditions and impaired capacity, and has had personal contact with the subnormal. He has a knowledge of com- mercial design and of the tools and processes not only in hand but in machine industries as well. The first semester of the fourth year gives the opportunity for the study of pedagogy and for more medical reading, with special study of fatigue, function of regulated activity, and the mechanism of re- covery through the psychology of occupation. The purpose is not to give the student sufficient medical knowledge to enable him to deter- mine the treatment by occupation, but to enable him to carry out in- structions intelligently and to cooperate in securing the results the doctor wishes achieved. " The physician may prescribe occupation in a somewhat general sense, as, indeed, he might prescribe in the diet more protein and less carbohydrate ; the decision as to whether it shall mean a dropped egg or a bit of beefsteak, less potato or less toasted bread, falls more naturally to the province of the nurse." 1 While the doctor may recommend a sedative, or a stimulating occu- pation, or active exercise for certain stiffened joints, it is left to the skilled occupational therapeutist to decide whether the desired results 1 Invalid Occupations, by Susan E. Tracy. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 31 will be best accomplished and best suited to the vocational needs of the patient by typewriting, motor mechanics, drafting, planning, or agriculture. The emphasis in design and crafts in the senior year lies in methods of teaching rather than in technical proficiency. The last semester of the fourth year is reserved for practice teaching under the direc- tion of an experienced occupational therapeutist. Such a course as outlined suggests ideal conditions in its cooper- ation with factory inspector and the hospital departments of social service and occupational therapy. If such conditions do not exist, the course of study might be shortened to three years and the student required to have some teaching and factory experience before becom- ing a director. The course might be shortened still further to ad- vantage provided the student has knowledge of the type of institu- tion and patients with which he would come in contact. For instance, it would not be necessary for the student to have a knowledge of factory processes and industry if his patients are in a private sanitarium recruited from the leisure or professional classes. On the other hand, if his patients belong to the working classes, and come from the farm, the skilled or the unskilled trades, he might eliminate the design and crafts from his course of training and specialize more particularly on the therapeutic effect of industrial occupations and vocational education. A student already possessing technical knowledge or medical knowledge would be able to shorten the above course to a large extent. Both men and women may become expert directors and assistants of occupational therapy. When classes are separated it is desirable that women teach women and men teach men. When, however, occu- pational therapy is given to really sick men, as occurs in many in- stances, women with the natural ability of the nurse have been found to make the ablest instructors. When men are able to follow a fairly regular course, and especially when it has a technical value, it is expedient that the instruction be given by men who are proficient in their lines. Such a general course as outlined would necessarily prepare the student to be a jack-of -all-trades. This is desirable in the case of training of the occupational therapeutist who is unassisted and who must offer a wide range -of activities. It is equally desirable in the training of the director of occupational therapy of a unit sufficiently large to include several assistants. The assistants should have spe- cialized training in different lines. While they should be familiar with the kind of instruction necessary for the subnormal, they do not require the wide background described in the course of training for directors. Assistants may be recruited from the ranks of competent nurses with a knowledge of tools, or technicians with a knowledge of the problems involved in teaching the handicapped. QUALIFICATIONS OF TEACHERS FOR VOCATIONAL, EDUCATION. Ill addition to the requirements of the regular vocational instruc- tor, the instructor of the disabled soldier must know those points in which his soldier pupils will be different from the normal pupils to which he is accustomed. The shop instructor, even more than the instructor of related or academic subjects, must be highly skilled in 32 TRAIXIXG OF TEACHERS FOR OCCUPATIONAL THERAPY. his trade for the reason that many of the men will have had experi- ence in that trade and that, unlike the raw youth in vocational classes, they will be critical and unwilling to learn from one not markedly their superior. As a rule, the boys of vocational education age are eager, quick, and teachable, whereas many of the returned soldiers, though young enough to have receptive minds, are of maturer age. The fact that they have been returned unfit for further military serv- ice indicates that in some way, either by lessened vitality or perma- nent handicap, they are below par. Moreover, the experience of war has been a mentally paralyzing experience and the instructor must be patient and must understand his pupil. In addition to intelligent sympathy, the instructor must .maintain regularity and meet the requirements of the vocational school, for vocational education leads directly to employability. The patients do not enter the vocational classes until the medical authorities have discharged them or else state that their physical condition will permit a regular course of study. The duty of the instructor, aside from giving the technical infor- mation, is to take the patients, after their periods of convalescence, in which the demands of occupational therapy may not always have been as stringent as desirable and prepare them to meet the full and regular requirements of industry. Inasmuch as up to the time of discharge the patients have been more or less constantly under mili- tary discipline, and since they must enter industry as civilians the period of preparation for civilian life coincides with the period of vocational education. The instructor may be of valuable assistance during this trying time by maintaining a discipline in the school that is initiated and participated in by the patients themselves. He must, moreover, teach them to be self-reliant, to think for themselves, to work hard, and to observe hygienic rules of living which are self- imposed rather than commanded or ordered. The best vocational instructors must be selected for training the disabled patients, not only because they require the best possible in- struction but because the problem of teaching them is particularly difficult and important. EQUIPMENT. (a) Invalid occupations. The equipment for invalid occupations is necessarily restricted to that which may be used in bed or a chair, and is of a very light character. Bed tables, slanting desk, and a bed bench are necessary. The slanting desk should be tilted to any angle which may accommodate the restricted positions of patients sustaining fractures, injuries, and deformities. The bed bench allows a small vise, and not only permits many occupations otherwise im- possible for lack of the strength required in holding, but allows oc- cupations for the one-armed. The occupations possible cover a wide range, depending upon the patient's education and inclination. A typewriter will enable those patients who have become blinded or who have lost the use of their right hand to write letters to their friends, pass the time, and exercise stiffened fingers. Typewriting is an occupation of interest and profit. Other patients will be interested in the elementary principles of bookkeeping, salesmanship, mechanical drawing, mathematics, etc., TRAINING OF TEACHERS FOB OCCUPATIONAL THERAPY. 33 while those without a rudimentary education may be benefited by learning to read, write, and figure. Whittling, bookkeeping, net and hammock making, leather work, and other light work requiring such equipment as small looms, hammer, pliers, paste, scissors, knives, raffia, twine, rules, paper cutters, letter presses, etc., are practical for invalid occupations. (b) Occupational therapy. Crafts, commercial training, educa- tion, and drafting require only a small outlay of equipment. As oc- cupational therapy, however, attempts to give training of a practical type and to provide vocational education wherever possible in the trades, the equipment must permit at least the elementary stages of such training. The average small hospital will not be able to afford either an elaborate or extensive equipment for this purpose. In fact, even technical schools, with a variety of equipment, are not always able to teach all of the skilled trades, and the student must, in many instances, get his final instruction in the factory itself. Elementary processes, foundation work, and related subjects may be selected for trade training for the hospital unable to provide an extensive equip- ment. Simple processes, with a theoretical knowledge and an im- proved general education, are of practical value. The problem of equipment is simplified in large county or State institutions. Not only is a large equipment needed to accommodate the patients, but the institution may economically afford to specialize in one or more industries giving real trade training and finding a market in other institutions as well as providing necessities for the institution itself. The repair and upkeep of a group of large institu- tions under direction furnish valuable training. Besides the oppor- tunity of a possible machine shop, woodworking shop, farm, and care of building and motor trucks, printing may not only teach the essen- tials of the printing trade, but provide the printing of all record blanks, notices, reports, etc., for the hospital, as well as the printing of other county or State material. Since the reconstruction hospitals will be located in different sec- tions of the country and the patients will be sent to the hospitals suited to their needs nearest their homes, it will not be necessary to install all lines of occupations in industry, commerce, and agriculture in every hospital. For instance, the hospital in the Middle West would need agricultural opportunities rather than the textile trades of New England. Those occupations should be taught which are typical in the area to whicji the patients will return. Moreover, it is advisable to separate the patients according as their disabilities require special medical and occupational treatment. For instance, the blind are grouped together so that they may have the benefit of skilled oph- thalmologists and the instruction of those specially trained for teach- ing the blind. They will, moreover, be taught only those occupations which it is practical for the blind to follow. The same is true of the deaf and the tubercular. It is desirable that the tubercular and gassed patients should have work of a light character, free from dust and fumes, and requiring deep breathing. Out-of-door work can be found for cured tubercular patients in rural communities or for those who wish to go to the land, while light work out of doors or in well- ventilated factories and offices may be secured for city patients. Only those industries which exist in a given area and which are suit- 42298 S. Doc. 167, 65-2 3 34 TRAILING OF TEACHERS FOB OCCUPATIONAL THERAPY. able for orthopedic patients, or which are capable of modification, need be offered in the orthopedic curative workshop. Cases of neu- rasthenia, shell shock, and insanity should not only be separated from other cases, but from one another. Inasmuch as complicated and noisy machinery and intricate processes are not adapted to neuras- thenic or shell-shock cases, the equipment for these curative work- shops may be comparatively simple, including gardening and outdoor work, hand industries, drafting, blue-print making, general educa- tion, and only elementary stages in shopwork. Hopeless insanity may be provided for in the regular asylums. The general hospital would have to provide the greatest range of equipment in its curative- workshop, but it could be limited to the industries in the district and omit those occupations particularly suited to the blind, deaf, tuber- cular, etc. The upkeep of the reconstruction hospitals, all repairs, carpentry, glazing, plumbing, machine work, driving, care of motor trucks and gardens should be performed by the patients under direction as part of the course of training. The responsibility of the Government to provide practical occupa- tional therapy for the returning of the men to the industries from which they were taken will necessitate equipment suited to the pur- poses and needs for training the disabled soldiers in the curative workshop. The problem of equipping the curative workshop is unlike the problem of equipping the private, the county, or State institutions, where the outlay in expense must be considered in rela- tion to possible returns from the shop, and where many of the patients, while benefited by occupational therapy, will never be able to follow wage-earning occupations. Unlike many of the patients in these public institutions, the majority of the disabled soldiers will be able to follow wage-earning occupations, provided that the occu- pational therapy designed for them is immediate and practical. It is a far-sighted economy to return men to industry by training them to be self -supporting and independent economic units, and to attain this end the Federal Government is justified in making a large expenditure for the equipment of the curative workshop. The problem of equipping the curative workshop becomes then one of intelligent expenditure and cooperation with other Federal agencies, so that the equipment may provide practical training in itself or else be of such a type as to prepare for subsequent vocational or factory training, which in turn prepares for employment. PART II. FUNCTIONS OF OCCUPATIONAL THERAPY. It has been long known that treatment by occupation has a definite therapeutic value. Originally the benefit was supposed to be due entirely to the fact that such treatment " killed time " for the patient, but later it was found to have a definite effect on the mind and spirit, and consequently a favorable reaction on the physical condition. It was frequently observed that, while the patient's mind was absorbed in mastering an occupation in the hospital workshop, his interest was awakened, his ambition stimulated, his morbid and brooding thoughts eliminated, and his hope and self-confidence were restored. More recent analysis of the function of occupational therapy discloses the fact that, in addition to producing mental changes, it may also impose certain bodily changes. Although the fields of the mind and the body are fundamentally related, occupational therapy may be considered from the point of view, first, of psychological functions and, second, of physiological functions. PSYCHOLOGICAL FUNCTIONS. In every functional disturbance, in addition to disorders of the central nervous system, there is a mental reaction. Pain, anemia, impairment of circulation, and sense impressions and emotions, such as anxiety and depression, are all communicated to the brain, which may be either highly sensitive or dull and apathetic, often showing such extreme symptoms as ennui, melancholia, restlessness, morbid introspection, discouragement, and fear. In ennui the tonicity of the muscles is affected so that they actually contract less strongly and develop less force. In melancholia the general physique, and especially the heart, is acted upon. Restlessness, or so-called nerv- ousness and lack of concentration, is muscular activity of a wasteful type and gives rise to harmful fatigue. Morbid introspection pro- duces a particularly vicious cycle of thinking, since continued atten- tion focussed on any particular part of the body may actually in- crease its morbid condition. Discouragement and fear have a tendency to impair circulation, which may produce serious results upon the heart, digestive apparatus, and muscles. It lies within the province of occupational therapy to regulate and improve some of these conditions. Ennui and melancholia, for ex- ample, may give place to a more normal state when the patient has become interested in an occupation. Inasmuch as those who suffer from ennui and melancholia are particularly susceptible to fatigue, the occupation chosen for their cure should be simple, and the treatment should be given in short periods in order to avoid 35 36 TRAILING OF TEACHERS FOR OCCUPATIONAL THERAPY. undue fatigue. Variety and more complicated processes are neces- sary, however, as the patient improves, and gradually the treatment should require increasing concentration. Again, restlessness, nerv- ousness, and lack of concentration require the focussing of the attention upon constructive work. An occupation of a sedative or relaxing type which may have a certain degree of monotony about it which is not exacting and which may be pursued for long periods of time has a tendency to normalize. For the morbidly introspective patient an occupation must be selected which will turn away his accustomed line of thinking and at the same time offer sufficient inter- est and variety to hold his attention. Recovery may frequently be measured by the greater complexity of occupations undertaken, each demanding greater application than the one before it. Dis- couragement and fear may be overcome by a simple or monotonous occupation, provided the patient masters it and continues to perform it with satisfaction to himself and with growing self-confidence and hope. The mechanism of mental recovery by occupational therapy is simple. " But one idea can occupy the focus of attention at a given time." * In other words, an occupation which requires the patient's attention excludes, at least temporarily, all harmful thoughts. As Dr. J. Madison Taylor has pointed out : It is to the last degree unfortunate for the patient if suitable conditions are not provided with outlets for energies until evil mental habits have continued beyond the stagnation point where they may be radically corrected. All persons are subject to variations in self-control, to ups and downs of < iHTgy, impulse, emotion, action, judgment. Some minds are inherently well poised, but most have suffered greater or less derangement in normal responsiveness to external and internal impres- sions. There is then disharmony between receptibility, interpretation, impulse, and determination. Such a disharmony leads to many complications but may be cor- rected if " volition can be made to precede action " and " decision and action made clear and enforced." Properly directed occupation can do much toward developing volition and its proper execution. It may, for instance, stimulate an idea. In some persons ideas spring to life in profusion, in perfection, and in- stantaneously; others require much time, and then ideation is often unclear. Training can do much to enhance or retard. 3 The idea or sensation has a natural desire to express itself in action. If there be no image there will be no concept, and no concept can be formed without an accompanying motor outflow. 2 It is the task of the occupational therapeutists to direct this motor outflow so that indecision, doubt, and fear do not prevent the logical execution of the idea. Execution may be guided during the performance of the occupation. As the patient progresses he should be given occupations demanding more intricate and difficult mental processes and requiring more rythmic, accurate, and deliberate physical movements. 1 Occxipntipnal Therapy, by William Rush Dunton, jr., instructor in psychiatry, Johns 2 P Dr? S J. Madison Taylor. Psychic Hypertension : Restoration of Mind Control by Motor Training in Relaxation. International Clinics, Vol. II, series 22, 1912. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 37 Muscular energy is so closely associated with tlie integrity of neurons that all influences affecting them become of extreme significance, whether bearing upon mental or physical competency. Right habit formation is based on right guiding in motor impulses, and is essential to right thinking. * * * Per- haps in time mankind will learn that exercise is a normal and needed use of motor machinery, developmental, educational, or reparative. 1 Muscular training and the development of the entire motor forces in action may be carried on by properly prescribed and conducted occupations for " work is the product of action, good work, of normality in the sum of actions." 1 The mental poise, control, optimism, and activity thus newly ac- quired reacts favorably upon the entire body and facilitates recovery by assisting in such of ^the functions of life as nourishment, the pro- duction of digestive juices, and the cycle of metabolism. Prof. Amar 2 has noted in this connection that soldiers who have per- formed some praiseworthy act and are consequently happy recover rapidly from their wounds. Amroise Pare, the great French surgeon of the sixteenth century, went so far as to say " the happy always recover." However exag- gerated this statement may be, the fact is significant that contentment reacts favorably upon the entire physical system and that sadness or worry produces a condition characterized by muscular-nervous de- pression, inhibition, retarded respiration, and enfeebled heart and circulation. PHYSIOLOGICAL FUNCTIONS. Physical recovery is measured by the growing muscular power of the patient, his coordination, and his resistance to fatigue. Neither of these can be acquired suddenly ; they must be developed by gradu- ated activity. Muscular exercise affords varied and valuable fields of usefulness. It relieves the heart by emptying the veins ; it replaces fat by muscle, and thereby prevents the stagnation of blood and lymph in tissue which does not spontaneously expel it; it increases oxygenation of cells and tissues ; and it enhances digestion and metabolism. Activity is essential to health; it is necessary in rebuilding tissues and in the process of recovery. Dr. Taylor, in his Remarks on the Treatment of Chronic Disease, goes so far as to say : Much can be achieved by bringing into line the functional power of the organs and tissues so as to secure the completest transformation of dynamic into kinetic energy no matter what the morbid agency. Health and recovery depend to a large extent upon thoroughness of oxygenation. Faulty oxygenation results in accumulation of acids and toxins. While respiration is the basis of oxygenation, the mus- cular system is a powerful aid. Muscular activity produces deep breathing, and the oxygen acquired through the lungs and consumed by the muscles in contraction provides natural oxygenation and de- stroys acid products. 1 Dr. J. Madison Taylor. Psychic Hypertension : Restoration of Mind Control by Motor Training in Relaxation. International Clinics, Vol. IT, series '22. 101 2 Direct eur clu Laboratoire de Recherches sur le Travail Professional au Conservatoire National des Arts et Metiers. 38 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. The most powerful drugs can do little for ultimate restoration of capacity if the great oxygenating laboratories, the muscles, cease to play their essential cooperative part. 1 All muscular activity is registered in respiratory functions. The deeper breath, the fuller heart beat, the quickened circulation are true tonics. The problems of oxygenatioii and oxidation can be made sim- ple, and can be applied in the routine of daily work. For these rea- sons it is the task of the occupational therapeutist to direct the ac- tivity of the patient so that he shall benefit^by the exercise of his oc- cupation, adapting the exertions required in that occupation to the patient's changing physical condition. When the gain in strength warrants further movements of the arm, trunk, neck, and legs, they can be employed with advantage, measured by time and forcefulness, rather than by the number and variety of movements. 1 The proper activity of the invalid is most important, for the reason that his endurance is limited, easily fatigued, and his motor ma- chinery tends "to lose range, scope, elasticity, and nicety of ad- justment.'' After acute illness there follows slower oxidation * * * and also, partly as a consequence of this, a habit of mind discouraging energizing, or there may follow injudicious impulses to action, the product of commendable yet imperiling tissues far from stable and which require wise training. 1 The relation of activity to fatigue is fundamental ; the weaker the patient the less his resistance to fatigue. Great care must be exer- cised that no strain falls on any part, for the body is no strc than its weakest organ, and too great or prolonged muscular activity produces sarcolacite and carbonic acids in excess of oxidation, which may result in hyperacidity and subeatabolism. The value of proper activity is so great and the danger of over- doing or doing the wrong kind of thing is so serious that no patient should undertake any kind of exercise or occupation without the order of the physician. The exercise should then be directed and 'watched by one skilled in this particular practice and trained to note signs of fatigue. It is the duty of the occupation*! thera- peutist to restrain feverish and excitable attempts on the part of the patient or to strengthen languid motion, and, above all, to carry out the doctor's orders intelligently. For instance, the doctor may prescribe certain movements of the arms. These movements may be accomplished by dumb-bell exercises, but they can be made far more effective and of greater interest to the patient if a hammer, plane, or saw is used instead. The weight of the tool, the nature of the material iron, copper, etc., annealed or tempered; wood, hard or soft all call for different lands of exercises and varying degrees of energy. Different muscles are used in planing the top of a surface from those used in planing an under surface or taking off an edge. The patient may hold his body rigid, using only the muscles of his arm in hammering and expending as much energy on the down stroke of the hammer as in lifting it on the up stroke. In such a case relaxation, bodily rhythm, and coordination are impossible, and the arm must experience unnec- essary strain and fatigue. On the other hand, the patient may stand 1 Dr. J. Madison Taylor. Motor Education in Convalescence and Invalided States. Medicine, September, 1905. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 39 with his weight on his left leg, provided this is in accordance with his physical condition, and feel the impetus from the ankle or toe of his right foot extend through and coordinate all the muscles of his body, which terminates in an even and rhythmic lifting of his right arm. The hammer, with nicely balanced head and handle, allowing vibration, describes an arc and falls of its own weight with a blow far more forceful than can be effected by using strength on the downward stroke, and thus the patient's strength is conserved by half. The law of repose, as stated by Jules Amar, reads : The muscle returns to a state of repose in proportion to the speed with which it was exercised. 1 The expenditure of energy is in proportion to the activity of the muscles, in relation to their coordination and contractions and the intensity, duration, and speed of their movement. All these fac- tors determine the degree of fatigue, and must be considered in any attempt at muscular restoration. The following laws of Chauveau may be noted in this connection : x The expenditure of energy is proportional to the effort of the contraction of the muscles, to the duration of the effort, and to the degree of muscular recovery. There exists the correct effort and speed to produce the maximum work with the minimum fatigue. Occupational therapy may accomplish a general toning of the heart, lungs, vasomotor system; increase resistance to fatigue ; develop physical efficiency by intelligently conserving wasteful energy; exer- cise particular parts to regain their functions; train sense organs which have become blunted by disorders of a nerve or traumatic origin ; and improve the entire psychic condition of the patient. INTERNAL DISEASES, INJURIES, AND POSTSURGICAL TREATMENT (NOT ORTHOPEDIC). The method of building up the physique and of increasing re- sistance to fatigue necessarily differs for different types of dis- ability. After eliminating disorders of the central nervous system, disabilities, from the point of view of their occupational treatment, fall into two main classes first, internal diseases and injuries; and, second, cases requiring orthopedic treatment or surgery. The most frequent disabilities included under internal diseases and injuries are tuberculosis, heart trouble, arteriosclerosis, rheuma- tism, kidney trouble, and general debility and surgical cases not orthopedic. The occupational treatment of each of these disabilities has many points in common, such as the gradual increase of nervous and cardiac tonicity by regulated muscular activity, improved mental condition, and avoidance of strain and fatigue. The doctor must, of course, prescribe the kind and extent of the exercise in each case. There are, however, a few important points to be considered in the occupational treatment of certain disabilities. For instance, the emphasis must be on "graduated labor" in tuberculosis. This is advocated by Dr. M. Patterson, of Frimly, England. Progress in the cure of tuberculosis must begin with com- plete rest, necessary to check the disease, though ultimately weaken- ing the muscles and bodily functions. When the patient is up and 1 Translated from Organisation Physiologique du Travail, by Jules Amar. 40 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. begins his exercise it must be by prescription * of the doctor and increased from as short a period as 15 minutes once a day to 30, 45 minutes, 1 hour, 2 hours, etc., till the patient is able to work 8 hours a day at an occupation demanding a fair degree of muscular exertion. The occupation of the patient should be selected in no haphazzard way, but should be considered in the light of his future employment. The speed with which he may increase the periods^of his exercise depends upon his temperature, pulse, sputa examination, and the ob- servations of the physician. A work chart further assists the physi- cian in shoAving the patient's methods of work, reactions, and fatigue. u Cured, but unfitted for labor," is the chronic complaint of tuberculosis patients. This does not apply to those patients who have received occupational treatment during convalescence. With- out such treatment patients not infrequently suffer a serious recur- rence of the disease upon attempting a normal day's work with muscles weakened by long disuse in the sanitarium. The occupa- tions for the tubercular should necessarily be light, requiring deep breathing, outdoors if possible, or, if indoors, in a well-ventilated room of even temperature and free from fumes, dust, and dampness. The Association for the Prevention and Relief of Heart Disease 2 states that more people die from heart disease in New York City than from tuberculosis, and that the death rate from heart trouble is steadily increasing. Vital statistics of the Census Bureau show that heart disease is one of the three diseases causing nearly one- third of the deaths in the registration area of the United States. Methods of treatment for heart disease are undergoing changes, but a proved method of treatment includes exercise, prescribed either by a heart specialist or by one who has had wide experience with the dangers, difficulties, and complications of heart disease. The emphasis in the occupational treatment of heart trouble, like that in tuberculosis, lies in the graduation of the exercise. There is no disability in which prevention and early treatment may play a more decisive part than in heart trouble. Adequate convalescence, graduated exercise, and proper occupation, with avoidance of sudden muscular exertion, may prevent heart trouble of a serious and hope- less type. 3 1 At Mumlale Tuberculosis Sanitarium, Milwaukee County, Wis., an exercise permit card signed by the physician is given the patient when he is able to go to the work- shop. It has been found to be a matter of psychology to head the card " exercise permit." The patients enter more enthusiastically into that which is permitted rather than required. On a bulletin board in the shop is posted each week the names of those patients who are permitted increased working hours. The patients take great pride in the bulletin board and post items of interest, such as work of patients in other places, suggestions of articles to be made, etc. The bulletin board has not only improved the morale in the workshop, but has created an interest and spirit throughout the entire sanitarium. 2 The Winifred Masterson Burke Relief Foundation has made valuable contributions to the study of convalescence, not the least of which has been the convalescence and treatment of cardiacs. At the convalescent home maintained by the foundation, of which Dr. Frederic Brush is superintendent, 800 patients suffering from organic heart disease have been treated. Many of them have returned to productiveness after a record of months in the hospitals. 3 The 1914 report of the Social Service Bureau of Bellevue and Allied Hospitals shows that, without adequate convalescence, occupation, and suitable work, " the progress of the ' cardiac ' is a downward one if he is of the laboring class. His latter history is usually that of a ' hospital repeater ' and dependent. * * * We accept his decline to misery and dependency as inevitable, not realizing that, even from the economic point of view, this is a wasteful attitude." Medical and social care of cardiacs has decreased the time spent in hospitals. They have lessened the patient's suffering, lessened expense, and improved industrial efficiency. A record of 6 cases showed that 251 days, or an average of 42 days per case a year, were spent in the hospital. Not a single day \yas spent in the hospital by the samp 6 cases after entering the class for cardiacs. A saving of $439.25 was thus effected. Moreover, the earning capacity of 35 patients was in- creased from $12,477 before attending the class to $20,347.50 after attending, an in- crease of 71 per cent. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 41 In arthritis the situation is somewhat the same as in heart disease. Much of this class will naturally be cared for along with heart disease, and heart disease is going to be covered in more comprehensive ways in the neap future. 1 Arthritis, paralysis, and deformities following nerve injuries, and selected cases of tabes dorsalis are benefited if muscles and joints, are not allowed to stiffen and become inactive. Patients suffering from kidney trouble are liable to extreme fatigue and lassitude. Their occupation must be light, and they must not be exposed to cold or uneven temperature. In all cases of general debility, protracted surgical dressing cases, and serious internal diseases, convalescence is an important feature of recovery. As Dr. Brush has said of convalescent institutions, they adopt the most effective restorative agency known "to the half- sick, the handicapped and subnormal, the failing, the depressed. Sleep, exercise, rest, feeding, amusements, diversional and hardening occupations, companionships, care of minor ills, mental and moral slants, home betterments at the same time, and future enx ployment are all studied and adjusted to the individual * * * and the results are inevitable and inspiringly good." Dr. Brush describes his occupational treatment at the Burke Foun-: dations, White Plains, N. Y. He says : One soon learns that convalescence at best is fully half mental. Our occupa- tion is considered not chiefly diversional but remedial, reconstructive, curative, convalescent, normalizing. It is not a side issue; it costs; it is our best medi- cine. It is prescribed, in writing, for more than one-fourth cardiacs, hyper- thyroids, choreics, all the border mental and nerve folks, the inherently restless, all long stayers, the temperamentally difficult, the quitters, the pampered, the disheartened. Of the result of the work cure he has said : We have records of these people back at normal living. We are knowing that they were not lazy only mislead, mismanaged, misenviroued. Now come the newer long-term and more testing phases, giving (ever w T ith a small per- centage of failures) end-products, which may be indicated as follows: Cardiacs who have been much in hospitals and dependence strengthened to maintain steady occupation ; * * * nearly nervous and mental borderliners of many kinds, turned back by occupational and mental therapy principally to fair liva- bility and content, * * * rheumatics in limited selection, given long terms, particularly for their hearts' sake, and at last sufficiently toughened for com- petition by graduated play and work, * * * various subnormal youths set forward with weight, blood, nerve, posture and character, and educational addi- tions that are fairly permanent; protracted surgical dressing cases in large numbers carried to earlier and solider healing plus hardening for work, hyper- thyroidism afforded long rest plus nerve and heart training with notably worthy results * * * these are some of the better and harder things now being done in convalescent institutions. ORTHOPEDIC SURGERY. The following classification of orthopedic cases corresponds to that which haa been decided upon by the British Government and is the outlined classification of the Surgeon General of the United States Army : (a) Derangements and disabilities of joints, simple and grave, including anchylosis. (ft) Deformities and disabilities of feet, such as hallux valgus, hallux rigidua, hammer toes, metatarsalgia, painful heels, flat and claw feet! 1 Dr. Frederic Brush. The Convalescent Field Its New and Changing Border Lines. Modern Hospital, June, 1916. 42 TRAINING OP TEACHERS FOR OCCUPATIONAL THERAPY. (o M.iluuited and miimited fractures. (0 a month. Took five months' course of commercial work and is now earning ,$87.50 as bookkeeper in the ordnance department. Pvt. J. E. Billett was a general laborer previous to enlistment, earning a variable wage. He took a six months' course in woodwooking room at Deer Lodge and is now earning an average wage of $70 a mouth as a wood carver at the Alaska Bedding- Co. Pvt. Wilkie was a blacksmith's helper before enlistment. He took a short course in the blacksrnithing and oxyacetylene-wekling class at the Kelvin School and is now employed by the Winnipeg school board as a blacksmith and oxyacetylene welder, at a salary of $90 a month. No. 22921, Sergt. , Twelfth Battalion : " It is indeed gratifying for us (returned soldiers) to know that there is such a place as the vocational-training school, to which we can go on our return to Canada. " I had the pleasure of being there for two months, studying shorthand and typewriting, and then, through your recommendation, I was able to get a very good position as visitor in the Montreal district ottice of the board of pension commissioners for Canada." The following letters express the points of A'iew of three grateful Englishmen and one Irishman. 1 DEAR BOYS : I joined up on August 30, 1914, in the Royal Engineers and was wounded at Loos by a ritle bullet in the head, leaving my right arm paralyzed and at times severe pains in the liead. I must say this made me very despond- ent and downhearted, and I did not look forward very hopefully to the future on my discharge from hospital. I believe I was one of the first boys to start a course of training for disabled soldiers. I must say that the careful instruc- tion which we boys received greatly bucked and encouraged us for the future. 1 started work for the New System Telephone Co. under the chief engineer, who lias greatly interested himself in me and other wounded soldiers to be tele- phone engineers. The work is of an interesting nature. I was a butcher before joining up, but having trained on for this new work I can now look forward to the future with a light and glad heart. I can only say to all the boys who may read this don't be downhearted. I was once, but not now. So cheer up, boys. Believe me, yours, sincerely, A. CLAY. SIK : I left school at the age of 14 and then worked at a cement factory as a laborer. After serving six years and reaching the position of a leading cook I was blown up in the North Sea by the enemy on board H. M. S. Lightning, a destroyer, in which I was dangerously wounded and lost my right leg. I used to worry when I thought how I could earn my living the rest of my life, but after I heard there was a chance to learn a trade I cheered myself up and went in for handsewn bootniaking. I am sure there are good prospects in life once it is learned. I have now finished my training of a year and am going into a job in the West End of London. I have been trained free at the Cordwaiuers' Technical College, where we had good teachers and are well cared for. I was pleased when I got my first 9s. 9d. for the pair of ladies' shoes I made. I can make all sorts, so I shall be able to take work all the year around. Yours, respectfully, CHARLES W. WOODING. We went out to the Mediterranean and then to Gallipoli, where I was badly wounded and lost my right leg (very high amputation). My previous occupa- tion having been that of a gardener, I began to wonder what I should do. I then joined a special course of electrical work whilst in hospital and went to a training center after leaving and got on so well that I got a good job at the C. A. V. Magneto Works, where I am doing very well; the work I have to do suits me, as I can sit down at it. I would advise everyone who can not go back 1 Recalled to Life, No. 1. 72 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. to their old jobs to learn a trade. I am earning more now than I did before I joiiied up, apart altogether from my pension. CH. E. JANKS. I was in the merchant service before the war, but joining the Irish Guards March, 1915, went out to France, took part in the fighting at Loos, and was wounded at Ypres. I got a shell wound in the shoulder which has rendered my right arm nearly useless. I took advantage of the offer of being trained as an electrician storekeeper, and after three months' training have obtained a good situation, and the work is quite easy for me notwithstanding my disablement, which prevented me following my former occupation. F. POWER, Lute Irish Guard 8. SUGGESTED REGISTRATION AND RECORD "BLANKS FOR CHARTING PROGRESS OF PATIENTS. The following blanks are suggested for charting the necessary data of each patient from his entrance in the hospital until his discharge and placement in industry, vocational school, or institution. Hospital registration, Form 1, provides the patient's name, rank, and home address. It shows the handicap with which he enters the hospital, his previous education and training, his former occupation, income, and the possible future occupation he will be able to follow, with suggestions for vocational training or improvement. The social information will be of value in placing the men, and the opportunity for communicating with persons interested in the patient's welfare is provided. The curative shop weekly record, Form 2, indicates the patient's changing physical and mental conditions, with physician's instruc- tions and recommendations of the vocational expert. The observa- tions of the instructor, which show the patient's methods of work, the quantity and quality of his output, will be of value in placing. Hospital discharge, Form 3, is printed on the reverse of Form 1, hospital registration, which has already recorded such social history of the man as is desirable. Provision is made on Form 3 for showing changes in handicap, education, and vocational training since conva- lescence in the curative workshop. The patient's placement, whether in industry, vocational school, or institution, is recorded, as well as" the persons communicated with and responsible for his follow work. The vocational school weekly record, Form 4, shows the student's progress in vocational education and his qualifications for employ- ment. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY, 73 0) g I -d a .2 S g' | i 8 ^ i 8 g - ^ ...Medical g 1 4 | 4 File No 1 i 1 j i i 5 | 1 O h 1 ft? ? FORM 1. ,L KEGIST] j 1 j ! i ^ ! HOSPITJ Knriolv Huh _c 't I 1 5 i j 1 j C 2 ^ r c ^ .! i \ 5 H i || i Training. ~f c E 't c ft i i | w ! 2 1 X c / 3 i ; ' i, j 3 e 1 < 1 ' C < i 'i t i' II ' P k i j 3 9 74 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. 75 i it: obable inc suppo & I 1 j 1 5 " w 7 I H * 1 M .2 | 2 e 02 ,2 t 1 03 | ^ ^ Institutic r^ c^ OQ K- W tt | 5 g 1 1 g 1 1 O K ; 73 | * g rC c^ r,. I c T3 1 E E | Comm 76 TRAINING OF TEACHERS FOR OCCUPATIONAL THERAPY. I I I a H-q tf O * m hand ncy. 1 . o.2 l| "3 I o THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW AN INITIAL FINE OF 25 CENTS WILL BE ASSESSED FOR FAILURE TO RETURN THIS BOOK ON THE DATE DUE. THE PENALTY WILL INCREASE TO SO CENTS ON THE FOURTH DAY AND TO $1.OO ON THE SEVENTH DAY OVERDUE. MAR 6 l4b MAY 13 1946 IMTCDI IDD AOV I r*\AHi INTcRUBRARY LOAN OflT Z 2 1390 i twiv nr TAI IP RFBK "wsrur NOV ? 8 nQ4 11 V f O HJ3T U.C.BERKiLlY LD 21-100m-12,'43 (8796s) Gaylord Bros. Makers Syracuse, N. Y. PM. JAN. 21,1908 YC 371847 UNIVERSITY OF CALIFORNIA LIBRARY