THE WORK OF OUR HANDS The Work of Our Hands A Study of Occupations for Invalids BY HERBERT J. HALL, M.D. AND MERTICE M. C. BUCK NEW YORK MOFFAT, YARD & COMPANY 1915 COPYRIGHT, 1915 BY MOFFAT, YARD & COMPANY INTRODUCTION THE following words appeared in a recent Boston Herald editorial: "One of the many stultifying effects of war has already found a pathetic example in the Industrial Home for Crippled Soldiers which has been established in Lyons, France. Recognizing the terrible bur- den of incapacitated men a burden not only on the finances but on the general esprit of the country France has taken the institution at Charleroi, Belgium, as a model for its new school, which will open as soon as possible. Here, as at Charleroi, there will be seven de- partments: Shoe-making, bookbinding, har- ness making, tailoring, basketry, matting weaving, and bookkeeping. And here thou- sands of men, most of them young, many of them destined for careers of wide helpfulness, will come, grateful to pick up sufficient knowl- edge to make them partially or entirely self- supporting for the rest of their shattered lives." It is evident that dire necessity must rapidly vii 359152 viii INTRODUCTION develop in Europe an industrial idea which social thinkers and workers all over the world have been dreaming about and applying in a small way for many years. The need of ade- quate work for the handicapped in this country is not less real than in Europe, if it is less strikingly evident. A war that goes on year after year between the machine and the man, between disease and the man, keeps our ambulances busy and taxes our charities in no uncertain way. The hospi- tals do their best, our charitable organizations are very efficient, but there are thousands of men and women in every great city doomed to idleness and dependence because of injury or some illness that makes ordinary work out of the question. The man out of work because of hard times is badly enough off. What of the man who because of some crippling or disfigurement can never hope to work again? Put yourself in that man's place imagine the despair and the final degeneration that must sap at last all that is brave and good in life. Then there is the economic side. We know that wealth depends upon productive industry. INTRODUCTION ix The really well to do community or the really prosperous man must be constantly at work, adding to the world's store of valuable things. The moment industries stop there is waste and desolation. Although the plight of the handicapped workers in this country is very desperate, much has already been done toward improvement of their condition. Strangely enough the most hopeful progress has been made among the in- sane in the various state hospitals. It has been recognized for many years that mentally dis- turbed and depressed people are better off and get well more quickly if their faculties can be used in some simple and effective way. The first steps that were taken gave the patients simple work to do in the wards and in the service of the institutions. This housekeeping work served a very good purpose, although it was no doubt occasionally abused by the over- driving of certain patients who were willing and able. On the other hand, it left out a great many patients who could not adapt them- selves to such occupations. Within the last decade the superintendents of these hospitals have generally realized that x INTRODUCTION by developing the manufacture of goods needed by the institution a great range of pa- tients could be interested and their work uti- lized. The visitor to one of the more pro- gressive state asylums to-day will be deeply impressed with the many activities which are going on. The patients participate in all the household work, especially in the laundry and in the kitchen. They are also employed in the manufacture of clothing, shoes and furniture. They are making and remaking mattresses, and, best of all, they are employed very largely upon the farms in the raising of crops for the use of the institutions. Officials everywhere acknowledge that there is no one remedy so potent as work in these unfortunate cases. Interest is aroused, old faculties are restored, and recovery is hastened. Incidentally a very great saving is made to the state; many thou- sands of dollars yearly in each institution. Very lately it has been realized that a certain number of patients who cannot be interested in these more common pursuits will find interest and development in some of the handicrafts, such as weaving, knitting, and basket making. The casual visitor will again be surprised to see INTRODUCTION xi how far these crafts have been followed and what excellent work is turned out. The idea of occupation for the handicapped has progressed far enough in this country so that it is now rare to find any institution for chronic patients where there is general idleness. The worst offenders in failure to supply work for the patients are the private institutions where people of means are treated. Here it will not infrequently be observed that patients who would be far better off to be occupied are allowed to sit in idleness day after day, week after week. The day will come when such treatment of any patient able to do even a very small and unimportant work will be consid- ered a disgrace. The idea of work for the handicapped both as a remedy and as a means of partial self-sup- port has been developed lately in the interest of the many sufferers from chronic heart dis- ease. Diseases of the heart unfortunately at- tack most frequently those people who are engaged in the most arduous pursuits, who are exposed to bad weather, and who must do heavy lifting and work for long hours. It has been found that after hospital treatment these xii INTRODUCTION patients go back to their old occupations. There is nothing else to do, and they almost invariably relapse and have to be treated all over again. Until very lately there has been no outlook for such cases except a gradual going to pieces under the existing conditions. A little over a year ago there was established at Sharon, Connecticut, a home for convales- cent heart cases* where the patients were taught a new trade, the making of concrete flower pots. Artistic molds were provided, and the technic was worked out in such a way that good results were assured from the tech- nical point of view. It was found that this trade could be carried on without overstrain- ing the injured hearts of these patients, and that most of the men grew stronger under the work, because, as is well known, a moderate ex- ercise strengthens the heart that is diseased just as surely as overwork injures it. These men have been kept in the home in Sharon for several weeks or even months, then sent back to their homes in the city, not to take up their old and too strenuous occupations, but to carry *The workshop has recently been transferred to the Burke Foundation Convalescent Home at White Plains, N. Y. INTRODUCTION xiii on in a specially supervised city work shop the quiet trade which they had acquired at Sharon. The astonishing part of this semi-charitable enterprise is that it has been able to pay a con- siderable number of handicapped workers fair wages from the sales of the flower pots. As is well known, there are many workshops for the crippled and the blind in many parts of the country, all successful in relieving the harm and illness that are attendant upon idle- ness, if they are not justified from the commer- cial and artistic point of view. These small beginnings are pointing the way to very large possibilities of effective industries for the handicapped. It seems likely that a careful and expert study of many industries will reveal the possibilities of modification that will make the labor of the handicapped a thing of great power and value in the industrial and social life of the country. The handicap that keeps a man from the regular industries may be very slight indeed, yet the regular industries cannot change their rules and system for the sake of giving him employment. Neither can we go on forever wasting the potentialities of the slightly handi- xiv INTRODUCTION capped. The way out seems to lie in the es- tablishing of special industries where the handicapped may be favored and yet given a chance to use what strength and intelligence they have. The whole idea is so simple it is a wonder that it was not fully developed long ago. Side by side with machine work of many kinds are the possibilities of more careful hand work re- quiring time and intelligence and warranting both. Take, for instance, two trades, weaving and cement working. It is evident that hand weavers cannot expect to compete with the power looms. Yet with care and skill avail- able in a hand weaving shop it is possible with special oversight of the workers to turn out products which the power looms could never accomplish and which are eagerly sought be- cause of the charm and interest which belongs to a specially woven fabric. In the making of cement flower pots there could never be the hope of turning out a cheap commercial prod- uct by hand, but the handicapped workers at Sharon are making such a variety of new and interesting shapes, so well decorated and col- INTRODUCTION xv ored, that the demand for the wares is constant and dependable. There are two principal elements which enter into the situation and make it hopeful. First of all the fact that many of the men and women who must avail themselves of these special industries are of unusual education and capacity. Secondly, it will be more and more feasible to call to the consideration of the prob- lem the highest type of able-bodied industrial and artistic direction. There is no reason why these handicapped industries should not com- mand the best engineering talent and the best possible cooperation of designers and crafts- men. Undirected and unsystematized, special industries of this sort would undoubtedly fail pathetically. But a small part of the skill and intelligence which is given to the regular in- dustries will find abundant opportunities for the handicapped workers. In the end the sys- tem may turn out to be not charitable at all but a definite business proposition. The problem is relatively simple in the va- rious charitable and semi-charitable institu- tions. Here it is being found that a large part xvi INTRODUCTION of the necessary hospital supplies can be manu- factured on the premises. As for instance, in one Massachusetts asylum for the insane, where cement bricks and tiles are made in great quan- tities, then used in actual building operations for the state. And in many other institutions where a large part of the food supply is raised on the farm by the labor of the patients who are able to do such work. The great difficulty is encountered when the chronic patient is obliged to leave the institu- tion and go back to his home. There organiza- tion ceases and he finds his handicap painfully evident. The case of the cured or partly cured tubercular patient and of the cured insane is pertinent enough. These people, like ex-con- victs, are looked upon with suspicion. They are either not wanted because their strength is inadequate or because the employer is afraid that some accident will happen. In increasing numbers the discharged pa- tients of the great institutions have learned occupations or trades during the time of treat- ment. There has already been some talk, par- ticularly in Massachusetts, of the establishment of outside workshops where under special ob- INTRODUCTION xvii servation chronic patients discharged from the hospitals may find opportunity for remunera- tive work. At first thought it seems impos- sible that any industry conducted for the bene- fit of the handicapped could have successful operation without large charitable support, but a little ingenuity and persistence will in time overcome this prejudice. Take for instance the trade of laundry work- ing. As has been stated, a very large number of the patients, particularly in the hospitals for the insane, are employed in the laundry. There, although their mental capacity may be comparatively small, they are patiently trained to perform certain necessary parts of the labor. Most of these patients could not go into a reg- ular steam laundry and succeed. It should be quite possible to establish special laundries where such operatives could be successfully em- ployed. The workers would need to be di- rected by officers who had had experience in the asylum laundries, but with such direction there would be little doubt of success. It is possible that such laundries might have to be subsidized and that their field should be limited so that they would not overlap or compete with the ex- xviil INTRODUCTION isting industries. Those who know the situa- tion realize that there is a wide need of careful hand laundry work. The machines tear and destroy fine fabrics too fast. These handi- capped workers might well be trained to do this special slow work which householders now find great difficulty in getting accomplished. A special price could reasonably be asked for such work and this would offset in some degree the slowness and intermittent efforts of the work- ers. If the discharged and handicapped patients from hospitals all over the country could be given legitimate work which would secure them even half of the usual wage, a very great load would be lifted from charity, and a still greater load from the minds and hearts of the workers. There are many hard working families in which the burden of one idle member is a very serious matter. If that patient could be given work which would earn even a very small amount of money the difficult atmosphere of the home would be quite changed. There is immediate and pressing need of a new system which will modify old industries and create new ones that will give the handi- INTRODUCTION xix capped a fair chance. The thing must be done systematically and intelligently. If it is done in this way there is no limit to the industrial possibilities. We have been studying the prob- lems of efficiency for the able bodied and with astonishing results. Careful study of the handicapped and their industrial possibilities will be well repaid. The thousands who are now idle, not from choice but because they no longer fit the regular industries, represent a source of power and of wealth that has been curiously overlooked. These men and women are the waste human product of the industrial world, a product so valuable that its use would mean a revolution in industrial and in charitable affairs. The skeptical will say there is no doubt about the need of special occupations for handicapped people, but basket making and chair caning and such crafts will not go very far toward the actual support of thousands of needy peo- ple. Such doubters have only to visit the un- promising field of the state asylums to be quite convinced of the enormous economic and moral possibilities of specialized work for the handi- capped. In the workshops of these hospitals xx INTRODUCTION may be seen any day in the year hundreds of people contributing in no small way to their self support by means of carefully directed labor. The principle is proven under these cir- cumstances many times over and its applica- tion to the needs of a much larger and more promising class outside the hospital is only a matter of detail. It must not be forgotten that unemployment is as harmful for the well to do as it is for the poor. The writer of these chapters undertook ten years ago to meet in a small way the needs of a class of people who were not in actual want but who from illness or the overstrain of mod- ern life had been obliged to give up their usual occupations. It removes some of the doubt as to the practicability of special industries for the handicapped to know that a young physician in a small town could, without capital, develop in ten years three self-supporting industries, for the benefit of men and women who need to bring back courage and efficiency through the slow accomplishment of manual work. The industries which have been used are pottery, hand weaving, and cement working. That none of them have gone bankrupt although INTRODUCTION xxi managed a good deal of the time without espe- cial business ability speaks volumes for the vi- tality of the idea. These experimental workshops began very simply with hand weaving under a compe- tent teacher. This laid the foundation for a considerable industry. The pottery served its purpose as a school for a time, then became professional and is now in that class. The cement working, which is the latest addition, promises well as an industry and is exceedingly useful from the medical point of view. The workshops are at present run in connection with a sanatorium where people of means are given the usual medical treatment for con- valescence and for nervous exhaustion. The shops themselves are conducted by profes- sional teachers and by assistants who come as apprentices to learn the trades that they may in turn become teachers. These appren- tices have often enough been themselves pa- tients who were obliged to make a living and who found opportunity in this way. School teachers who have broken down in their work have found quieter and more practical occu- pation in this new field. During the past five xxii INTRODUCTION years these medical workshops have equipped nine people who are now earning a living in other institutions. Six of these were them- selves patients, the subjects of nervous exhaus- tion in one form or another. One, a teacher of music who for several years had been quite helpless and hopeless, is now earning a salary of $1200 as the head of a social settlement system. One is independent as a teacher of weaving to the blind, two are in charge of hos- pital workshops, and two are earning their living as potters. The sales of products from all these work- shops amounted in the past year to about $5000. True, there was no profit, but the shops have given an opportunity for experi- mental work and they have served their pur- pose as a school where people of means who are broken down nervously or physically may grad- ually regain strength and efficiency under medical observation. Part of the product of this institution is the result of skilled labor em- ployed for the purpose, and part of the work is done by people who had broken down and who have gradually regained strength. * It is only fair to say that some of the workers who were INTRODUCTION xxiii not so originally have become highly skilled and should rank as professional. But that does not detract from the significance of the enterprise. It seems reasonable to suppose that similar and other industries might be established elsewhere with increasing benefit to the people. Aside from important economic considera- tions medical men will find that carefully con- ducted industries will add a very strong new remedial measure to their practice. If a young woman comes into the doctor's office complaining of sleeplessness, fear of insanity, indigestion and nervous weakness, the long train of trying symptoms familiar to every practitioner, that patient should be sent to some medical workshop as soon as she has had sufficient rest to make it possible. There un- der the influence of quiet work she will forget and leave behind her such symptoms as are of purely nervous origin and the physician will then be able to tell with certainty how much of the trouble is physical and in need of the usual medical treatment, and how much is to be disposed of by the acquirement of courage and self control. There is no better way of xxiv INTRODUCTION separating the real from the imagined, and no better way of leaving fear and unhappiness behind. Carefully regulated work is a remedy of the first order. It must be used with dis- cretion and care, or like any other remedy it may do more harm than good. Such briefly is the idea of the work cure. The following chapters will consider in a more detailed way how the principle has been or may be applied in charitable or private practice. The first section of the book, written by Dr. Hall, is based upon his experience of ten years in building up a series of medical industries in a private sanatorium at Marblehead, Mass., an institution dealing largely with people of means who have been given manual work as a part of the treatment of nervous disability. The second section, written by Miss Buck, is founded upon her experience of many years in the actual teaching of handicapped patients, mostly mental and organic nervous cases in charitable or semi-charitable institutions in New York City. The writers are indebted to the Board of Directors and the Superintendent of the Lin- coln Hospital and Home in New York; and INTRODUCTION xxv to the supervision and hearty interest of the Medical and Nursing Staff and the Social Service Director of the Neurological Institute of New York City; also to the Trustees and Superintendent of the Massachusetts General Hospital in Boston; the Industrial School for Cardiac Convalescents at Sharon, Connecti- cut; and to a large number of physicians, craftsmen, teachers and patients without whose assistance and encouragement the following chapters could not have been written. Free use has been made of the material in numerous articles published by Dr. Hall from time to time in the Boston Medical and Sur- gical Journal, and the Journal of the Ameri- can Medical 'Association. Dr. Hall takes this opportunity to acknowl- edge with especial gratitude the assistance of the craftsmen and designers who have from time to time devoted themselves to the problems of his experimental work. These workers have had experience not only in the developing and the application of crafts and trades for handicapped labor but they have given very generously of their time and strength to the actual teaching of patients. The Misses xxvi INTRODUCTION Jennie and Ruth Turner, both hand weavers of the highest order, have made possible a very considerable progress along this important line. Miss Margaret Weddle has developed a practical department of dyeing. Miss Wed- dle's dyed yarns are now used effectively in the hand- weaving of several institutions. Miss Edith Griffin has now devoted several years to the difficult subject of cement working for invalid workshops Mr. Percy Griffin has done original work in the iron foundries work lead- ing toward the manufacture of molds suitable for cement castings. Miss Jessie Luther, now an active teacher of crafts in the service of Dr. Grenfell in Labrador, deserves much credit for pioneer work in weaving. She was the first craftsman employed in the medical workshops in Marblehead. Mrs. Edwd. Tutt, Messrs. Arthur Baggs, Arthur Hennessy and John Swallow have made possible the self-support- ing pottery. Miss Frances Wood and Miss Florence Riley have been able assistants in cement working and weaving. Miss Annie Aldrich and Miss Maude Milner have given valuable service as designers. These craftsmen and their assistants, many INTRODUCTION xxvii of whom have been themselves invalids, have shown that self supporting workshops may be run in connection with a private sanatorium they have helped to make clear the possibilities of a comprehensive system of industries for the charitable institutions. The writers are also indebted to Dr. Walter Fernald and to Dr. Elwood Worcester. Both these gentlemen have reviewed the manuscript and have given valued suggestions and en- couragement. CONTENTS CHAPTER PAGE INTRODUCTION vii PART I I WORKSHOPS IN GENERAL HOSPITALS 1 II MANUAL WORK FOR PATIENTS IN STATE AND COUNTY HOSPITALS 12 III SANATORIUM TREATMENT FOR PEOPLE OF SMALL MEANS 33 IV TEACHER AND PUPIL 46 V THE TRAINED NURSE AND THE WORK CURE ... 51 VI THE WELL-TO-DO PATIENT AT WORK 57 VII THE INDUSTRIAL PROBLEM OF THE TUBERCULAR . . 61 VIII HANDICAPPED LABOR AND THE LAW 66 PART II I TEACHING OF THE HANDICAPPED 71 II METHODS OF TEACHING 85 III READJUSTMENT 89 IV ORGANIC NERVOUS DISEASES 95 V HYSTERIA 120 VI EPILEPSY 128 CHOREA 133 VII MENTAL DISEASES 142 VIII BORDER-LINE CASES 156 IX WORK WITH THE AGED 160 X NEURASTHENIA 166 PSYCHASTHENIA 175 XI WORK WITH CRIPPLES 180 APPENDIX 187 LIST OF ILLUSTRATIONS Weaving Room, Devereux Mansion ..... Frontispiece PAGE Workshop of the Burke Foundation Convalescent Home . 4 Knitting Machines, Massachusetts School for Feeble- minded ............... 18 Cement Flower-pots ............ 42 Basketry and Weaving ........... 96 Making Iron-framed Canvas Laundry Bags ..... 146 In the Wards of Lincoln Hospital ........ 162 Occupation Room at Hospital for Ruptured and Crippled 182 THE WORK OF OUR HANDS THE WORK OF OUR HANDS PART I I WORKSHOPS IN GENERAL HOSPITALS THE Massachusetts General Hospital has with- in the past year established a medical workshop in a basement of the new out-patient building. This shop is a hospital department, authorized by the trustees and supervised by the executive staff. The cost of running is very little as there is but one salaried worker. The heat, light and rent cost the hospital nothing as the rooms are kept open anyway. The shop is still very small, accommodating never more than six patients. It has, however, practically paid for itself in the first year through the sale of its products. No one doubts the need of part-time work for handicapped people. The difficulty has been to find such employment. This hospital C;'Y.7 : THE WORK OF OUR HANDS shop is equipped with molds for the manufac- tures of cement flower pots, seats, sundials, and such garden accessories. The idea was care- fully tested and worked out for two years by craftsmen in the writer's experimental shops at Marblehead, and later in a more elaborate way in the studio of Mr. Clarence Denny of Hyde Park, Massachusetts, who has generously sup- plied the hospital with special appliances. The molds and appliances have been so constructed as to insure success from the mechanical and artistic points of view. Nothing is left to the choice and initiative of the workers, who are elected from among the chronic out-patients of the hospital people who would otherwise be idle at home or working at some hard, unsuit- able employment. This is, so far as is known, the first attempt of a general hospital to pro- vide work that can be regulated to the capacity of its crippled out-patients, with the idea of protecting these people from the evil effects of idleness or overwork, and for the purpose of keeping them in good physical and economic condition so that they will be less likely to need further ward treatment. The Shop at the Massachusetts General Hospital has employed WORKSHOP IN GENERAL HOSPITALS 3 the subjects of various disabilities, including paralytics, accident cases with loss or disabling of members, cases of rheumatic arthritis and post operative disability of many kinds. The fact is that this important element of adequate work for partly disabled patients has never been fully met by any outside charitable agency. If the hospital is to undertake to im- prove conditions in the life of the patient after his discharge, it may well begin by providing work. Work with a money return must be the substantial basis of all such improvement. Without that basis, our charity may often enough be wasted. The social service workers have in the past few years accomplished a great deal in the right direction. The Social Service Com- mittee of King's Chapel in Boston had in Miss Grace Harper a woman who knows the trades and who was remarkably successful in finding work for handicapped people. But the doors of the regular industries are, often enough, closed to the handicapped. Business is geared too high to give more than an infrequent, sub- ordinate place to men who are not able-bodied. It is easy to believe that the whole idea of 4 THE WORK OF OUR HANDS specialized work is impractical. If the es- tablished factories and workshops of the world must employ only the most efficient, how can charitable institutions without experience and with crippled workers hope to accomplish ade- quate results? This first hospital workshop in Boston has begun to show the possibilities of an industrial system of tremendous economic and social importance. Not many years ago the great manufacturing plants were throwing away by-products that are now worth their annual millions. The industrial world is throwing away untold values in damaged hu- man material, the reasonable salvage of which might save a great deal of money and an amount of human suffering too great to be reckoned. About the same time as the founding of the Massachusetts general workshop, a move- ment began in New York City to provide some kind of light work for the cases of heart disease that are discharged relieved from the various hospitals. These cases of organic heart disease are, of course, much benefited by their short sojourns in the hospitals during acute stages of the disease, but they almost in- WORKSHOP IN GENERAL HOSPITALS 5 variably drift back into the wards and they are naturally worse each time. Having no other trades they attempt their old too arduous and exposed occupations. The result is al- ways the same; they break down again and again. Such a cycle is poor economy and poor humanity. Realizing this, the Burke Foundation financed the beginning of an in- dustrial school for convalescents at Sharon, Connecticut. The idea of this school is to keep cardiac cases under favorable conditions for about three months and at the same time to teach them a trade, in this case the making of cement flowerpots and other articles of commerce such as those made at Marblehead and in Boston. The first year's work has been so encouraging that two workshops have been established in New York City so that the men who have learned the trade in Sharon may come back to their homes in the city and go daily to the city shops for employment. The medical reports on these heart cases are most encouraging. The work can be gauged exactly with experience so that the patient gives all the strength he is able without reach- ing the point of fatigue. The simple arm 6 THE WORK OF OUR HANDS motions of the technique are as good as espe- cially designed exercises for improving the strength of the circulation, and yet as a result of these movements there is a product of im- mediate market value. The actual financial possibilities of these hospital shops cannot be predicted. They will have to be run intelli- gently and on business principles. At the present time the shops show a growing market with encouraging return. They employ nine men and pay nine dollars a week. A letter from the director says, "Their hours are from nine to twelve. Most of the men are exam- ined once a week by a heart specialist. Some of them have improved so much that an exam- ination once in two or three weeks seems to be enough. All of the men have improved one hundred per cent, since their return from Sharon." At the Massachusetts General the men and women have been paid between four and six dollars a week. At the end of the first year it was found that the shop had paid for all its equipment and supplies, the salaries and other expense, and had a deficit of but $800.* The cement garden and flower pots of these * This deficit has since been wiped out by the profits of special sales. WORKSHOP IN GENERAL HOSPITALS 7 institutions are only a crude beginning. If the work succeeds so well now, the future is very bright, for not only can this kind of ware be improved and extended, but new manufac- tures of various kinds can be added. With good planning and time the shops should justify themselves from every point of view. The first requirement of development is this: That the new handicapped industries must not attempt to compete with machinery along the established lines. The second re- quirement is an assured market for all prod- ucts. This implies that the choice of products shall be wise and far-seeing and that the work- manship shall be good. The third require- ment is that the work shall be of a kind adaptable to physical and nervous limitations. If we were to attempt to make flower pots out of clay as they have been made for gen- erations; if our shop force of handicapped people were to compete with the jigger- wheels and the enormous kilns of the great potteries, we should not only fail, but we would amply deserve our failure. But we propose to make flower pots in a new way out of cement this time, and cast in molds that can be handled 8 THE WORK OF OUR HANDS by a crippled girl quite as well as by a strong man. If our molds are proportioned and de- signed by an artist of full ability, then the situation changes. The strong men may bend to their wheels, turning out cheap and rather ugly flower pots that sell, to be sure, by the hundred thousand. The greater industry goes its way, and it will not interfere in the slight- est degree with the smaller, slower, but equally justified, process. This particular new product gives to the public at a moderate price more expensive than terra-cotta, less expensive than glazed pottery a beautiful and useful article of common use. The material for these cement flower pots costs from three to ten cents each, the selling price is usually from fifty cents to one dollar. Thus is the second requirement fulfilled, or as nearly fulfilled as can be the case with any new idea. We are counting on the well-known market for flower pots, and on the especial characteristics and middle-priced value of our ware. The third requirement is more easily met than most of the uninitiated would suppose possible. Here is the key-note of the success WORKSHOP IN GENERAL HOSPITALS 9 of all handicapped labor. There must always be a fully trained instructor and a sufficient number of able assistants. Handicapped workers alone are hopeless and helpless; under careful direction there is no end to their pos- sibilities. Cement working is but one of many possible modifications of existing industries. The shops at Marblehead, and in many other places, have developed hand-weaving to a high degree of perfection. By our three require- ments, hand-weaving is available for convales- cent or permanently limited people. We would be absolutely lost if we were to attempt to make on hand-looms, cloth such as could be more readily made by power machinery. But by developing especial patterns and individual effects designed by clever craftsmen, we pro- vide a business capable of supporting a great many handicapped workers. At Marblehead is made a small woolen blanket for babies. The material costs about sixty cents. If the workers were to weave a similar length and width of plain wool, they could not sell it for a dollar, but because there is an attractive de- sign and because the ends are finished well, 10 THE WORK OF OUR HANDS these specialized blankets sell for five or six dollars. It takes about a day and a half to make one such blanket. The factories could not produce the same thing hand weaving is distinctive and better but the hospital work- shops can take the time, and such a course may mean a partial self-support where help is greatly needed. A great deal of combined medical and in- dustrial observation will be needed before the idea of hospital industries can be carried out in a really adequate and comprehensive way. It seems reasonable, however, that the idea should be taken up by the proper authorities in the larger and smaller general hospitals. The way has been shown for a beginning at least. Occupation for the handicapped is a fine adventure there is no telling what it may lead to along clinical or economic lines. If there were no other justification for the work, the production of hope and courage under adverse conditions would be enough. The idea is one of enlarged and improved so- cial service; it means a chance for the handi- capped to make at least a partial living when other opportunity is denied. This is the very WORKSHOP IN GENERAL HOSPITALS 11 root of Social Service. No amount of kindly advice and social or hygienic uplift can ever take its place. There is a fair chance of reaching the moral and social needs of a man after he is given work to do while he is idle his various needs can be reached only with great difficulty. Hospital authorities who may object to such enterprises need only be shown that work for handicapped people is of definite medical value. The new workshops may well be recognized as legitimate clinical departments of any charitable hospital. One has only to see the discouraged and depressed paralytic take heart or the incurable grow happy and contented under this system to be convinced of its medical value. II MANUAL WORK FOR PATIENTS IN STATE AND COUNTY HOSPITALS THE practice of medicine has changed in no way more remarkably than in the new respon- sibility it assumes for the social and moral welfare of its patients. We need no longer call attention to the need of social service in connection with hospital and dispensary work it is an established thing. That the charita- ble institution, and especially the state hospital, should concern itself seriously with the matter of carefully specialized work for its patients both in and out of the hospital is a newer con- ception that merits careful attention. When work is proposed for a sick man in hospital or out, the first thought is a revulsion. It would seem that the sick might be left in peace to recover at leisure. But we are not thinking of the acute and more painful ill- nesses in which work is impossible. There are thousands of people in the state and county 12 MANUAL WORK FOR PATIENTS IN HOSPITALS 13 hospitals who cannot ordinarily be depended upon for intelligent work, but who have ca- pacities that are being developed with no in- considerable profit to everybody concerned. To say nothing of the economic possibilities, work is almost a moral necessity. It is essen- tially an expression of good-will and common service that helps to keep life wholesome. Even if it does not mean much money return it can always bring some degree of self-re- spect. There need be no quarrel with diver- sion and amusement, but there comes a time when these things pall and there is need of real employment. It is no new thing for the chronic patients in the state and county hospi- tals to be given work to do. Such action has, however, until recently, been desultory, and due to the chance initiative of individual su- perintendents. There is growing up now a new science of work which will not be satisfied with the demand of household service from those who are most able. The -new science will study the possibilities and the effect of productive work upon each patient, and it will require measured work for therapeutic as well as economic reasons. 14 THE WORK OF OUR HANDS There are many state hospitals where to- day a great deal of useful house or ward work is done by the inmates. Here and there may be found well-equipped workshops. The cut- ting and making of clothing for the patient's own use is one of the best outlets for unused energy. Through the installation of knitting machines it has become possible for patients to make such things as stockings, sweaters, mit- tens and caps in great quantities. These products represent real money value. Among the occupations already found useful for the insane and feeble-minded are brush- and broom-making, cane-seating, rug-making, and the hand-weaving of many fabrics, printing for institutional use, lace-making, cabinet- making and shoe repairing. These things are all done well by the people who would ordi- narily be considered useless members of so- ciety. The only difference is that a great deal of time is consumed and especial conditions of oversight and system must be maintained. The work is professional in the best sense. It is rare to find poor craftsmanship. More- over, here is a valuable means of treatment, most potent toward creating efficiency and the MANUAL WORK FOR PATIENTS IN HOSPITALS 15 restoration of disordered functions, a valuable means of treatment that should cost nothing. Here is a medical agent of the first quality which may actually save the State large sums of money. It is true that many institutional superintendents do not know how much money is saved by the occupation of patients. One of the best managers in the country con- fessed to the writer that the repairs on boots and shoes done in his workshops would cost the institution in excess of $5,000 annually if done by outside help. He did not, however, publish that amount or other much larger sav- ings in the various departments because he was afraid that the politicians and perhaps the friends and relatives of the patients would look upon the matter as an exploitation of helpless inmates and so put a stop to all work. In this shoe-repairing shop where the foot- wear of twelve hundred people is kept in re- pair, a long row of happy boys with their mouths full of brads, hammers out a cobbler's chorus that answers all the objection of ig- norance. The employment of the insane in the ward and house work of the institutions is a long 16 THE WORK OF OUR HANDS established custom. A great deal of money is saved this way that would otherwise be spent for service. This is undoubtedly the oldest form of occupation for the insane. Under careful restriction it is wise and legitimate. But no kind of occupation is so liable to abuse or so difficult to apply scientifically. Dr. Eva C. Reid of San Francisco in a recent article on "Ergotherapy in the Treatment of Mental Disorders" * says of the female patient: "If she shows an inclination to work she is given a trial in the laundry, sewing- or dining-room of the institution. If she proves careless or inefficient in her work, she is sent back to the ward. Because she allowed an 'iron to burn out,' spoiled a garment in the making, or broke a few dishes, many a poor soul has been condemned to perpetual idleness, for the re- mainder of her life. . . . On the other hand if a patient proves to be a willing and efficient worker, she is condemned to a life of hard labor. In every state institution we find old demented patients whose life has become an existence of hopeless drudgery with no time allowed for recreation or diversion." * Boston Medical and Surgical Journal, August 20, 1914. MANUAL WORK FOR PATIENTS IN HOSPITALS 17 Such a conception of work for the insane is not much longer to be tolerated. There must be no routine employment without the most careful consideration of the medical and social needs of the patient. If these needs can be met by carefully planned house and ward service well and good otherwise that work must be done by hired help, and the difference made up in some other department of labor. Farming and gardening present themselves as primitively possible. As a matter of fact these pursuits have been carried on for a good many years with great success in many insti- tutions. Naturally, better farming is done when the work is in the hands of able-bodied and experienced men, but there is an enor- mous amount of routine that can be done per- fectly well by the handicapped when there is steady and careful supervision. Among the feeble-minded and the insane such work has its largest development. Ordinarily the boys and men farm in small gangs under the direc- tion of competent foremen. These foremen are sometimes professional farmers, but often enough they are old patients who have be- come competent. The asylums report excel- 18 THE WORK OF OUR HANDS lent work and splendid financial returns and they also report mental and bodily improve- ment, less restlessness and violence among pa- tients otherwise inclined to be difficult. Here is fine healthful work. Every stroke of the shovel and hoe that does not overtax the strength is clear gain to the patient, and to the commonwealth. The idle farm and the idle patient seem existing for each other. The time has come when economy and therapeutics both demand the raising of crops, road-mak- ing, the grading and draining of land. It is a question whether it is wise for state hospitals to engage in the manufacture of ar- ticles to be sold outside in the open market. This is done sometimes and with apparent ad- vantage. In one large New England city, where there is a state hospital, the local trade is supplied with brooms and brushes made in the hospital. Certainly it is wise to manufac- ture articles which can be used in the hospital where they are made or in other state institu- tions. The matter of reward in return for industry is still open for discussion. It seems only fair that direct money returns should be made to MANUAL WORK FOR PATIENTS IN HOSPITALS 19 the patients or their families. In some cases extra freedom, especial diet, etc., will be enough. Beyond a fair return to the worker or his family money saving should be largely returned to the State that it may diminish in some degree the increasing burden of support. There are great possibilities of the reciproc- ity between institutions. One hospital might well specialize in some line, such as the making of socks and stockings. In this way high skill could be acquired and a large and desirable output be maintained for the supply of an in- creasing chain of institutions. If we bear in mind two essentials, that the patient must be benefited physically and mentally by the work and that the product must be first class in every respect, we shall not go far astray, and we shall begin to reach the financial gain as well as the clinical ad- vantages of the new system. Already such beneficent occupation is the rule rather than the exception; The great need now is of system and classification. We must know surely what classes of cases react best to given kinds of work and we must make common knowledge of the difficulties and sue- 20 THE WORK OF OUR HANDS cesses of institutional occupations all over the world. This much is certain, that there are vast sources of productive power lying unnec- essarily idle in the state institutions for the in- sane. State hospital superintendents agree that much useful work is possible, that it may represent large savings to the State and that productive occupation is welcomed by patients of all classes. In the prisons of most States productive oc- cupations occupy a foremost place adequate systems of exchange of commodities have been established between institutions and an im- mense saving is made for the State. No one doubts the advantage to the prisoners. Our insane and feeble-minded are prisoners in the larger and better sense, they are restrained for the safety of the community and for their own advancement. It would seem that there is no good reason why these mental "prisoners" should be denied the advantages offered to criminals. A series of questions sent recently to super- intendents of state hospitals throughout the country brought most interesting answers. The questions were as follows: MANUAL WORK FOR PATIENTS IN HOSPITALS 21 1. What work is being done by insane or feeble-minded patients in your hospital? 2. What is the effect, generally speaking, upon: A. The excited cases, B. The depressed cases, C. The feeble-minded cases? 3. Does the work of your patients represent a definite saving in money to the institution? Is this saving great or small? Almost without exception the answers were enthusiastic in regard to the value of occupa- tion for patients of all classes, and with very few exceptions the saving to the institution was considerable. Extracts from some of the letters follow: EASTERN STATE HOSPITAL, WlLLIAMSBURG, VA. G. W. BROWN, M.D., SUPERINTENDENT In answer to Question 1 will state that a large number of our men work on our farm and garden; about the yards and grounds. Some of them work at carpenter's trade, some in the shoe shop, baker's shop, tailor shop, some in the chair and mattress fac- tory, some in the kitchen and of course a great many of them do janitor work. We are now erecting a new Infirmary and a great many of our male patients 22 THE WORK OF OUR HANDS who are able bodied (70 per cent.) do some kind of work. All the clothing for the patients is made at the Institution both for men and women. A great many of them do fancy work and we have a special instructress who makes an effort to retrain our dementia praecox cases and some of the dements. This is in needle work, fancy work, and rug weav- ing. In answer to Question % will state that a great many of all classes are improved ; however, we do not work our acutely excited cases. We generally keep these on the ward and give them hydrotherapeutic treatment until they become tractible; after which time we make an effort to get them out on the farm and yards and give them outside employment until they become more quiet. In answer to Question 3 will say that we have no definite figures which we can give you. I am certain that this labor is quite a saving to the Institution. I figure that it reduces our wage scale about one-half. VERMONT STATE HOSPITAL WATERBURY, VERMONT DON. D. GROUT, M.D., SUPERINTENDENT The effect upon all classes of having what work they are capable of doing is beneficial in every way. The work of the patients is profitable in every way ; it lessens our per capita cost of maintenance very materially, probably fifty per cent. MANUAL WORK FOR PATIENTS IN HOSPITALS 23 TOPEKA STATE HOSPITAL TOPEKA, KANSAS T. C. BIDDLE, M.D., SUPERINTENDENT Aside from the farm and garden work, I have, in recent years, been doing much of our construction with patient labor. The insane under supervision of one or two competent constructionists can be em- ployed successfully in any kind of building enterprise, especially concrete construction. Throughout the two years we have been able to supply our male patients with a large amount of con- genial employment. The usual request of our pa- tients is to be allowed to go out with the working parties and an opportunity to engage in some use- ful exercise. We find no remedial agent that affords more positive results in restoring the mental balance of our cases. Unfortunately, we find greater diffi- culty in providing suitable occupation for our female inmates. This can best be provided by establishing a crafts and art department, under the direction of a competent instructor. It is a well established fact that much can be done in stimulating recovery in cur- able cases through useful occupation. STATE OF NEW YORK, CENTRAL ISLIP HOSPITAL G. A. SMITH, M.D., SUPERINTENDENT We have found the effect of diversional and other occupations more beneficial than any other one therapeutic agent. This applies to substantially all cases except the delirious. Eor the latter class we, 24 THE WORK OF OUR HANDS of course, pin our faith largely on the several hydrotherapeutic agents. While the labor of our patients represents a definite saving in dollars and cents, we regard that as nothing when the beneficial effects on the mental and physical condition of the individual patient is taken into consideration. BOSTON STATE HOSPITAI>, DORCHESTER CENTRE, MASS. H. N. FROST, M.D., SUPERINTENDENT 1. The enclosed list of patients' occupations, out- side of hospital routine work, shows in more detail what our patients are doing. 2. The effect of this industrial activity, generally speaking, is decidedly favorable, diminishing excite- ment, stimulating those who are depressed and in- active, and putting some degree of efficiency into the feeble-minded. 3. The work of our patients represents a con- siderable saving in money, which, however, I am not able to give in figures at this time. Patients 9 Industries Women: Sewing, mending, embroidery, crochet- ing, lace making, tatting, weaving, spinning, rug mak- ing, basketry, straw braiding, hat making, knitting, raveling, stenciling, kindergarten work, paper work, bead work. MANUAL WORK FOR PATIENTS IN HOSPITALS 25 Men: Mattress making, upholstery, furniture re- pairing, chair caning, basketry, straw hat manufac- ture, mat making, rug making, weaving, stocking knitting (machine), broom making, cement and clay modeling, metal work, leather work, wood carving, cabinet making, picture framing, book binding, etc. Dr. George Kline of the Danvers (Massa- chusetts) State Hospital reports a saving of about $1400 a year on one item, the making of soap from the waste fats of the institution. The men who do this work enjoy it and take great pride in their product. A general idea of the extent of State Hos- pital occupation in Massachusetts may be ob- tained from the following table published in Bulletin No. 7 of the Massachusetts State Board of Insanity: Occupations and Industries Herewith is presented a report of a survey of occu- pations for a single day at each of the State institu- tions under the supervision of this Board, being an average day's work, showing the whole number of patients at each hospital on that day, the number employed, those unable to be employed, and the num- ber idle, with per cents. THE WORK OF OUR HANDS Iff A H a . =-2 W *$ o S H . S> H M UM YED O 00 (30 rfi rH CO b- r Ci "H -* CO rH 5 0* CD CO rH 0> r G* CO t- t*- CO 00 CO t- 5 05 *O *005t--J050 **: <* cc i- * ^^co^^"*'-!'-! ^ G* ' ^O "5 CO * CO* t^ O CO CO 5 rH O O 5 05* b-' rH O5 rH rH G< rH rH G< CO G< CO rH CO D ^ O CO ^O CO CO '$< CO O 1-; 05 CO. rn at $0.12 44.88 Blueberries, quarts, 785, at $0.14 109.90 Cabbage, pounds, 2,599, at $13 per ton 16.89 Carrots, bushels, 154%, at $0.60 92.88 Cider, gallons, 440, at $0.15 66.00 Chard, bushels, 36, at $0.40 14.40 Chicken, pounds, 85%, at $0.24 20.58 Cordwood, cords, 115, at $5 575.00 Corn, green, bushels, 36, at $0.60 21.60 Cucumbers, boxes, 32, at $1 32.00 Cucumbers, pickling, pecks, 15, at $0.35. . . . 5.25 APPENDIX 209 Dandelions, bushels, 7, at $0.35 $ 2.45 Ensilage, corn, tons, 60, at $5 300.00 Eggs, dozen, 1,018%, at $0.25 254.58 Fodder, barley, ton, 1, at $6 6.00 Fodder, cabbage, ton, 1, at $5 5.00 Fodder, corn, tons, 8, at $5 40.00 Fodder, millet, tons, 2, at $5 10.00 Fodder, oat, tons, 2, at $5 10.00 Fodder, rye, tons, 7, at $5 35.00 Fowl, pounds, 111, at $0.17 18.87 Grapes, pounds, 165, at $0.04 6.60 Hay, bluejoint, tons, 11, at $11 121.00 Hay, English, tons, 24, at $20.75 498.00 Hay, millet, tons, 2, at $12 24.00 Hay, rye, tons, 6, at $15 90.00 Lettuce, boxes, 13, at $0.25 3.25 Mangel-wurzels, bushels, 63, at $0.25 15.75 Manure, cords, 65, at $6 390.00 Manure, hen, barrels, 14, at $0.75 10.50 Milk, quarts, 20,180, at $0.05% 1,143.53 Muskmelons, crates, 3, at $1 3.00 Onions, bushels, 117, at $0.60 70.20 Parsnips, bushels, 20, at $0.65 13.00 Pears, bushels, 14, at $0.75 10.50 Peas, green, bushels, 23 at $2 46.00 Posts, fence, 175, at $0.20 35.00 Potatoes, bushels, 971, at $0.55 534.05 Pumpkins, pounds, 2,500, at $0.01 y 2 37.50 Radishes, bushels, 3y 2 , at $0.75 2.62 Rhubarb, pounds, 1,125, at $0.01 11.25 Spinach, bushels, 12, at $0.35 4.20 Squash, summer, barrels, 6, at $0.60 3.60 Squash, summer, barrels, 6, at $0.60 3.60 Squash, winter, pounds, 2,340 at $20 per ton 23.40 Stakes, fence, 250, at $0.10 each 25.00 Strawberries, quarts, 327, at $0.12 39.24 Tomatoes, green, bushels, 8, at $1 8.00 Tomatoes, ripe, bushels, 7, at $1 7.00 Turnips, bushels, 85y lo , at $0.75 63.83 210 APPENDIX GENERAL Beef, cow, pounds, 6,216, at $0.09 $ $59.44 Beef, steer, pounds, 3,763, at $0.12 y a 470.38 Calf skin, 1, at $0.75 .75 Calves sold, 26, at $4 104.00 Calf sold, 1, at $7 7.00 Calf sold, 1, at $6 6.00 Guinea pigs sold, 392 118.70 Hides, cow, green, pounds, 754, at $0.12 90.48 Hides, steer, green, pounds, 375, at $0.12 45.00 Ice, tons, 842, at $3 2,526.00 Lamb, pounds, 544, at $0.16 87.04 Lumber, oak, chestnut, maple, 10,000 feet, at $25 M 250.00 Lumber, hemlock, spruce, pine, 56,000 feet, at $20 M 1,120.00 Milk, quarts, 111,200, at $0.05% 6,301.33 Pigs sold, 3 20.00 Pork, fresh, pounds, 16,009, at $0.12 1,921.08 Sawdust, cords, 16, at $2 32.00 Slabs, cords, 16, at $2 32.00 Stone, crushed, tons, 1,295, at $1 1,295.00 $14,986.20 Total farm products $40,092.70 LIVE STOCK Bulls, 2 $ 250.00 Calves, 15, at $26 390.00 Cockerels, 100, at $0.50 50.00 Cows, 47, at $80 3,760.00 Guinea pigs, 187, at $0.30 56.10 Heifers (one-year), 9, at $46 414.00 Heifer (two-year) ,1 50.00 Hens, 405, at $0.75 303.75 Hogs, 13, at $25 325.00 Horses, 18 3,280.00 Oxen, 15 1,725.00 Pigs, 8, at $5 40.00 APPENDIX 211 Pullets, 286, at $0.60 $ 171.60 Roosters, 9, at $1.25 11.25 Sheep, 5, at $15 75.00 Shoates, 52, at $10 520.00 $11,421.70 THE END RETURN TO the circulation desk of any University of California Library or to the NORTHERN REGIONAL LIBRARY FACILITY Bldg. 400, Richmond Field Station University of California Richmond, CA 94804-4698 ALL BOOKS MAY BE RECALLED AFTER 7 DAYS 2-month loans may be renewed by calling (510)642-6753 1-year loans may be recharged by bringing books to NRLF Renewals and recharges may be made 4 days prior to due date DUE AS STAMPED BELOW SEP Z 1995 d 1995 LIBRARY USE ONLY JUN o i ?oon UIHUULAIIUN DEPT. 20,000 (4/94) YB 15313 U.C.BERKELEY LIBRARIES UNIVERSITY OF CALIFORNIA LIBRARY