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CONVALESCENT MEDICINE 
Manual of Physical Therapy 
Manual of Occupational Therapy 
Emergency Treatment of Acute War Neuroses CONVALESCENT MEDICINE 
Manual of Physical Therapy 
Manual of Occupational Therapy 
Emergency Treatment of Acute War Neuroses 
A Collection of Articles Reprinted, With Permission, From War Medicine 
Ril The United States Office of War Information 1945 MANUAL OF PHYSICAL THERAPY Reprinted from War Medicine 
March 1942, Vol. 2, pp. 295-329 
Copyright, 1942, by American Medical Association 
MANUAL OF PHYSICAL THERAPY 
INTRODUCTION 
The Division of Medical Sciences of the National Research Council was 
asked to furnish the medical departments of the United States Army and Navy 
with compact presentations of necessary information to be used by medical officers 
of the Army and Navy in the emergency. In response to that request, this 
manual was prepared by the Division’s Subcommittee on Physical Therapy and 
the Council on Physical Therapy of the American Medical Association. The 
personnel of these groups is as follows: 
Subcommittee on Physical Therapy, Division of Medical Sciences, National 
Research Council: 
John S. Coulter, M.D., Chairman, Chicago 
Frank H. Ewerhardt, M.D., St. Louis 
Kristian G. Hansson, M.D., New York 
Frank H. Krusen, M.D., Rochester, Minn. 
Walter J. Zeiter, M.D., Cleveland 
Council on Physical Therapy of the American Medical Association 
H. E. Mock, M.D., Chairman, Chicago 
Eben J. Carey, M.D., Milwaukee 
Anthony C. Cipollaro, M.D., New York 
W. W. Coblentz, Ph.D., Washington, D. C. 
J. S. Coulter, M.D., Chicago 
A. U. Desjardins, M.D., Rochester, Minn. 
Frank D. Dickson, M.D., Kansas City, Mo. 
W. E. Carrey, M.D., Nashville, Tenn. 
Frank H. Krusen, M.D., Rochester, Minn. 
Frank R. Ober, M.D., Boston 
Ralph Pemberton, M.D., Philadelphia 
H. B. Williams, M.D., New York 
Howard A. Carter, Secretary, Chicago 
The manual is also listed under the editorship of the Committee on Informa- 
tion of the Division of Medical Sciences, which includes the following men: 
Morris Fishbein, M.D., Chairman, Chicago 
J. J. Bloomfield, Washington, D. C. 
John F. Fulton, M.D., New Haven, Conn. 
Richard M. Hewitt, M.D., Rochester, Minn. 
Ira V. Hiscock, Sc.D., New Haven, Conn. 
Sanford V. Larkey, M.D., Baltimore 
Robert N. Nye, M.D., Newton, Mass. 
The detail of the editorial work has been done by the editorial department of 
the American Medical Association. 
Lewis H. Weed, M.D. 
Chairman, Division of Medical Sciences of the National Research Council 
Morris Fishbein, M.D. 
Chairman, Committee on Information of the Division of Medical Sciences of the 
National Research Council 
Charles C. Hillman, M.D. 
Colonel, Medical Corps, United States Army, War Department Representative, 
National Research Council 
Captain, Medical Corps, United States Navy, Navy Department Representative, 
National Research Council 
Charles S. Stephenson, M.D. CONTENTS 
PAGE 
Chronic Arthritis and Rheumatoid Conditions 3 
Sprains and Dislocations 11 
Traumatic Synovitis 11 
Contusions and Muscle Strains 12 
Volkmann’s Ischemia (Contracture) 12 
Bursitis ' 12 
Nonsuppurative Tenosynovitis 13 
Fractures 13 
Peripheral Nerve Injuries 16 
Stiff Joints 17 
Amputations 18 
Circulatory Diseases of the Extremities 22 
Painful Feet 24 
Backache 24 
Traumatic Cerebral Spastic Paralysis 26 
Gonococcic Infections Resistant to Chemotherapy 26 
Dementia Paralytica 27 
Cutaneous Diseases 27 
Tuberculosis 33 
Psychiatry and Neurology 35 3 
CHRONIC ARTHRITIS AND RHEUMATOID CONDITIONS 
General Considerations.—The use of external heat, both locally and 
systemically, is of value for combating a large variety of conditions, 
medical as well as surgical. Within the medical field the clinical states 
in the treatment of which heat is probably most widely employed are 
the psychoses, neurological disturbances and various phases of the arth- 
ritic and rheumatoid syndromes. For the last-mentioned conditions the 
application of heat is more extensive and varied than for any other. 
The full benefits to be derived from the systemic use of heat in this con- 
nection are not always forthcoming from the heat alone, however, 
and sometimes depend on contrasting and accessory applications of cold. 
APPLICATION OF HEAT 
Systemic response to heat is characterized by an increase in circula- 
tion proportionate to the rise in body temperature, overventilation of 
the lungs and loss of water through the expired aid, through the skin 
and, following baths, through the urine also. 
A chief end product of metabolism, carbon dioxide, escapes through 
the lungs, sweat and urine, and one of the fundamental effects of 
exposure to heat appears to depend on this fact. Under systemic appli- 
cation of heat, the general body metabolism is increased and carbon 
dioxide is formed in quantities larger than normal. Overventilation of 
the lungs, however, washes this out in greater proportionate amounts. 
Various acid substances, such as phosphates and sulfates, resulting 
from increased metabolism escape through the urine, and certain fatty 
acids, including lactic acid, are eliminated through both the urine and 
the sweat. The net result, therefore, of the loss of these acid substances, 
chiefly carbon dioxide, is a relative excess of alkali in the blood and 
probably in the tissues. Systemic alkalosis results, and the excess of 
alkali is then eliminated through the urine and sweat until the normal 
acid-base equilibrium is restored. Sustained alkalosis may lead to tetany. 
A belief in the value of “elimination” in the treatment of arthritis has 
long been popular, but there is only limited evidence to support this as 
an important factor in itself. Elimination of water in the form of sweat 
may, however, contribute to a betterment of the physiologic disturbances 
accompanying the rheumatoid state. The possibility that a low grade 
“edema” of some tissues accompanies certain phases of the arthritic 
syndrome cannot be dismissed from consideration. There is, however, 
definite evidence that some of the other effects achieved by exposure to 
heat play an important role in the treatment of arthritis. These effects 
are chiefly those arising from the heightened circulation and possibly 
from an increased metabolism. 
Evidence of changes in the circulation is to be seen in the obvious 
influence on the capillaries of the skin of the cold contrast baths or 
douches so successfully used in institutional treatment at the conclusion 4 
of the “bake” or the hot bath. A true “metabolic whip” is afforded by 
cold water properly used. 
Systemic Exposure to Heat.—Those patients who are fairly robust 
afford the best opportunity for this practice. It is important to remember 
that systemic exposure to heat in any form may occasionally have dis- 
tressing consequences, either immediately or after a course of treat- 
ment, and it is therefore essential to exercise caution in subjecting to 
such treatment patients who are ill equipped to stand it. 
It is difficult to determine beforehand the arthritic conditions which 
will best respond to exposure to heat, but it probably has its best results 
in those in which tissue edema is more or less obvious. Atrophic (rheu- 
matoid) arthritis in some stout women responds exceedingly well to this 
measure. In others of less robust makeup beneficial results may not 
be forthcoming, and the condition of the patient may be aggravated by 
the additional burden imposed. Patients with hypertrophic arthritis 
(osteoarthritis) are in general more robust and can better withstand 
systemic exposure to heat. It is important to recognize, however, that 
heat may act as a form of trauma to persons with hypertrophic arthritis 
and must therefore be carefully administered. It must be pointed out 
here that exposure to heat or hydrotherapy constitutes only one measure 
of treatment in the rheumatoid problem and must not be followed 
except in correlation with other established principles of treatment. A 
patient with arthritis should not be subjected to the measure under dis- 
cussion until a complete medical examination has indicated the justifica- 
tions and indications for it. 
The “bake” or the bath may be given alone, in which case profuse 
sweating is induced and the subject is allowed to rest for an hour or 
more to compensate for the somewhat debilitating effects; more fre- 
quently, the exposure to heat is briefer and sufficient only to inaugurate 
or induce mild diaphoresis. After this procedure, which is generally 
administered with the patient in a sitting posture, a “tonic” shower, or 
douche, is given, beginning with water considerably above body tem- 
perature, which is shortly changed to water slightly below body tem- 
perature. This change is best accomplished by an attendant who directs 
on the patient a jet of water, the temperature of which is under control. 
An exposure of about eight minutes to the electric cabinet “bake,” 
followed by a so-called Scotch douche or other form of cooling hydro- 
therapy permits the subject to go at once out into the air with a sensa- 
tion of exhilaration and well-being instead of lassitude. Even persons 
of robust constitution should be subjected only gradually to these pro- 
cedures, but by beginning cautiously even patients of a highly asthenic 
type can be educated to stand them and can be benefited by them. 
The sweating process alone, without the cooling contrast shower, is 
more easily attained and can be brought about by means of the hot pack 5 
Fig. 1.—Application of a full hot pack (from Krusen, F. H., Physical Medicine, 
Philadelphia, W. B. Saunders Company, 1941). 6 
or hot bath in almost any household. In many instances the metabolic 
stimulus given by this single procedure is of great value and should be 
utilized when circumstances justify it. 
The general regimen briefly outlined can be carried out more or 
less successfully in the home, but the full achievement of such results 
as follow conduction of these measures by skilled persons in adequately 
equipped institutions can hardly be expected. 
The subject of the influence of induced fever (hyperpyrexia) on 
various disease states has undergone rapid development, and this pro- 
cedure is now almost specific for certain conditions, especially gonococcic 
infections. Chronic atrophic and hypertrophic arthritis are not, however, 
diseases on which hyperpyrexia can be said to exercise a favorable 
influence. There is some evidence to indicate that perhaps in a few 
phases of the arthritic syndrome, especially in the more acute ones, 
beneficial results may occasionally follow induction of sustained fever 
with temperatures up to 104 F. 
Local Application of Heat.—The local application of heat to involved 
joints may be comforting and helpful in the treatment of arthritis. 
Among other influences, local exposure to heat dilates the blood vessels, 
induces general hyperemia and brings about changes in the vessel walls 
which permit diapedesis of leukocytes. Local exposure to heat, however, 
may be followed by unintended systemic effects if carried out improperly 
or to extremes. In applying heat locally in the case of a rheumatoid 
syndrome, care must be exercised to avoid adding trauma to the dis- 
ease i'process, especially in the case of hypertrophic arthritis (osteo- 
arthritis). 
Heat is readily applied in the patient’s own home by means of 
some simple devices. 
Homemade Baker : An inexpensive homemade baker can be con- 
structed. 
Paraffin Baths: If electricity is unavailable in the patient’s home, 
local applications of ordinary hot paraffin may be employed as a sub- 
stitute for the simple radiant heat devices. 
The following directions are given to the patient for the use of these 
baths at home: Hands. Fill the top of a large double boiler (6 quarts 
[5.7 liters]) with paraffin (6 to 8 pounds [2.7 to 3.6 Kg.]) and fill 
the lower part with hot water. Heat until nearly all of the paraffin is 
melted. To avoid burns, be sure a piece is left unmelted. Remove the 
double boiler from the fire, and take the top out of the water. 
With the fingers separated, dip the hand quickly into the paraffin, 
being careful not to touch the sides or the bottom of the boiler. Remove 
the hand. When the paraffin is hardened, dip and quickly remove the 
hand again. Repeat until a thick glove is formed. Peel off the paraffin 
glove and put it back into boiler. Make two or three gloves, according 
to the length of treatment prescribed by the physician. 7 
If exercise is prescribed, squeeze and mold the piece of warm paraffin 
in the hand before putting it back in the boiler. 
Large Joints.—Protect the bed and floor from dripping paraffin with 
paper. Melt 2 pounds (0.9 Kg.) of paraffin in a small double boiler, 
according to the technic just described. With a new paint brush (2 
to 2y2 inches [5 to 6 cm.] wide), dip into the melted paraffin and spread 
it over the joint. Repeat the spreading of hot paraffin until the joint is 
completely covered. Work the brush back and forth only enough to 
spread the hot paraffin smoothly over the previous layer. Continue 
painting over the hardened layer until a thick coating is made inch 
[32 mm.] or more). Remove the coating, put the paraffin back into 
Fig. 2.—An inexpensive home baker for therapeutic use, designed for applying 
heat to the legs and arms. The specifications for the baker are as follows: length, 
17 inches (43 cm.) ; width, 14 inches (36 cm.) ; overall height, 14y£ inches 
(37 cm.); altitude of arc, 5 inches (12.5 cm.); frame, He by % inch (0.16 by 
1.5 cm.) strap iron; reflector, highly polished tin sheeting; two double receptacles, 
General Electric Company, catalog no. 66722, 250 volts, 650 watts; four mazda 
lamps, 60 watts. The tin is riveted to the strap iron. The receptacles are con- 
nected in multiple with a heavy lamp cord 6 feet (183 cm.) long, to the end of 
which is attached a bubble plug. If the baker is to be used for applying heat to 
the body, the supports should be 2 or 3 inches (5 to 7.5 cm.) longer. 
the boiler and apply additional coats for the length of time prescribed 
by the doctor. 
Hydrotherapy: Whirlpool baths. A simple whirlpool bath for home 
use can be constructed inexpensively. Tub baths. It has been found that in certain forms of atrophic 
arthritis mild febrile reactions may tend to control an exacerbation of 
the disease. 
For a robust patient it is entirely possible, under proper medical 
supervision, to obtain a febrile reaction at home by placing the patient 
in his own bathtub. The temperature of the water may be varied 
between 98 and 105 F. (36.6 and 40.5 C.), and the duration may vary 
from ten to forty-five minutes. Usually, the patient’s oral temperature 
will rise in thirty minutes to approximately 101 F. (38.3 C.), sweating 
is induced and the general metabolism is stimulated. In all cases milder 
temperatures and shorter periods should be used at first, the tempera- 
ture and duration being increased at subsequent sessions, according to 
the patient’s tolerance. 
Fig. 3.—A homemade whirlpool bath to be used for relief of edema, for painful 
cicatrices, for trophic lesions resulting from prolonged suppuration and as a prep- 
aration for local massage. The specifications for the bath are as follows: a copper 
washboiler; a Y* inch (1.27 cm.), 90 degree elbow; a Yz inch, 90 degree street 
elbow; a inch tee; Y% to Y& inch (1.6 to 0.3 cm.) bushing; % inch pipe; outlet, 
Ya inch (1.9 cm.) nipple with locknuts and a gasket, and Y* inch galvanized iron 
pipe, enameled white. The street elbow is tapped inside at the male end to fit Ys, 
inch bushing. One-eighth inch pipe is used for the nozzle. A local tinsmith can 
assemble this unit. Although a factory product would look better and would be 
more convenient, its therapeutic efficiency would be no greater. 
Contrast baths. Contrast baths are especially useful in the presence 
of cold and clammy extremities. The patient should obtain two buckets 
or pans of the proper size and shape for immersion of the feet or hands. 
One container should be filled with hot water at comfortable tolerance, 
at a temperature from 105 to 110 F. (40.5 to 43.3 C.) ; the other con- 
tainer should be filled with cool tap water, from 60 to 65 F. (15.5 to 
18.3 C). 9 
The best routine has seemed to be one in which five minutes of heat 
and two minutes of cold or four minutes of heat and one minute of cold 
are employed. One should always start and end with immersion in 
hot water to obtain the best vascular response. An application should 
last a total of nineteen or twenty-four minutes. 
massage 
General Considerations.—In view of the fact that massage is fre- 
quently given in conjunction with local exposure to heat and occasion- 
ally subsequent to systemic exposure to heat, attention should again 
be directed here to the physiologic effects of the latter, referred to in 
the section “General Considerations.” 
It would appear that massage partakes somewhat of the nature of 
exercise, but studies from the chemical standpoint show that this is 
not wholly the case. In order to understand the influences of massage, 
it is important to consider briefly the nature of the response of the 
body economy to exercise. Actively contracting muscles bring about 
the production of lactic acid in amounts sufficient to change the reaction 
of the blood; true acidosis develops. The increased acidity thus induced 
may persist for as long as fifty minutes after an amount of exercise 
equivalent to 3,500 kilogram meters in three and one-half minutes. 
This is about comparable to the amount of exercise taken by a man 
weighing 150 pounds (68 Kg.) climbing a hundred and fifty steps at 
the rate of one step a second. 
After massage given as vigorously as was clinically practicable to 
persons unaccustomed to it there developed none of the evidences of 
acidosis that follow active exercise or the evidences of alkalosis that 
follow systemic exposure to heat. There was no increase in organic 
acids such as would have presumably occurred had lactic acid been 
produced and eliminated as it is during exercise. After massage of 
considerable severity the hydrogen ion concentration of the blood 
showed no change comparable in magnitude to that following exercise. 
Massage is accompanied, therefore, by neither the alkaline swing 
following systemic exposure to heat nor the acid swing following active 
exercise. 
Light pressure produces an almost instantaneous, though transient, 
dilatation of the capillary vessels, although heavier pressure may pro- 
duce dilatation of more enduring nature. Microscopic observation of 
fields in which only a few capillaries are open, and hence in which only 
a few can be seen, reveals tfcat pressure of this kind may cause prac- 
tically all the smaller vessels to become visible because of the blood 
flow created through them. 
After massage there are an increased rate of blood flow and a change 
in the vessel wall, which is evidenced by the “sticking” and emigration 10 
of leukocytes. Massage is thus accompanied or followed by an increased 
interchange of substances between the blood stream and the tissue 
cells, with'an altered and presumably improved tissue metabolism. 
It is not difficult to recognize in a gross way clinically the pos- 
sible mechanical influence of massage in returning fluid from the fixed 
tissues to the general circulation. When the clinician determines the 
presence of edema in the lower limbs by pressing with a finger to 
induce pitting, he is really carrying out on a small scale the principles 
of massage. If these principles are applied on a large scale and skil- 
fully, the fluid so displaced is returned more easily to the circulation 
for removal through the kidneys. The influence of massage here 
described has application, in conjunction of course with other measures, 
to cardiac dysfunction accompanied by peripheral edema and also to 
the low grade tissue edema seen frequently with chronic arthritis. 
The beneficial effects accruing to the patient with arthritis from 
massage are exerted partly through the lymphatics involved, but it 
would be improper to suppose that the general effects of massage on 
the circulation are brought about through mechanical agencies alone. 
There can be small doubt that the nervous system contributes under 
massage, probably through the sympathetic division, to a reflex influence 
on the blood vessels of the parts concerned. 
It must be borne in mind that a necessary consequence of dysfunc- 
tion of muscle tissue, for which massage is often indicated, is the pro- 
duction in the muscle of some of the products of dysfunction. Massage 
is capable of promoting the removal of some of these substances, as is 
well exemplified in its influence on the extravasations of blood and 
other debris consequent on traumatization of muscle or other tissue. 
In this connection it is important to point out that in many debili- 
tating states, such as chronic arthritis, it is possible to expedite removal 
into the blood stream of the products of faulty metabolism to such an 
extent that toxemia with fever may be induced. Great care, there- 
fore, must be exercised under such circumstances to avoid overtreat- 
ment, especially with elderly people. 
In connection with arthritis, local massage can usually be preceded 
with profit by the application of heat to the involved part. 
Under nearly all circumstances, massage for arthritis should be 
directed to the neighborhood of joints rather than to the joints them- 
selves and should be unaccompanied by movement of the joints. 
“Churning” of the joint is to be studiously avoided. One of the com- 
monest errors made by masseurs in general is that of inducing twist- 
ing movements in the joints of the finger or in other joints, together 
with passive flexion and extension of nearly all involved joints. Sub- 
siding arthritis may easily be perpetuated or made worse by activities 
of this sort. 11 
Therapeutic Massage.—There are four main types of therapeutic 
massage. To secure relaxation, the patient should always be recum- 
bent even when massage is being given to an extremity. 
1. Superficial Stroking Massage: This consists of the passage of 
the hand over an area of the patient’s skin with a slow, gentle and 
rhythmic movement. This aims to produce only a reflex effect. To 
secure this effect the pressure must be extremely light and each move- 
ment must be repeated in the same direction. 
2. Deep Stroking Massage: The aim of this form of massage is 
to empty the veins and lymphatics and to press their contents in the 
direction of the natural flow. It is essential to have the patient’s 
muscles relaxed, to take advantage of gravity, to make the movements 
deep but not heavy and to make them always in the direction of the 
venous flow. The hand of the operator must be adapted to fit the con- 
tour of the area being treated. 
3. Kneading Massage: This consists in grasping, wringing, lift- 
ing, rolling or pressing a part of a muscle or a muscle group. This 
form of massage aims to assist venous and lymphatic circulation, to 
stretch retracted muscles and tendons and to aid in stretching adhesions. 
The essentials in kneading massage are the same as those set forth for 
deep stroking massage. 
4. Friction Massage: This consists in pressing deeply on the 
part under treatment and passing the hand in a circular direction, 
moving the superficial over the underlying parts. The effect of fric- 
tion is to free adherent skin, to loosen scars and adhesions of deeper 
parts and to aid in the absorption of local effusion. Friction is an 
important massage manipulation around joints and for small areas, 
such as the hands, feet and face. 
Local applications of cold with rest, proper compression bandaging 
and elevation are indicated for immediate treatment. Later, splints or 
bandages (including plaster of paris bandages) should be removed and 
replaced after the daily treatment by heat from an electric lamp baker 
or a whirlpool bath followed by massage. On the whole, fixation by 
a removable plaster splint and daily application of heat and massage 
are to be preferred to strapping with adhesive plaster, which does not 
permit recourse to physical therapy. 
SPRAINS AND DISLOCATIONS 
TRAUMATIC SYNOVITIS 
During the acute stage hot applications and splints or mild traction 
should be used to immobilize joints motion of which causes pain. 
After the first stage, of acute inflammation, lasting fr.om one day to 12 
possibly a week, the secondary stage, of absorption of effusion and 
restoration of function of the joint, begins. During this stage, heat 
and massage are vitally important in aiding these processes. 
Means of treatment similar to those used for traumatic synovitis 
are valuble also in case of contusions or muscle strains to secure absorp- 
tion of the products of hemorrhage, to eliminate swelling and pain 
and to secure restoration of function. Collections of blood if not 
absorbed may form hematomas, with possible calcification, or may be 
infected through the blood stream and become abscesses. It is impor- 
tant, therefore, to secure an early absorption of blood clots and so lessen 
the amount of scar tissue which forms among the muscle fibers and 
permit closer approximation of the ruptured fibers. 
CONTUSIONS AND MUSCLE STRAINS 
A common injury of this type is rupture of some of the fibers of 
one or more of the muscles of the calf of the leg. This injury should 
be treated by splinting the foot with the heel elevated in order to relax 
the achilles tendon and by binding the leg with a firm dressing of 
adhesive plaster to give support to the muscles. The patient is 
instructed not to bear any weight on the ball of his foot for at least 
three weeks. At the end of a week application of heat and massage 
of the muscle of the calf are begun. 
When a ruptured tendon or muscle has been operated on, heat and 
massage are essential for several weeks in order to prevent fibrosis 
and to restore proper movements of the tendons. 
Practically all patients with injury of a muscle are benefited by 
heat, massage and active and passive movements at some time or other 
during the course of recovery. 
In the nonsurgical treatment of this condition, improvement is often 
obtained by gentle continuous stretching of the contractures by splinting. 
Heat and massage constitute one of the best means available for assisting 
in the repair of the damage that has been done and to prevent so far as 
possible the subsequent contractures that result. Careful stretching of 
the contracted muscles should be performed. The treatment should 
progress as rapidly as possible to active assisted exercises and then to 
active free motion. 
VOLKMANN’S ISCHEMIA (CONTRACTURE) 
This condition, often seen about the elbow and the shoulder joint, for 
example, and resulting from acute or chronic strain, is susceptible to 
improvement or cure by heat and massage. 
BURSITIS 13 
During the acute stage, when the pain is severe and the muscles are 
irritable, it may be best to immobilize the part temporarily and to apply 
moist or dry heat until this irritability has subsided. 
In general, it may be said that for these conditions heat, massage 
and exercises are usually begun after the acute inflammatory reaction 
has disappeared. 
NONSUPPURATIVE TENOSYNOVITIS 
Tenosynovitis is seen most commonly in the extensor tendons that 
move the fingers and the wrist. It must be treated by splinting to 
immobilize the tendons and by applying heat. This is continued as long 
as any symptoms of crepitation, pain and weakness persist. Massage is 
contraindicated. 
FRACTURES 
General Considerations.—The effectiveness of treatment of fractures 
today cannot be based solely on securing union of the fractured bone or 
bones, for the rapidity with which the patient is returned to work and 
the extent to which function is restored must also be taken into con- 
sideration. At the present time it is generally conceded that a fracture 
should be treated as a surgical emergency and reduction carried out at 
the earliest possible moment and adequate fixation immediately applied 
with local or general anesthesia. 
The proper after-care of a fracture consists principally of maintaining 
fixation of the fractured bone or bones until union has occurred, the early 
restoration of normal circulatory efficiency in the involved region and 
the building up of muscle tone and power so that normal use may be 
resumed at the earliest possible moment. Physical therapy, properly 
and intelligently employed, can be of inestimable service in this period 
of after-care in hastening recovery. 
Types of Physical Therapy Useful in the Treatment of Fractures.— 
In order that physical therapy may be intelligently used in the treatment 
of fractures, it is necessary that its purposes and aims be clearly defined 
and recognized. They can be briefly stated as follows: (1) promoting 
the early absorption of hemorrhage and traumatic exudate; (2) relaxa- 
tion of muscle spasm to relieve pain and discomfort; (3) reestablishment 
of normal circulatory conditions in the affected extremity, blood stream 
and lymphatics, which insures a more rapid and complete healing of the 
fracture, and (4) building up in the muscles of the extremity that tone 
and flexibility so necessary to normal use. These effects are brought 
about by physical agents acting on the neuromuscular and neurovascular 
reflex mechanisms and through the stimulation of muscles by physical 
means or voluntary action. Broadly speaking, there are four basic 
forms of physical therapy which may be employed in the treatment of 
fractures to accomplish the purposes catalogued. 14 
Heat: Heat as a physical agent may be applied by a number of 
devices, such as a therapeutic lamp, whirlpool baths, hot packs and 
ordinary light bulbs set up in a cradle. To bring about the best results 
heat should be employed at low intensity and over a considerable period. 
Massage: The type of massage most useful in the treatment of frac- 
tures is light stroking massage; the movement should be slow, even, 
steady and always in the same direction, that is, lengthwise of the part 
in the direction of venous circulation. It should be remembered that 
massage employed to get rid of hemorrhage and exudate and to reduce 
swelling acts by bringing about improved circulatory conditions and does 
not rub the exudate out of the part by pressure and force. 
Muscle Stimulation: Muscle contractions may be produced by 
voluntary effort or by electrical stimulation. Voluntary contraction of 
muscle groups is incomparably superior to any form of artificial stimula- 
tion. Limited voluntary use is made possible by employing fixation 
(with traction or with hinged splints) which holds the fractured bone or 
bones securely but permits the guarded use of adjacent joints, by using 
molded plaster splints instead of circular plaster dressings and also by 
having the patient “set” the muscles of the injured extremity a number 
of times each day; such “setting” of the muscles can be carried out even 
when the limb is completely encased in a plaster dressing. 
To avoid painful contraction some form of sinusoidal current may 
be used. The Council on Physical Therapy will furnish a design for 
making a faradic sinusoidal coil. This coil produces a sinusoidal current 
which will give graduated muscular contractions as described by Bristow 
and Smart. The value of these contractions is primarily the increase 
in circulation in the muscle. 
The Reduction Period.—Practically, physical therapy can play but a 
minor role in the reduction period. However, when for any reason it is 
impossible to proceed with the immediate reduction of a fracture, even 
if the delay is but a few hours, heat and gentle massage may be used to 
advantage. 
The Postreduction Period.—It is in the immediate postreduction 
period that exudate and hemorrhage which will become organized into 
scar tissue about the muscles, tendons, vessels and nerves and will 
interfere with the movement of the joint can largely be removed by 
restoring normal circulatory efficiency to the part as early as possible. 
It is quite true that the institution of physical therapy at this time 
is often difficult because the part is encased in a fixation dressing, but by 
the use both for bed and for ambulatory patients of traction which allows 
ready access to the part for physical therapy, by the use of apertures in 
plaster dressings, by the use of hinged splints which allow movement 
in adjacent joints without disturbance of the fracture site, by the use 15 
of open splinting and by frequent “setting” of the muscles, it is usually 
possible in most fractures to use heat, massage and muscle contraction 
throughout the period of fixation to the great advantage of the patient. 
So-called open splinting has in recent years been used more and more 
in the fixation of fractures; this permits the employment of physical 
therapy to a satisfactory extent. 
In addition to “setting” muscles in this postreduction period, active 
muscle contraction may be encouraged in several ways. Even with the 
forearm and arm encased in a circular plaster splint, if the fingers are 
free the patient can exercise the muscles of the forearm extensively by 
squeezing and relaxing his grip on a rubber sponge. 
Fig. 4.—Plan for a walker to assist in the reeducation of certain patients in 
walking. 
The Period of After-treatment.—The role of physical therapy in the 
after-treatment of fractures may be stated to be helping the patient to 
regain voluntary use of the muscles and voluntary control of impaired 
joints of the injured extremity. Heat, massage and muscle stimulation 
can reduce swelling; can decrease pain, soreness and stiffness in weak 
and degenerated muscles; can improve vascular and lympathic circula- 
tion ; can stimulate neuromuscular and neurovascular impulses, and can, 
in brief, make it easier for the patient to use the impaired part and to 
build up voluntary control. They cannot, however, make him well. 
The patient, in the last analysis, is master of his fate, and physical 
therapy is but the tool which enables him to carve out his recovery with 16 
the least discomfort, with the greatest speed and to the fullest extent. 
It is active use of the extremity carried out by the patient himself 
which completes the recovery. 
The movements which are used should be designed to bring about 
normal action of the joint in the most natural manner. Having the 
patient go through the motions of brushing the air after fracture of the 
elbow, driving nails with a light hammer after fracture of the wrist, 
turning a door handle after fracture of the forearm and reaching for 
objects placed at a gradually increased height after fracture of the 
shoulder illustrate the methods which may be used to encourage the 
patient to use the extremity in a normal manner. 
Role of Occupational Therapy.—Occupational therapy of the func- 
tional type is chiefly valuable because it supplies a real incentive for 
the patient to use the impaired part. A definite task is given to him to 
perform, and in spite of himself he becomes interested in completing it, 
with the result that he is inspired to renewed effort and unconsciously 
develops the attitude of mind which is necessary for recovery. Occupa- 
tional therapy is a useful way of overcoming the subconscious resistance 
of the patient to normal use of an injured part for fear he will suffer 
a relapse. 
PERIPHERAL NERVE INJURIES 
Proper splinting, heat, massage, electrical muscle stimulation and 
under-water and muscle reeducation exercises are the usual physical 
agents used for peripheral nerve lesions. Heat and massage are used 
to improve circulation, which thus lessens congestion and a tendency 
to fibrosis. In peripheral nerve injuries the flaccidity of the muscle 
deprives the blood vessels of the natural protection given them by 
proper muscle tone, and as the arterioles are extremely delicate it is 
easy to overdo the massage, produce paralytic dilatation of these 
arterioles and increase the condition one is striving to overcome. There- 
fore, the massage should be delicate and given for a short period, and 
the paralyzed muscle should not be pressed between the fingers or 
against the bone. The treatment here is the daily application of heat, 
proper massage with gentle stroking and kneading of small areas and 
passive joint motions to prevent joint stiffness. Electrical muscle 
stimulation is an aid which when overused causes the same effects as 
overuse of massage. Two or three contractions of each muscle daily is 
ample. Again, it is important to remember that there is no muscular 
protection for the delicate vessel walls and only the most gentle manipu- 
lations are essential. All deep kneading, compressing and vibrating 
movements are contraindicated. Even in the stroking movements, care 
must be taken not to compress the muscles against the underlying bone. 
Massage in itself is ineffective unless there is proper splintage to 
prevent the healthy muscles from contracting and the paralyzed muscles 17 
from overstretching. Massage should not be allowed to replace muscle 
reeducation movements, as muscle strength is increased only by active 
exercise. 
STIFF JOINTS 
Exclusive of cases of bony ankylosis or cases in which there are 
pathologic contraindications, massage, exercise and continuous traction 
or stretching by splints have an important place in the treatment of stiff 
joints. Adhesions inside or outside such a joint occur in great variety 
and in a large number of cases are susceptible to gentle stretching. 
Fig. 5.—Plan for a Kanavel table for exercising the forearm, wrist and hand. 
For this type of stiff joint, deep stroking massage, followed by deep 
kneading of the muscles above and below the joint, is used. Some one 
of the methods of heating the limb should precede these manipulations. 
Friction massage is indicated immediately over the joint. The fingers 
should work over all the joint, pressing the infiltrated areas and scars. 
After massage resistive exercises and active movements are used. 
It is important to remember that heavy massage, exercises and 
movements may cause some reaction, but if the pain from this passes 
off in an hour it is not detrimental. If it persists longer and there is 
an increased swelling, injury to the ligaments, muscles and vessels has 18 
undoubtedly occurred, with effusion which may organize into more 
adhesions. In such an event massage and exercises should be abandoned, 
the joint put at rest and heat applied until the reaction has passed. Then 
the efforts shbuld be resumed with less vigor. 
In the treatment of stiff joints the patient often expects too much 
of massage and heat. Active exercise and proper splinting are more 
important, and it must be explained to the patient that these agents are 
to be used in spite of temporary discomfort. Proper splinting with con- 
tinuous traction is of great value and must not be neglected. 
AMPUTATIONS 
Heat, massage and exercise play an important part in preparing the 
stump of an amputated limb for early and efficient function. 
Heat.—In stumps of recent amputations the local circulation is 
usually diminished and may be increased by heat applied locally at the 
moderate temperature of 96 F. for twenty minutes every two or three 
hours. At no time should this temperature be exceeded in amputations 
for diabetes or for peripheral vascular disease. Radiant heat is applied 
by an infra-red generator or by an electric lamp “baker.” While heat 
used locally is the most potent vasodilator, it is fraught with danger 
when employed over areas of diminished circulation. It is safer to use 
a cradle at the root of the limb or over the abdomen; this will result in 
the same increase in circulation within the limits of the capacity of the 
diseased vascular bed. 
Several types of baths (contrast and whirlpool) are used in applying 
heat to the stump to aid in the control of inflammation. Ordinarily, 
hot baths should not be used routinely because they soften the skin and 
thus delay prosthesis. 
Massage.—In stumps healing without complication, massage should 
be started six or seven days after amputation. 
When massage is given the patient is recumbent with the stump 
placed so that all the muscles are as relaxed as possible. The application 
of some form of heat usually precedes the treatment, which is given 
for ten to fifteen minutes daily. Massage should not be used in the 
presence of infection. 
Exercise.—All exercises are prescribed by the surgeon. As the 
condition of the stump permits, the physical therapeutist instructs the 
patient in the various exercises and supervises a regular exercise period. 
Unless there is some contraindication, the patient is directed by the 
surgeon while the dressings are still in place, a week or ten days after 
amputation, to pound the end of the stump gently with the palm of his 
hand. The force and number of blows increase as rapidly as the condi- 
tion of the stump permits. 19 
Fig. 6.—Plan for a massage table. All the boards are £4 inch (1.9 cm.) thick 
and the legs measure 2 by 2 by 29% inches (S by 5 by 74 cm.). 
Figure 7 
Figure 8 
Fig. 7.—A method of applying traction for contractures which limit the extension 
of the hip after amputation through the upper third of the thigh. 
Fig. 8.—Apparatus for shoulder abduction exercises after arm amputation. 20 
Fig. 9.—Plan for adjustable parallel bars to be used for walking reeducation 
Fig. 10.—Plan for stall bars to be used as a means of exercise by patients who 
have undergone leg amputations. All of the wood should be white oak of grade 1. 
The rungs should be tapered to 1 inch (2.5 cm.) diameter at each end and \l/± inch 
(3 cm.) diameter in the center, and all surfaces should be smoothly finished and 
polished. The scale of the plan is an inch to the foot (2.5 cm. = 30 cm.). 21 
For efficient use of an artificial limb the strength of the muscles in 
the remaining part of the amputated extremity must be equal to the 
muscle power of the opposite normal member. Active exercise is the 
means by which muscle strength of the stump is increased, and applica- 
tion of such exercise diminished the two great difficulties accompanying 
the use of an artificial limb—limitation of motion of the joint and 
Fig. 11.—Plan for exercise steps to be used by patients who have undergone leg 
amputations. All of the wood should be select yellow pine, and unless otherwise 
specified all boards should be Y inch (1.9 cm.) in thickness. All exposed edges 
should be neatly beveled. The scale of the plan is an inch to the foot (2.5 cm. 
= 30 cm.). 
weakened muscles in the stump. Active exercise can be started within 
a few days after operation. 
Definite directions should be given for active and resistive exercises, 
which should be performed at least four times a day. 22 
Arm Amputation: Abduction exercises for the shoulder prevent 
atrophy of the deltoid and the supraspinatus muscles and external rota- 
tion prevents atrophy of the infraspinatus and the teres minor muscle. 
Numerous exercises can be devised for patients who have undergone 
amputation of the arm by using a simple apparatus consisting of a 
weight, a cuff, a rope and two pulleys. In this apparatus the rope is 
attached to the cuff fitted around the stump and passes through one 
pulley fastened to the wall near the floor, over the other pulley fixed 
to the wall near the ceiling and then to the weight. 
Leg Amputations and Reeducation: Learning the mechanics of 
standing and walking with an artificial limb involves reeducation as 
to the coordination of movement in the muscles of the stump and as 
to the tactile, muscular and joint sensation in the remaining part of 
the limb. If while still in bed patients who have undergone amputation 
have had exercises for extension and adduction of the hip, reeducation 
in standing and walking is not difficult. 
As a first step in learning the mechanics of using an artificial limb, 
the patient is taught to stand upright with his artificial leg directly 
under him and with his weight distributed equally on the two legs. 
After learning the mechanics of walking, the patient puts them into 
practice by walking between parallel bars, which are used for support. 
When this has been mastered he is taught to walk with short steps, 
using two canes, and then to walk with longer steps, using only one 
cane. Stall bars and steps may also be used as a means of exercise. 
CIRCULATORY DISEASES OF THE EXTREMITIES 
Vascular Exercise.—The influence which causes a collateral circula- 
tion to increase is, fundamentally, reactionary hyperemia. Just how a 
generalized vasodilatation of the smaller arteries of a limb shall be 
secured is immaterial. It is not even certain that there is one best way 
for every person. 
The Buerger-Alien Exercises: Position 1. Lying on his back, with 
a watch in sight, the patient rests his legs on an inclined plane raised 
to an angle of 30 to 45 degrees. He keeps them so raised until the 
feet are thoroughly blanched, a matter requiring, as a rule, two minutes. 
Position 2. The legs are lowered and the patient sits with them 
hanging over the edge of the bed. While the legs are dependent, the 
feet and toes are put through a series of motions: The ankle is flexed 
downward and then upward; the foot is rocked inward (tibial muscles 
flexed) and then outward (fibular muscles flexed) ; the toes are spread 
(extended) and then closed (flexed). As these exercises go on, the 
feet become flushed. They should turn a strong pink well out on the 
tips of the toes, a matter requiring one to three minutes. But if they 
become cyanotic or painful, they should at once be elevated. 23 
Position 3. For five minutes the patient lies supine, with the legs 
horizontal in bed and wrapped in a woolen blanket warmed by a hot 
water bottle or an electric pad. In this way the reactionary flush 
secured by position 2 is maintained. 
The cycle is put through three to six times at one session, and the 
sessions are repeated two to four times each day. 
Fig. 12.—Buerger-Alien exercises (from Homans, J., Circulatory Diseases of 
the Extremities, New York, The Macmillan Company, 1939). 
Vascular Exercise by Other Special Methods: Exercising devices 
more elaborate than the Buerger-Alien exercises include (1) the 
oscillating bed, (2) the suction and pressure boot and (3) intermittent 
venous occlusion. 24 
PAINFUL FEET 
In the condition of painful feet due to traumatism or possibly to 
infection, semirigid and spastic feet can frequently be made more flexible 
by means of physical therapy, in conjunction with the use of proper 
supports for the feet. 
Sometimes there is so much pain from foot strain that no form of 
shoeing or altering of the shoe will give relief. In such instances it is 
best to keep the patient off his feet entirely until the pain has gone. 
To prescribe exercises for a painful, uncomfortable foot which is 
already overburdened does not seem sound therapy. When the symp- 
toms have been relieved, however, exercises are indicated. Too many 
patients become easily discouraged with foot exercises and give them 
up long before benefit can be expected. The reasons for this are bore- 
dom, lack of interest in prolonged treatment and too many exercises 
to be done at one time. If the exercises can be boiled down to one 
maneuver, the surgeon will get more cooperation. This one maneuver 
will increase the tone of the muscles that control the arch of the foot. 
The patient is shown how to flex all his toes strongly and, at the same 
time he flexes them, to adduct and invert the foot. This position is 
held momentarily. The contracted muscles are relaxed slowly and the 
contractions are repeated several times, morning and evening. One 
will find that in the long run more patients will perform this combined 
exercise than would do a dozen different exercises ten times each. It 
is important that the patient cultivate the habit of performing this 
exercise at frequent intervals, standing or sitting and with the shoes on. 
Physical therapeutic measures are indicated in the rehabilitation of 
lame backs. The indications for such a measure depend largely on the 
acuteness, the length and the cause of the attack. 
BACKACHE 
One of the first rules in caring for a joint is to do nothing which 
will increase the symptoms. Therefore, all treatment should be designed 
to make the patient more comfortable. 
Treatment of the Acutely Painful Back.—Rest; The first require- 
ment is rest in the most comfortable position, as it helps to reduce 
muscular spasm in the powerful muscles of the spinal column and thus 
permits the back to resume its normal posture gradually. 
Heat: Treatment with this agent is soothing and also helps to relax 
spasm and to relieve pain. Heat should be applied judiciously and for 
about thirty minutes at a time. Long-continued applications of intense 
heat defeat the purpose for which they are intended. It must be remem- 
bered that prolonged and excessive heating does not cure. Short 
applications of heat promote the circulation, whereas long applications 25 
of intense heat harm muscle tone. The simplest devices for applying 
heat are useful, that is, the small luminous heat lamp and the hot 
water pack. 
Daily Massage: At this time the lightest possible massage may be 
given if the patient will tolerate it. Exercises are contraindicated. 
When the more acute symptoms have abated, the massage may be 
increased and the patient may be up and about wearing some form of 
protective apparatus. 
Exercises: When the acute state has subsided, when the spinal 
movements are not restricted by muscular spasm and when the patient 
can reverse his lumbar curve without pain, exercises to restore power, 
increase motion, restore coordination and improve posture are indicated. 
At first these should be simple and should be prescribed in small doses 
at frequent intervals. 
The muscles which are most important are the gluteal and the 
abdominal muscles. Early exercising of the muscles of the back will 
not help the back, since to increase the power in these will increase the 
lumbar lordosis. The following exercises are recommended: 
1. Deliberate firm contractions of the abdominal muscles with raising 
of the head, contractions of the gluteal muscles with pressing of the 
lower part of the spinal column against the table or any exercises pro- 
ducing pelvic roll are suggested. Exercises of the muscles of the lower 
part of the trunk will tend to restore coordination and to relieve 
muscular spasm. 
2. For backache due to muscular injury, producing hemorrhage and 
muscular spasm, exercises designed to cause relaxation are used. These 
exercises should be deliberate and not too forceful, and should include 
bending of the trunk sideways and forward flexion and extension. 
3. Sometimes backache is due to muscular spasm or muscular short- 
ening, such as occurs in the erector spinae muscle, the tensor fascia 
lata, the hamstrings or the achilles tendons. Here the exercises should 
be prescribed for stretching these shortened muscles and tendons by 
leverage movements of the body. 
These more or less specific exercises are complemented by general 
postural exercises, such as lying on the back, lowering the chin, 
dropping the lumbar portion of the spinal column and the knees to the 
table and raising the chest, pelvis and feet. The same effect is obtained 
by sitting on a chair and maintaining the tallest sitting position possible 
for two to five minutes or by standing against a wall, relaxing the 
posterior portion of the neck and the lumbar part of the spinal column 
against the wall and stretching the knees. 
The aim of the physician should be to restore the normal physiologic 
curves of the spinal column, since to do so will remove the principal 
precipitating cause of the lame back due to bad mechanics. 26 
In cases of spastic paralysis, except for mild stroking and gentle 
kneading, massage is contraindicated, as the muscles are in a state of 
hypertonicity. The stroking should be firm, slow and even. The 
kneading is performed with the two hands on opposite sides of the 
limb, and the pressure should be gentle, although here the pressure 
may be firmer as the muscle tone is increased and there is not as much 
danger of injuring the muscle or arterioles as in flaccid paralysis. 
TRAUMATIC CEREBRAL SPASTIC PARALYSIS 
It is usually advantageous in cases of cerebral spastic paralysis to 
precede the massage with heat and to follow it with movement. The 
difficulty is to secure motion without exciting spasm. The patient should 
then be taught to perform some voluntary movements of a simple 
nature. These movements can usually be best taught by the use of 
occupational therapy. 
For adults with cerebral spastic paralysis massage and passive 
movements are useful adjuncts to prevent the development of muscular 
contraction and joint stiffness, but the patient must be made to under- 
stand that these maneuvers are not going to restore power in his limb. 
His participation is essential to reestablish normal impulses from the 
brain to the muscles. His own effort to accomplish active motion is 
the most essential element in his treatment. Muscle training is best 
carried out by rhythmic motions of both hands or both legs at the same 
time. This gives more symmetric synchronous movements of both 
extremities than does the use of only the extremity involved. 
GONOCOCCIC INFECTIONS RESISTANT TO CHEMOTHERAPY 
Since the introduction of sulfanilamide and its derivatives into 
therapy, the need for artificial fever in the treatment of gonorrhea has 
become less. For two groups of patients, however, fever therapy may 
still be desirable. These are (1) the small percentage of patients who 
cannot tolerate the sulfanilamide compounds because of reactions and 
(2) the somewhat larger group in whom the drugs do not eradicate 
the disease. For the latter (sulfanilamide-resistant) group, a combina- 
tion of therapy with sulfanilamide compounds and hyperpyrexia has 
proved efficacious; for the former (sulfanilamide-intolerant) group, 
fever therapy alone may be employed, since the combination of fever 
and chemotherapy may lead to a greatly intensified drug reaction. 
Acute arthritis is the gonorrheal complication which has proved to 
be most favorably influenced by fever therapy alone or combined with 
chemotherapy with sulfanilamide compounds. When combined treat- 
ment is used, a single fever session of ten hours preceded by eighteen 
to twenty-four hours of adequate chemotherapy appears to be the 
method of choice. 27 
DEMENTIA PARALYTICA 
There is still disagreement and controversy over the relative merits 
of malaria and artificial fever in the treatment of paresis. At present, 
the argument cannot be settled, and the middle point of view is that 
since malaria and mechanical fever are both of demonstrable value, the 
physician should choose that method with the use of which he is most 
familiar, which is most readily available and which best suits the social, 
financial and medical requirements of the individual patient. 
In the experience of the United States Public Health Service Com- 
mittee, mechanical fever gave the highest percentage of clinical remis- 
sions in patients treated with an average of sixty-nine hours of fever 
with a temperature above 101 F. (38.3 C), during 70 per cent of 
which total fever time the temperature was above 105 F. (40.6 C.), 
with a maximum of 106.9 F. (41.6 C.). Equally good results were 
obtained by treating patients with an average of forty-four hours of 
fever with a temperature above 101 F. (38.3 C), during 57 per cent 
of which time the temperature was above 106 F. (41,0 C), with a 
maximum of 107 F. (41.7 C.). This committee has expressed the 
opinion that artificial fever maintained at temperatures above 106.7 F. 
(41.5 C.) introduces unnecessary hazards. 
CUTANEOUS DISEASES 
ULTRAVIOLET THERAPY 
Many cutaneous diseases are definitely helped by ultraviolet irradia- 
tion. In the past many more cutaneous diseases were treated with ultra- 
violet rays than at present. Dermatoses benefited by this mode of 
therapy are briefly discussed in alphabetic order. 
Acne Vulgaris.—This condition is divided into a number of clinical 
varieties. Acne indurata is common. Flushing doses of ultraviolet or 
solar radiation once or twice a week often cause the eruption to improve 
or disappear, but unfortunately recurrence is the rule. Postacne scars 
are improved by exfoliating doses of ultraviolet rays from a quartz 
mercury vapor glow (cold quartz) lamp. 
Dermatitis Herpetijormis.—'This condition is extremely pruritic and 
in many cases cannot be cured. When general body irradiation with 
ultraviolet rays is used in association with other methods of treatment, 
the pruritus may decrease and the patients are thus made more 
comfortable. 
Dermatophytosis.—This is sometimes improved by irradiation with 
ultraviolet rays. Acute forms with intense inflammatory reaction may 
be made worse by exposure to ultraviolet rays. 
Eczema Seborrhoeicum.—Occasionally irradiation with ultraviolet 
rays improves this condition. Patients with chronic patches are 28 
especially helped when treated with fairly intensive doses. In general, 
it may be stated that ultraviolet irradiation has been of limited service 
in the management of this form of eczema. However, some persons 
with recalcitrant eruptions are helped with generalized irradiation. 
Chronic eczema of childhood and intertrigo are also benefited when 
treated with ultraviolet rays. 
Erysipelas.—Good results have been obtained by applying large doses 
of ultraviolet rays to the affected areas. The sulfanilamide compounds 
cause photosensitization, and the two agents should not be used 
simultaneously. General systemic treatment combined with ultraviolet 
rays is indicated especially for children and for elderly people. 
Furunculosis.—Generalized irradiation with either natural or arti- 
ficial ultraviolet rays is beneficial in treating multiple recurrent furun- 
culosis. 
Neurodermatitis.—Circumscribed forms appear mostly in adults, 
whereas the disseminated variety occurs commonly in children. Patients 
with either type improve when given generalized treatments. Small 
doses which are applied often are better than large doses. Excessive 
erythema should be avoided. 
Naevus Flammeus.—Port wine marks are almost impossible to 
eradicate. Blistering doses of ultraviolet radiation with or without com- 
pression may eradicate faint lesions or may reduce the color of the more 
pronounced lesions. The treatments may have to be administered for 
several months or years before improvement is noted. 
Pityriasis Rosea.—Apparently it is exfoliation that effects the cure, 
and for this reason ultraviolet rays from a quartz mercury vapor glow 
(cold quartz) generator are preferred to other forms of ultraviolet rays. 
The course is certainly shortened and complications are avoided by 
treatment. 
Psoriasis.—Ultraviolet rays in suberythema doses applied to the 
individual lesions of psoriasis several times a week will at times promote 
resolution. The results seem to be even better if the lesions are first 
anointed with an ointment containing 3 per cent crude coal tar. Daily 
irradiation of the entire body with suberythema doses of solar or 
artificial ultraviolet rays may control the disease but will not prevent 
recurrences. Ultraviolet rays from any source are distinctly helpful in 
most cases of psoriasis. A severe reaction, however, should be avoided. 
Sycosis Vulgaris.—This chronic pustular folliculitis of the bearded 
region is recalcitrant. Patients are usually better in summer. Localized 
and general body irradiation with artificial ultraviolet rays may be 
of value. 29 
Telangiectases.—This condition can be improved with carefully 
applied ultraviolet rays in doses sufficient to provoke a severe reaction. 
Only a small area should be treated at any one time. 
Tuberculosis of the Erythema Induratum of Bazin: Gener- 
alized and localized irradiation with ultraviolet rays combined with rest, 
proper diet and injections of tuberculin often yields good results. 
Lupus Vulgaris: This disease abates when treated with ultraviolet 
rays. A great deal of time and patience is required, but the results 
often reward the effort. A combination of generalized and localized 
ultraviolet irradiation is generally employed. 
Scrofuloderma: Satisfactory results have been observed with ultra- 
violet rays. As in all the tuberculodermas, best results are obtained 
with adequate attention to the general health, suitable diet, injections 
of tuberculin and daily generalized body irradiation with either natural 
or artificial ultraviolet rays. 
Tuberculosis Cutis Orificialis: Satisfactory results have been noted 
when tuberculosis of the orificial mucous membranes has been treated 
with ultraviolet rays. As this form of tuberculosis is generally a ter- 
minal manifestation of visceral tuberculosis, everything possible to make 
the patient comfortable must be done. 
Ulcers.—Irradiation with artificial ultraviolet rays or with solar 
rays has been helpful in some cases of indolent ulcers and wounds. 
TREATMENT OF CUTANEOUS DISEASES BY PHYSICAL METHODS OTHER 
THAN IRRADIATION 
Definition of Terms.—The physical agents used in treating derma- 
tologic conditions are roentgen rays, radium, ultraviolet rays, medical 
diathermy, surgical diathermy, electrolysis, common ion transfer (ion- 
tophoresis), cautery, refrigeration and hydrotherapy. Medical dia- 
thermy and short wave therapy are used little in dermatologic condi- 
tions except for the treatment of syphilis. Surgical diathermy is 
employed much more frequently. The definition of terms used in this 
section are as follows: 
1. Medical diathermy: the use of a high frequency current for 
medical purposes. 
2. Surgical diathermy; the use of a high frequency current for 
surgical purposes. 
A. Cutting current: Biterminal high frequency current obtained 
from the primary winding of the high frequency transformer. 
B. Electrocoagulation: Biterminal (and at times monoterminal) 
high frequency current obtained from the primary winding of 
the high frequency transformer. 
C. Electrodesiccation: Monoterminal high frequency current obtained 
from the secondary winding of the high frequency transformer. 30 
Electrolysis.—A current suitable for electrolysis may be obtained 
from dry cells. The voltage employed for electrolysis is 22]/2 volts, 
and the milliamperage is usually from l/\ to 2 milliamperes. Devices 
for use with commercial direct and alternating currents are also avail- 
able. A cheap, convenient and satisfactory apparatus may be made 
from specifications furnished by the Council on Physical Therapy. The 
active negative electrode is a needle which is exceedingly thin and has 
a blunt end. 
Cauterisation.—The actual cautery consists of a red hot or white 
hot object which may be heated in a flame or kept constantly heated 
with an electrical device (thermocautery, electrocautery or galvano- 
cautery). 
Refrigeration.—Refrigeration is an important and useful method of 
treatment for many dermatologic conditions. Ethyl chloride spray is 
used for freezing prior to minor surgical operations and for destroying 
larva migrans. 
Solid carbon dioxide (commercial dry ice) is the most frequently 
used freezing agent. When dry ice is not available all that is required 
for manufacturing solid carbon dioxide in the office is a tank of carbon 
dioxide and suitable tubes or a special apparatus for its collection. 
Balneotherapy.—Balneotherapy, which is a dermatologic term refer- 
ring to the use of medicated baths and dressings wet with various 
solutions, is extremely valuable, especially in the treatment of extensive 
and inflammatory dermatoses. 
Cutaneous Diseases Responding Well to Physical Therapy.—Many 
cutaneous diseases respond exceedingly well to physical agents. A short 
description of the technic for treating each of these dermatoses follows. 
The diseases are arranged alphabetically. 
Adenoma Sebaceum.—These lesions are best treated with electrolysis, 
with superficial electrodesiccation or with applications of solid carbon 
dioxide. 
Clavus.—Soft or hard corns usually result from the wearing of 
improper shoes. The use of salicylic acid plaster is generally sufficient 
to clear up these lesions. Occasionally it is necessary to destroy a clavus 
with electrodesiccation. 
Cornu Cutaneum.—Cutaneous horns are precancerous lesions, and 
as soon as they are diagnosed they should be completely destroyed with 
electrosurgery with the affected area under local anesthesia. 
Cysts.—Mucous retention cysts may be excised or destroyed with 
electrosurgery. Sebaceous cysts are best excised. 
Fibroma.—Soft or hard pedunculated or sessile fibromas may be 
treated with electrosurgery or with electrolysis. It is inadvisable to 31 
excise or to destroy fibromas occurring in cases of Recklinghausen’s 
disease, because sarcoma may follow such treatment. 
Granuloma Pyogenicum.—Electrosurgical destruction of lesions with 
the affected areas under local anesthesia is the best method of treating 
this disease. 
Hypertrichosis.—The only practical and permanent method of safely 
removing superfluous hair is with electrolysis or light electrocoagulation. 
Keloids and Hypertrophic Scars.—In certain cases keloids and 
hypertrophic scars may be improved or eradicated by the combined use 
of roentgen rays or radium with surgical methods. Massage may be of 
some value in the treatment of hypertrophic scars. Properly applied 
solid carbon dioxide also has been found to be valuable in some cases. 
Keratoses.—Keratoses resulting from the administration of an 
arsenical, from seborrhea, from senility and from irradiation are best 
destroyed, with or without local anesthesia, by electrodesiccation. Solid 
carbon dioxide and thermocautery may also be used. 
Leukoplakia.—Leukoplakia is a precancerous cutaneous condition. 
Quiescent lesions require only careful observation. The proliferating 
verrucous and actively growing areas are best treated with electro- 
surgery. 
Malignant Growths.—Many of the cutaneous malignant growths are 
treated with electrodesiccation. Some of the squamous cell epitheliomas 
are destroyed with electrocoagulation or with electrocutting, which is 
followed up with roentgen or radium therapy. Before attempting to 
treat cancer of the skin one should be thoroughly familiar with all the 
methods used. 
Nevi.—There are several varieties of moles, and the appropriate 
management will be described under each type. 
Angioma Cavernosum: The superficial variety (strawberry mark) 
can be destroyed by refrigeration, electrodesiccation and excision. The 
best results, however, are obtained with properly applied radium or 
roentgen rays. The deeper and larger lesions also respond best to 
roentgen or radium irradiation but may be destroyed with solid carbon 
dioxide or by electrosurgery. Sclerosing solutions also yield excellent 
results. Treatment should be instituted at the earliest possible time. 
Naevus Araneus: These lesions may be destroyed with electrolysis 
or with light electrocoagulation, without scars. 
Naevus Flammeus: There is no satisfactory treatment for this 
condition. Carefully applied solid carbon dioxide may improve the 
appearance of some lesions. 
Naevus Unius Lateris and Naevus Verrucosus: These nevi may be 
treated with surgical excision, electrosurgery, electrolysis or with solid 32 
carbon dioxide. The method selected will depend on the type of lesion 
to be treated. Correct diagnosis is essential because these lesions often 
simulate malignant growths. 
Pigmented Nevi: Moles may be benign or malignant. Treatment 
depends on the type. The ordinary common mole with hair, light to 
dark brown in color, may be destroyed with electrolysis, solid carbon 
dioxide or electrodesiccation. Before any of these methods is used, the 
hair should be removed with electrolysis or with electrocoagulation. 
Disfiguring scars should be avoided. Good results are obtained in treat- 
ing flat pigmented moles without hair with solid carbon dioxide. 
Senile Angioma: Senile angiomas may be destroyed with electro- 
desiccation. 
Rosacea.—The dilated visible cutaneous vessels are destroyed with 
electrolysis. Properly applied electrosurgery improves the hypertrophy 
of the nose which sometimes follows rosacea (rhinophyma). 
Scleroderma.—Massage with cocoa butter is sometimes useful. Com- 
mon ion transfer (iontophoresis) with mecholyl chloride (acetylbeta- 
methylcholine hydrochloride) has been found to be useful in the treatment 
of this condition. 
Telangiectases.—Dilated superficial blood vessels from any cause 
may be permanently destroyed by electrolysis or by light electrocoagula- 
tion. Scarring should not result from this treatment. 
Tuberculosis of the Skin.—Lupus Vulgaris: Small discrete lesions 
can be destroyed with electrodesiccation or the actual cautery. When 
extensive areas are afifected, these destructive methods are impractical. 
Other general measures are more efficacious. 
Sarcoid of Boeck and of Darier and Roussy: These lesions may be 
destroyed with electrodesiccation, solid carbon dioxide or electrocautery. 
If they are extensive, general methods of treatment are preferred. 
Tuberculosis Verrucosa Cutis (Verruca Necrogenica; Warty Tuber- 
culosis of the Skin) : The lesions are generally solitary and small and 
are therefore amenable to treatment with destructive methods, electro- 
surgery being the one of choice. 
Verrucae.—Condylomata Acuminata (Venereal Warts) : Warts 
appearing around the genitals are best destroyed with electrosurgery 
with the use of local or proper general anesthesia. (Avoid explosive 
anesthetics.) 
Verruca Plana; Flat warts occur mostly in children and young 
adults. They affect the face, hands and forearms. Electrodesiccation 
without anesthesia, cauterization and the application of solid carbon 
dioxide are all suitable methods of treatment. 33 
Verruca Plantaris: Plantar warts are painful, and some are best 
destroyed by means of surgical diathermy with the area under procaine 
hydrochloride anesthesia. Solid carbon dioxide is sometimes used. 
Verruca Vulgaris: Small warts may be electrodesiccated without 
using anesthesia. Larger warts should be anesthetized before electro- 
surgery is instituted. They should be differentiated from lesions that 
have a clinical appearance of benign lesions but may be dangerous. 
Disfiguring scars should be avoided in the treatment of lesions which 
are benign and only of cosmetic importance. 
Xanthoma; Xanthoma Palpebrarum; Xanthoma Tuberosum Multi- 
plex.—'These lesions may be treated with trichloroacetic acid, solid car- 
bon dioxide, electrodesiccation or excision. 
TUBERCULOSIS 
Pulmonary Tuberculosis.—For uncomplicated pulmonary tuberculosis 
there is no clinical evidence to prove the indication for therapy with 
ultraviolet rays, and in this disease, even in quiescent forms, harm has 
been done by exposure to sunlight especially with too intense and pro- 
longed irradiation. Solar heat alone, especially in summer, can prove 
exhausting. 
Pleurisies.—When these, conditions occur in the course of obvious 
pulmonary tuberculosis as well as in cases of pneumothorax, they offer 
the same indications as does the pulmonary form of the disease. 
Tuberculous empyemas do not respond. 
Laryngeal Tuberculosis.— This condition is practically always sec- 
ondary to pulmonary tuberculosis, so that the indications for the 
treatment of the larynx depend on the nature of the disease in the lungs. 
Local treatment of the larynx is used in addition to the enforced rest 
and the hygienic regimen. Such local measures in particular include 
absolute vocal rest (silence), local medications and sprays and local 
application of the galvanic cautery. General ultraviolet ray exposures 
are made to the body, with at times additional laryngeal local exposures. 
The acute forms of laryngeal tuberculosis, particularly those with 
edema, are not indications for ultraviolet irradiation. 
Tuberculosis of the Lymph Nodes.—This condition may be seen 
clinically in three different stages, namely, as enlarged nodes which 
have undergone hyperplasia, as nodes which have proceeded to the stage 
of caseation and softening or as softened nodes which have perforated to 
the exterior through a sinus tract. In the first stage, general body 
exposures to repeated erythema doses of ultraviolet rays are not infre- 
quently followed by an inflammatory reaction at the nodes with slight 
pain, tenderness and swelling. In the majority of cases the inflammation 34 
subsides and the lymph node finally heals. About 30 per cent of nodes 
appear to show no tendency'to heal under ultraviolet irradiation alone, 
but with the addition of roentgen rays a large number will improve. 
Occasionally, nodes in the hyperplastic stage may become caseous under 
treatment at this stage with ultraviolet rays and may have to be treated 
surgically by excision. Under such circumstances these rays are of great 
value when used postoperatively in preventing the formation of tuber- 
culous sinuses. In the second stage of caseation, ultraviolet irradiation 
alone will frequently bring about resolution. When softened lymph 
nodes reach the stage of fluctuation, aspiration or incision is necessary, 
and then ultraviolet irradiation is most effective. In the third stage, 
excellent results are obtained in clearing up sinuses of long standing, 
but occasionally roentgen ray exposures may have to be combined with 
ultraviolet irradiation for complete healing to take place. Local irradia- 
tion of the sinus area should augment general irradiation of the body. 
Secondary Ulcerative Intestinal Tuberculosis.—This is the most 
frequent complication of pulmonary tuberculosis, occurring in 50 to 80 
per cent of the patients who die of pulmonary tuberculosis. Artificial 
ultraviolet ray and solar ray therapy, as well as a diet rich in vitamins, 
should be used in most cases, as they frequently relieve the symptoms 
and bring about recovery. When the desired results are not obtained by 
ultraviolet irradiation, roentgen treatment of the intestinal tract should 
be carefully given or other additional measures should be employed. 
Peritoneal Tuberculosis.—In cases of this condition therapy with 
ultraviolet rays always deserves a trial first. The serous exudative type 
generally responds to ultraviolet irradiation, both in children and in 
adults. The dry proliferative form, usually adhesive, is more refractory. 
Unilateral Renal Tuberculosis.—If the nature of this complication is 
recognized at the onset of symptoms and when such symptoms are slight, 
conservative treatment with ultraviolet rays can on rare occasions pre- 
vent the need of surgical intervention. As a rule, nephrectomy is 
indicated. 
For unilateral progressive renal tuberculosis or bilateral disease in 
which the more involved kidney is removed, ultraviolet irradiation is 
to be advised as a desirable postoperative treatment. 
Bilateral Renal Tuberculosis.—Ultraviolet irradiation is indicated. 
It may help render the disease quiescent; its occasional analgesic action 
on ulcerations of the bladder is particularly welcome. Advanced 
tuberculosis of both kidneys and of the bladder has rarely responded 
to any form of therapy, especially if the patient is cachectic. 
Tuberculosis of the Bones and Joints.—Heliotherapy, although not 
the mainstay of treatment, is employed in combination with other forms 35 
of therapy. Orthopedic measures, rest in the open and exposure to 
ultraviolet rays form the basis of conservative therapy. 
There are at present three definite schools of treatment, each with 
adherents. The first emphasizes the need for surgical intervention, 
especially fusion, in all cases of tuberculosis of the joints. The second 
school, represented by Rollier, is rigidly set against surgical interven- 
tion except in unusual instances. This school holds that light therapy 
combined with rest and traction can do far more than the surgeon’s 
knife. The third school adopts a more conservative attitude and teaches 
that the problem of tuberculosis of the joints is too complicated to be 
solved by one mode of attack and that in each instance numerous fine 
differentiations must be considered. Operative treatment, heliotherapy, 
therapy with artificial ultraviolet rays, braces and in some cases plaster 
of paris fixation all have their place in the treatment of tuberculosis 
of the bones and joints. 
PSYCHIATRY AND NEUROLOGY 
In treatment of the psychoses and continuous bath, cold wet packs, 
gymnastic exercises and . ies have their uses, especially for conditions 
due to excitement. 
In treatment of the psychoneuroses short courses of massage, cabinet 
baths and hydrotherapy are sometimes indicated to combat fatigue. 
The wet pack has been of use in combating insomnia. With all forms 
of neuroses, however, it should be definitely understood that physical 
therapy is only a small part of the total treatment. 
In cases of neurologic conditions electrical stimulation, massage, 
passive and active exercise, dry heat, hydrotherapy and fever therapy 
have long been utilized to relieve pain, to influence the metabolism of 
affected parts, to prevent muscular atrophy and to promote early return 
of function. Physical therapy for these conditions should not be under- 
taken without a thorough study of indications and contraindications, 
which will be found in the special articles and the larger treatises dealing 
with the different neurologic disorders. MANUAL OF OCCUPATIONAL THERAPY Reprinted from War Medicine, May 1942, Vol. 3, pp. 512-521; June 1943, 
Vol. 2, pp. 635-656, and July 1942, Vol. 4, pp. 83-104 
Copyright, 1943, by American Medical Association 
OCCUPATIONAL THERAPY 
A Manual Prepared by 
COUNCIL ON PHYSICAL THERAPY OF THE 
AMERICAN MEDICAL ASSOCIATION 
COMMITTEE OF THE AMERICAN OCCUPATIONAL 
THERAPY ASSOCIATION 
AND 
SUBCOMMITTEE ON PHYSICAL THERAPY 
COMMITTEE ON INFORMATION 
AND 
OF THE 
DIVISION OF MEDICAL SCIENCES OF THE NATIONAL 
RESEARCH COUNCIL 
The personnel of the groups which prepared this manual is as 
follows: 
Committee on Information, Division of Medical Sciences, National Research 
Council; 
Morris Fishbein, M.D., Chairman, Chicago 
J. J. Bloomfield, Washington, D. C. 
John F. Fulton, M.D., New Haven, Conn. 
Richard M. Hewitt, M.D., Rochester, Minn. 
Ira V. Hiscock, Sc.D., New Haven, Conn. 
Sanford V. Larkey, M.D., Baltimore 
Robert N. Nye, M.D., Newton, Mass. 
Committee of the American Occupational Therapy Association: 
Miss Marjorie Taylor, Chairman 
Winfred Overholser, M.D., Washington, D. C. 
Miss Marjorie Vetting 
Miss Sue Hurt 
Mrs. Helen M. Johnson 
Miss Mary Black 
Miss Mary Reilly 2 
Council on Physical Therapy of the American Medical Association 
J. S. Coulter, M.D., Chairman, Chicago 
Morris A. Bowie, M.D., Bryn Mawr, Pa. 
Eben J. Carey, M.D., Milwaukee 
Anthony C. Cipollaro, M.D., New York 
W. W. Coblentz, Ph.D., Washington, D. C. 
A. U. Desjardins, M.D., Rochester, Minn. 
Frank D. Dickson, M.D., Kansas City, Mo. 
W. E. Garrey, M.D., Nashville, Tenn. 
Frank H. Krusen, M.D., Rochester, Minn. 
Frank R. Ober, M.D., Boston 
George Morris Piersol, M.D., Philadelphia 
H. B. Williams, M.D., New York 
Howard A. Carter, Secretary, Chicago 
Subcommittee on Physical Therapy, Division of Medical Sciences, National 
Research Council: 
John S. Coulter, M.D., Chairman, Chicago 
Frank H. Ewerhardt, M.D., St. Louis 
Kristian G. Hansson, M.D., New York 
Frank H. Krusen, M.D., Rochester, Minn. 
Walter J. Zeiter, M.D., Cleveland CONTENTS 
Introduction 
Orthopedic and Surgical Conditions 
Fractures 
Dislocations 
Strains and Sprains 
Contractures Due to Burns 
Lacerations of Tendons 
Infections of Soft Tissues 
Infections of Bones 
Head Injuries 
Injuries of the Spinal Cord 
Injury of Peripheral Nerves 
Amputations 
Hysterical Paralysis 
Arthritis 
Tuberculosis 
Cardiac Conditions 
Neuropsychiatry 
Blindness 
Organization of an Occupational Therapy Section in an Army or Navy 
Hospital 5 
INTRODUCTION 
The psychologic and physiologic value of normal activity in work and 
in play is well recognized. The human machine is at its best in activity. 
If mental and physical activity contributes to the maintenance of well- 
being, it is even more vitally necessary when there is a deviation from 
normal. 
This principle was clearly stated by Raycroft,1 who said: 
The essential characteristic of life is activity—change—movement—achieve- 
ment—action and reaction with environment. These are a fundamental process. 
Any organ or function, whether physical or mental, whether a group of muscles 
immobilized in a cast or the process of reasoning deadened by a disordered 
mental condition, tends to deteriorate until it is no longer recoverable. 
It is only through activating the patient himself that normal processes and 
powers can be retained or improved and the symptoms of his disease can be 
influenced. 
Therefore activity therapy operates in harmony with physiological and psycho- 
logical laws and serves as a stimulus and director in the work of returning the 
patient, through his ozvn efforts, interest and will, back to normal patterns of 
life and expression. 
DEFINITION OF OCCUPATIONAL THERAPY 
Occupational therapy is an objective type of treatment prescribed by a 
physician to hasten a patient’s recovery from disease or injury or to con- 
tribute to his adjustment to hospitalization. 
The occupational therapist is professionally trained to carry out the 
physician’s prescription through the selection and adaptation of activities 
which meet the patient’s physical and psychologic needs. The activities 
used as treatment must be sufficiently interesting to the patient to 
motivate him to active participation. 
The therapist also provides the physician with information regarding 
the patient’s symptoms, reactions and progress while under observation. 
SCOPE OF OCCUPATIONAL THERAPY 
Preventive or Diversional Therapy.—This type of occupational 
therapy comprises simple, prescribed activities, including recreation, 
which serve to induce rest, to control general exercise, to prevent 
neuroses and to sustain morale. 
Functional Therapy.—This type comprises prescribed activities 
intelligently planned to assist in the restoration of articular and muscular 
function, to improve the general condition, to build up physical endurance 
and to aid in mental rehabilitation and the treatment of mental disorders. 
1. Raycroft, J. E.: Occupational Therapy, Occup. Therapy 18:241 (Aug.) 
1939. 6 
Prevocational Therapy.—This type comprises prescribed work or 
work processes planned to prepare a patient for return to his former 
employment or for vocational education. 
Mental Effects.—Occupational therapy (a) has a normalizing influ- 
ence—it is natural for man to be occupied, (b) eases emotional stress 
and restlessness, (c) gives an outlet for repressed energy, (d) arouses 
and develops attention, (e) replaces unhealthy mental trends with healthy 
ones, (/) substitutes encouragement for discouragement, (g) conserves 
the work habit and prevents invalid habits and (h) gives an opportunity 
for self expression and development of initiatives. 
EFFECTS ON THE PATIENT 
Physical Effects.—Occupational therapy (a) restores function to dis- 
abled joints, (b) aids in repairing muscle tissue and improving muscular 
power, (c) increases blood supply and healing processes, (d) builds up 
resistance to fatigue and (e) develops mental and physical coordination. 
Social Effects.—Occupational therapy (a) raises the morale of the 
patient, the ward and the hospital; (b) develops group responsibility and 
cooperation, and (c) gives opportunity for social contacts in normal 
activities. 
Economic Effects.—Occupational therapy (a) detects aptitudes, 
skills and capacities for vocational guidance; (b) evaluates disability in 
relation to vocational requirements; (c) establishes industrial habits and 
work tolerance, and (d) adjusts permanently institutionalized patients 
to participation in hospital industries. 
It is essential that there be the closest cooperation between the physi- 
cian and the occupational and the physical therapy department with fre- 
quent exchange of information if there is to be intelligent, ‘effective 
treatment and if the patient is to be returned to normal activity in the 
shortest possible time. A physician’s prescription is necessary for the 
protection of the patient and the occupational therapist. If possible, 
the occupational therapist should make ward rounds with the physician, 
so that treatment may be changed as indicated. The prescription given 
by the physician to the occupational therapy department on referring a 
patient should contain information which will lead to the intelligent 
care of the patient. 
THE OCCUPATIONAL THERAPIST AND THE PHYSICIAN 
The Council on Medical Education and Hospitals of the American 
Medical Association, 535 North Dearborn Street, Chicago, has formu- 
lated requirements for professional training in occupational therapy and 
examines schools of occupational therapy for accrediting. 
PROFESSIONAL STANDARDS AND SOURCES OF INFORMATION 7 
The value and effectiveness of occupational therapy depend on the 
training and experience of the technicians, who must have a sound con- 
cept of the conditions treated and the technics to be employed. A 
therapist whose background training is limited to a study of crafts 
cannot be expected to carry out a physician’s prescription adequately 
and intelligently. 
An efficient occupational therapist’s training must include the funda- 
mental sciences which give a basic understanding of the human being 
and of the mental and physical diseases and injuries the therapist will be 
called on to assist in treating. A broad training is necessary in the field 
of occupations or activities applicable to the motivation of the patient 
and in those which may be selected and adapted to meet the specific 
exercise needs or to control the desired mental processes and reactions 
of the patient. The worker must have imagination and ingenuity in 
adapting processes to fill the physician’s prescription and to contribute 
to the patient’s recovery. All the available resources must be coordinated 
to forward the physical, mental and social rehabilitation of the patient. 
In this manual only a few examples of activities applicable for specific 
treatments are suggested. Since each patient presents an individual and 
complex problem, a listing of activities might be misleading. 
ORTHOPEDIC AND SURGICAL CONDITIONS 
OCCUPATIONAL THERAPY AND THE PHYSICIAN 
A physician is usually responsible for the supervision of both the 
physical and the occupational therapy department in an orthopedic service. 
The two types of treatment should be carefully correlated if physical 
recovery and psychologic adjustment are to be hastened. 
A prescription signed by the physician is necessary for the protection 
of the patient and the therapist. This prescription is given to the 
therapist when the patient is referred for treatment and should contain 
information which will lead to the intelligent care of the patient. The 
following data should be included in the referral information and the 
prescription for functional treatment: 
Diagnosis 
Date of injury or onset of illness 
Psychologic factors 
General physical condition 
Present status of injury and precautions to observe 
Instructions regarding the removal of braces, casts, etc. 
Physical therapy—past and present 
Length of treatment period 
Frequency of treatment 
Specific results desired in treatment 8 
COORDINATION OF OCCUPATIONAL AND PHYSICAL THERAPY 
Orthopedic and surgical patients usually need both physical and 
occupational therapy; therefore, the importance of a coordinated program 
cannot be too much stressed. Coordinated, the two types of therapy 
supplement each other in a well rounded treatment. As isolated services, 
they may duplicate treatment to the serious detriment of the'patient. 
Heat and massage prepare the injured part for active exercise. When 
active exercise is indicated, an activity which centers attention away from 
disability frequently stimulates more rapid physical gain than uninter- 
esting exercise with attention centered on disability. Active exercise in 
occupational therapy should immediately follow the preparatory treatment 
of physical therapy. Therefore, the two departments should be close to 
each other and the patient’s schedule so arranged that he goes directly 
from physical therapy to occupational therapy. 
The occupational therapist should be informed regarding the plan 
of physical therapy for patients and occasionally observe their treatment, 
in order that her plans for them be well correlated with other procedures. 
The physical therapist should occasionally observe the patients in the 
occupational therapy department, where their attention is centered away 
from themselves and they are off guard. Frequently they use injured 
parts more freely than was believed possible by either the patient or the 
therapist. 
GENERAL CONSIDERATIONS 
In cases of surgical and orthopedic disability there is necessarily a 
period of immobilization, but there is no reason to allow the mental and 
the physical fitness of a whole person to suffer. Occupational therapy 
may be employed to maintain maximum general physical fitness of the 
disabled patient while the disabled part heals. It may also contribute 
to the mental fitness as a preventive of neurosis, as a treatment if accom- 
panying mental complications exist and as a builder of morale. Occupa- 
tional therapy also aids directly in the restoration of function to the 
disabled part when exercise is indicated. 
What Happens Physically?—Surgical and orthopedic disabilities 
often involve an otherwise normal muscular man whose whole engine 
is geared to carry him through a full day’s active work. While he is in 
bed, his voluntary muscles are practically idle and his involuntary 
muscular system is doing but a small part of the work which it was called 
on to perform previous to the accident. As a result, the muscles become 
flabby and the circulation slows up. Occupational therapy can assist in 
maintaining the physiologic balance. Activities which will exercise the 
muscles of the uninjured parts can be begun at once, and as soon as 
possible other groups of muscles should be brought into action. When 
he is able to get about, he does not require so much time in which to 9 
regain his usual strength and energy; thus the period of convalescence 
is shortened. Moreover, this generalized activity must not be overlooked 
later when specific activity for the disabled part begins but should be 
gradually increased as a means of building endurance and fitness for 
return to normal activity. 
Conclusion: From the standpoint of general physical fitness, exercise 
in occupational therapy should be prescribed for the uninjured parts as 
soon as a patient’s condition permits and should be continued in the form 
of graded activity all through convalescence, building physical fitness and 
endurance. 
What Happens Mentally?—Mock 2 stated: 
active treatment until the surgeon is assured that his patient is well on the way 
to an economic end-result; that is, able to carry on once more. The diagnosis 
of a broken back, a skull fracture or a fractured pelvis often strikes fear and 
dread into the heart of the patient; yet the treatment of these conditions in a 
large majority of cases is comparatively simple and the end-results are extremely 
good. Many times treatment consists of simply putting the patient to bed and 
keeping him as quiet as possible for from six weeks to three months, or, in some 
cases, in addition to rest, of traction applied to the lower extremities. The surgeon 
makes his daily round satisfied with the treatment of the physical condition and 
the progress that is being made, and never recognizes or even dreams of the 
fear and anxiety that are gnawing at the patient’s mind. When the day comes 
for the patient to leave his bed and begin to move about, the surgeon is dis- 
gusted with the lack of cooperation on the part of the patient, the unwillingness 
to try to help himself, and the absurdity of his complaints. . . . 
All such patients, in addition to the actual surgical treatment, need properly 
directed physical therapy and occupational therapy, which are the logical adjuncts 
to the usual surgical procedures. . . . Occupational therapy . . . [keeps a 
patient’s] mind and hands employed for a large part of the day, filling in the 
gaps between the surgeon’s visits and the physical therapy and leaving little time 
for the fears and germs of traumatic neurosis to develop. 
One of the commonest causes for traumatic neuroses is failure of continuous, 
It must be realized that the shock to the nervous system from an 
accident or a sudden crippling disease often causes greater suffering than 
the actual physical disability. The importance of the psychic factor in 
dealing with disabled persons must be recognized. 
Frequently, however, even after good surgical treatment and well 
directed physical therapy, patients fail to respond to treatment until their 
interest has been aroused and their ambition renewed by occupational 
therapy. Work is one of the greatest therapeutic measures and one 
that is often neglected. It diverts a patient’s mind from his disabled 
state; it improves morale and wakens or renews interest in creating 
something, and it gives promise of future usefulness to one whose future 
seemed hopeless. 
2. Mock, H. E., and Abbey, M. L.: Occupational Therapy, in Handbook of 
Physical Therapy, Prepared by the Council on Physical Therapy, ed. 3, Chicago, 
American Medical Association Press, 1939. 10 
Conclusion: From the standpoint of mental fitness occupational 
therapy should be prescribed for an injured patient as soon as possible. 
How Can Function Be Restored Most Quickly f—Normal function 
is restored through regular graded exercise. The sooner exercise is 
started, the more rapid and complete will be the return of function. 
Exercise must necessarily be done by the patient himself. Occupational 
therapy provides an incentive to exercise, centers attention- objectively 
and thereby minimizes fear. Activities can be specifically applied and 
graded to increase articular motion and muscular power or control. 
Conclusion: Occupational therapy should be prescribed as treatment 
for the disabled part as soon as exercise is permitted. Restoration of 
function should be emphasized as the patient’s own responsibility. 
SYMPTOMS TREATED THROUGH OCCUPATIONAL THERAPY 
Loss of Normal Articular Motion.—This loss may be caused by 
disease of or injury to soft tissues, unopposed muscular spasm or tissue 
adaptations from prolonged immobilization. 
Loss or Perversion of Muscular Function.—This may be the result of 
disuse (usually accompanying articular limitation) or lower motor neuron 
damage of the central nervous system or the peripheral nervous system, 
in the case of the latter damage either to a plexus or to a single nerve. 
Loss of Muscular Control (Due to a Lesion of the Central Nervous 
System).—This may result in the following symptoms: 
Spasticity, with hyperactivity of the spastic muscle, stretch reflex on 
attempted motion in the opposite direction and inability to relax and allow 
the antagonist to work. 
Athetosis, with constant involuntary motion and loss of normal 
involuntary motion. 
Ataxia, with loss of balance and sense of position. 
Circulatory disturbances. 
Loss of sensation. 
Loss of a part. 
Activities used as exercise must be selected and adapted to meet the 
patient’s exact need in restoring muscular power, range of motion or 
coordination. The plan of treatment must be flexible enough that activity 
can be increased or decreased as the patient’s condition indicates. 
EXERCISE CONSIDERATIONS IN THE USE OF ACTIVITIES 
Carpentry, metalwork, toolwork and innumerable other activities offer 
a wide range of possibilities in localizing action in groups of muscles, 
grading muscular power and increasing the range of articular motion. 
Work processes not only aid in functional restoration but provide an 
incentive to exercise and an adjustment to normal work. 11 
Exercise in occupational therapy functions to increase power, to 
develop control, to establish and maintain good posture, to promote 
nutrition—of a part or of the body in general—and to train in substitu- 
tion—in the absence of a part or in case of permanent paralysis. 
PRINCIPLES OF TREATMENT 
Exercise is directly planned to meet the physical need of the patient, 
and the activity used as exercise depends on the existing condition or 
combination of conditions. The following principles guide the therapist: 
Articular Limitations with Muscular Weakness.—Muscular Weak- 
ness : Graded resistive exercise is used to improve muscular tone. 
Resistance is controlled through the weight of equipment, materials and 
resistance in pulling. Increase of muscular power is necessary if the 
range of articular mobility is to be increased. 
Articular Limitation: Forced motion is graded in the range of 
mobility and the amount of force. Improvement of muscular power 
is essential to increase articular motion. 
Loss of Power Due to Injury of a Nerve.—The possibility of using 
occupational therapy as well as the method of using it depends on the 
following factors: the amount of power in the groups of muscles, the 
balance of power around the joint and the possibility of localizing 
muscular function. 
Treatment is directed toward establishing a balance of power and 
increasing the grade of power through the resistance offered by materials 
and equipment. 
The action of the group of muscles being strengthened should be 
in the direction of contraction. 
The position of exercise is determined according to the grade of 
power. 
With poor muscular power, contraction is possible if gravity is elimi- 
nated. A sling suspension may support the arm, thereby allowing full 
activity (see fig. 1). 
With fair muscular power, the patient can use the part against 
gravity or its equivalent in resistance. 
With good muscular power, the patient can use the part against 
outside resistance as well as gravity. The resistance of the materials 
and equipment is gradually increased as muscle power is regained. 
When muscles of two joints are involved, position of the adjacent 
joint should contribute to the mechanical advantage of the muscle being 
strengthened. For example, the wrist should be in extension in using 
the finger flexors, in flexion in using the finger extensors. 12 
Loss of Muscular Control Due to a Lesion of the Central Nervous 
System. 
Spasticity: Relaxation of the spastic muscles should be obtained, 
then the weak antagonists should be strengthened. A stretch reflex 
should be avoided. 
Athetosis: A consciousness and control of relaxation must be devel- 
oped to replace the involuntary relaxation which is lost. Relaxation 
Fig. 1.—The use of a sling suspension to relieve gravity. Square knotting 
serves as the exercise with the arm supported. 
should become habitual. If tension has developed in a patient because 
of a compensating effort to control athetoid movements, this tension 
must be reduced through conscious effort. 
Athetoid Movements: These must be reduced through the successful 
performance of gross movements and gradual development of finer move- 13 
ments—self consciousness increases athetoid movements. Therefore, 
activities which are absorbing and center attention objectively are 
preferable. Build on success, and minimize failure. 
Ataxia: Balance and coordination must be developed through cortical 
or voluntary control. The reestablishment of a muscle sense is achieved 
through eye to hand training. 
Grading on Basis of Muscular Poiver.—Assistive Motion: This may 
be based on (a) assistance of the operator or (b) assistance of the 
apparatus (bicycle, saw, treadle, loom). 
ADAPTATION OF ACTIVITIES IN EXERCISE 
Active Motion (Gravity Eliminated). 
Resistive Motion: This may be based on (a) resistance of gravity, 
(b) resistance against a contracture or (c) graded outside resistance 
(tools, apparatus or materials). 
Grading in Duration and Frequency of Work Periods.—Forced 
motion (forced stretching of a contracture) may be achieved in one of 
three ways: (a) forcing by muscular effort only (patient’s own effort 
to stretch), (b) forcing by muscular effort plus outside force (use of 
tools or apparatus) and (c) passive stretching (relaxation of muscles 
and exertion of force by the patient’s own body weight or by muscular 
effort from above the joint). 
Control of Activity to Meet Definite Needs.—Alternate Contraction 
and Relaxation; In any activity alternate contraction and relaxation 
of muscles is better than maintained contraction, which is fatiguing. 
Repetition: The desired motion should be capable of repetition for 
a controllable number of times. 
Grading of Muscular Power and Range of Motion. 
Localization of Action: The activity should permit action to be 
localized in the joint or group of muscles in order to obtain the desired 
results. The* proximal or the distal joint or both should be stabilized 
when necessary. 
Muscles Involving Two Joints: The position of the adjacent joint is 
important in order to obtain mechanical advantage for the muscle being 
strengthened. 
Coordination of Muscular Action: This is achieved through breaking 
up the activity into single motions, progressing to combined motions. 
Grade the position of the patient while performing the activity from 
that of complete relaxation to that requiring balance control. 
Adaptation of Activities to Meet Individual Needs.—Activities must 
be adapted to meet the exact exercise need yet must not be so distorted 
that the patient’s interest is lost. 
Position of Patient: The patient may lie flat, sit upright or stand. 14 
Position of Work: The work may be high, low, flat, upright or 
placed at an angle. The position of the patient and his work controls 
the arc of motion in exercise. 
Special Equipment: Support or localization may be obtained with 
special equipment, for example, a sling suspension (see fig. 1). 
Adaptation of Equipment; Adjustments may be made in the equip- 
ment to bring into play the desired muscular or articular activity when 
it cannot otherwise be obtained. 
Choice of Tools: Tools may be selected for size, weight or adjust- 
ability, such as tools with enlarged handles which may be decreased in 
size as function improves (see fig. 3). 
Choice of Materials: Materials may be selected for size, weight or 
hardness. 
Choice of Project: Size and shape of equipment, processes in 
construction and complexity may govern the choice of a project. 
Duration and Frequency of Work Periods: The plan depends on 
the patient’s tolerance. 
Method of Work: This depends on desired function. 
Cautions in Using Activities as Treatment.—The following factors 
should be considered: pain which persists longer than an hour after 
activity, swelling and local heat in a joint, stretching of paralyzed 
muscles, fatigue which persists, compensation of strong muscles for 
paralyzed ones and attempting processes beyond the patient’s physical 
or intellectual capacity. 
Progress Records.—Accurate and adequate records are essential for 
assuring the most effective treatment, for exchanging information 
between departments, for encouragement and incentive for the patient, 
for a cumulative knowledge of methods and results and for protection 
in recording treatments given. 
These records should include the following data: 
Description of the treatment, the exercise specifically directed to the 
injured part and the grade of activity for general fitness. 
Results noted in terms of increase in articular mbbility, muscular 
power, useful function and general physical endurance. 
Psychologic factors, such as cooperation, attitude, social adjustment, 
intelligence and symptoms pointing toward psychic disturbance. 
Skills and aptitudes which will point toward future training or 
placement. 
FRACTURES 
Purpose of Occupational Therapy.—In cases of fracture occupational 
therapy serves to maintain motion and strength in uninjured parts, to 
aid circulation and nutrition to the injured part, and to restore normal 
motion and strength when active exercise is indicated. (See the section 15 
on “Articular Limitation with Muscular Weakness” under the heading 
Principles of Treatment.) 
Bohler 3 wrote: “In any fracture, stiffness of the parts not injured 
is always the result of treatment, not injury—that is, neglect of motion 
from the first.” 
Kennedy 4 stated: 
There is a simple physical agent—active exercise—that is often neglected in 
fracture treatment. Active exercise should be prescribed from the moment the 
fracture has been reduced, the method of fixation decided on and fixation effected. 
A fracture patient enters the hospital a broken man, not a sick man physically or 
mentally. The less he is put in the category of the sick patient and the more 
he is treated as a person who was well an instant before the accident and 
expects to remain well, the shorter will be the period in which he needs con- 
valescent care. 
. . . Because one leg is injured there is no excuse for allowing the muscles 
of the neck, back, and three other extremities to deteriorate and greatly prolong 
the convalescence. Suppose on getting out of bed you will need to use crutches. 
Might you not prefer to have two strong arms and one strong leg to support 
you ? . . . 
The fracture patient needs work therapy—not a vacation but a hardening 
process. Ways and means should be devised to keep his mind and body occupied 
from the start. He should not be treated as a star boarder but as a perfectly 
well man except for one cracked-up part. If it is brought to the nurses’ attention 
and properly supervised, the patient can help with many things in ward work 
without disturbing the morale. 
Occupational therapy needs to be introduced much more widely in general 
hospitals. There are several excellent schools training persons to teach this. 
The great difficulty is to keep it from developing into a routine rather than 
using imagination to make the best adaptation for the individual patient. Physi- 
cians in general cannot know how to do this, but they should recognize its value, 
know when it is well done and back it enthusiastically. Occupational therapy 
is many times more valuable than the usual types of physical therapy for these 
patients. Even without a trained instructor and a shop, much can be done in a 
simple way if some one is interested in doing it. 
As an occupant of a general hospital the fracture patient is too often condi- 
tioned to become an invalid during his stay. Frequently he requires prolonged 
care to recover from his hospitalization rather than from his injury. . 
It would mean that a well man coming to a general hospital with a fracture 
would not be treated as if he were ill but as a convalescent from the start. 
He would be taught how to use all joints and muscles in the region of immo- 
bilization, commencing on the first day. He would be started immediately on 
general exercise to preserve the musculature which he brought with him. He 
would be given a job to do while in bed which would occupy body and mind 
and make him feel he was still a part of a moving world. As soon as he was 
out of bed he would be taught some form of occupational therapy, if possible 
similar to the work he did before he was hurt. 
3. Bohler, L.: The Treatment of Fractures, ed. 4, translated from the fourth 
German edition by E. W. H. Groves, Baltimore, William Wood & Company, 1935. 
4. Kennedy, R. H.: Active Exercise in Fracture Treatment, Arch. Phys. 
Therapy 2:720 (Dec.) 1941. 16 
Opinion varies as regards the injury itself. There are those who 
advocate gentle activity when fibrous union has taken place. Others 
maintain immobilization until there is bony union. Occupational 
therapy meets the needs of the exercise program from the lightest active 
motion, with no attempt to go beyond the existing range and with no 
resistance to the weak muscles, for the beginning treatment to forced 
stretching for an old stiff fracture, with strongly resisted motion to 
increased muscular strength. Hurt5 brought out the point that forced 
stretching in occupational therapy by the patient’s own effort is probably 
safer and more successful than that which is applied by another person. 
(See the section on “Articular Limitation with Muscular Weakness” 
under the heading Principles of Treatment.) 
Dickson 6 stated: 
Occupational therapy is a very useful way of overcoming the subconscious 
resistance of the patient to normal use of an injured part for fear he will suffer 
a relapse. It is often a useful bridge over the hiatus befween return of use and 
return to normal life and activity. 
Occupational Therapy with Reference to Fractures of Specific 
Regions.—Fractures of the Upper Extremity: Wilson 7 stated in part: 
All function of the upper extremity centers about and is subservient to that 
of the hand. The hand is the tool, and the forearm and upper arm, together 
with the various articulations, are merely the levers and gears that adapt the 
tool to its tasks and apply the power, and provide the means of movement. 
The usefulness of the upper extremity depends upon maintaining the delicate and 
multiple activities of the fingers and thumb. If these are lost, the result is almost 
as unfortunate as if the extremity were amputated. 
The treatment of fractures of the upper extremity must therefore be directed 
with the constant consideration of the necessity of preserving the mobility of the 
articulations and the suppleness of the muscles. 
Occupational therapy is particularly applicable in developing and 
maintaining functional usefulness of the hand. 
Fractures of the Shoulder Region: A common disability in fractures 
of the shoulder region is weakness of the deltoid muscle. When occupa- 
tional therapy is indicated, the arm should be removed from the splint 
with great care to prevent stretching of this muscle. Exercise may be 
given with the arm held at shoulder level in an overhead sling suspension 
apparatus (see fig. 1). 
When the strength of the deltoid muscle is equal to exercise without 
the sling suspension, a carefully graded program is started. At first, 
5. Hurt, S.: Occupational Therapy in Functional Work, Occup. Therapy 
19:163 (June) 1940. 
6. Dickson, F. D.: Physical Therapy in the Treatment of Fractures, J.A.M.A. 
111:1016 (Sept. 10) 1938. 
7. Wilson, P. D.: Treatment of Fractures in Specific Regions, in Mock, H. E.; 
Pemberton, R., and Coulter, J. S.: Principles and Practice of Physical Therapy 
Hagerstown, Md., W. F. Prior Company, Inc., 1934, vol. 2, chap. 5, p. 47. 17 
the weight of the arm will give enough resistance and only light activity 
is indicated. Later, strength is increased through the resistance offered 
by the equipment and material used. 
External rotation of the shoulder is essential for normal range of 
shoulder motion. This may be obtained through the use of the screw 
driver and special screws with threads running in a direction opposite 
to normal. The position of mechanical advantage for the outward 
rotators is with the arm held at a forty-five degree angle to the body 
(see fig. 2). 
Fig. 2.—The use of regular screws and special ones with threads running in 
the opposite direction. In the position shown supination of the forearm is obtained. 
The same work with the arm held at a 45 degree angle, from the body gives 
outward rotation of the shoulder. 
Carpentry with the use of various tools is adaptable for exercise of 
the shoulder (see fig. 3), as well as for exercise of the hand, forearm 
and elbow. 
Fractures of the Elbow: Fractures in or near the elbow joint fre- 
quently result in limitation often of motion of the elbow, supination of 
the forearm and loss of function in the wrist and hand. 18 
The miter saw may be used as exercise for elbo\y extensors (see 
fig. 4). 
Care must be taken to prevent the patient from compensating and 
getting motion in the shoulder instead of the elbow. When treating 
the forearm pronators and supinators, it is advisable to have the upper 
arm held to the side of the body in order to prevent rotation in the 
upper arm instead of localizing the action in the forearm. The afore- 
mentioned special screws (fig. 2) are used for this exercise. 
Fig. 3.—Carpentry, with the work at or above the shoulder level, is used for 
exercise for the back and shoulder. Tools requiring bilateral action prevent 
compensation. 
There are many useful occupations for increasing strength and 
motion in the elbow and the forearm. For the extensors planing, 
sawing, filing, sandpapering, knotting and loom weaving, of various 
kinds are some of the possibilities. Many of these occupations may 
also be adapted for treatment of flexors. 
Knotting (fig. 1) is also exceedingly good for supination of the 
forearm and may be adapted for pronation. It is a bilateral exercise 
preventing a muscular compensation. Fractures of the Wrist (Colies’ Fracture) : Soon after the cast is 
applied, motion in all unaffected joints may begin. With the wrist com- 
pletely immobilized in a cast, activity requiring full flexion and extension 
of the fingers should be given. Stiffness in the elbow and the shoulder 
should also be prevented through activity in full range of motion. The 
patient is usually fearful of exercise, and therefore interesting activities 
which distract his attention are preferable to monotonous subjective 
exercise. 
Fig. 4.—Sawing increases the muscular power of the flexors of the upper arm 
and the extensors of the elbow. 
After removal of the cast exercise should be planned to increase 
extension of the wrist and flexion of the fingers. One method of accom- 
plishing this is to use tools with large handles in sanding wood, filing, 
etc., as shown in figure 5. 
Fractures of the Lower Extremity: Wilson 7 stated in part 
The functions of the lower extremity are of a highly specialized type and have 
to do chiefly with weight bearing and locomotion. 
The ordinary individual can therefore tolerate a certain degree of limitation 
of the movements of the hip. knee or ankle with little functional loss; in dealing 
with fractures of the lower extremity, preservation of skeletal alignment is more 20 
important than restoration of complete mobility. This does not mean to imply 
that one should not aim for full restoration of movement, but that early mobilization 
of the articulations should never be prescribed if it involves the slightest risk of 
disturbing the alignment. 
Also, greater emphasis is to be placed upon active exercises performed regu- 
larly by the patient than upon massage or passive mobilization. 
The first exercise for fractures of the lower extremity should be 
non-weight-bearing. An apparatus providing such exercise for hip, 
Fig. 5.—The handles of tools and sandpaper blocks are built up to fit the 
hand and are reduced in size as the flexion of the fingers increases. 
knee and ankle and maintaining alinement is the bicycle jigsaw. Special 
pedal attachments make it possible to convert this exercise from one 
using the extensors only to a pulling action using the flexors. Pedal and 
seat shafts of extra length increase the flexibility of this apparatus and 
allow full flexion of the knee (see fig. 6). 
Fractures of the Spine: Neurosis is the great hazard among patients 
who have had spinal fractures. Early occupational therapy for diversion 21 
is essential to prevent neurotic patterns from developing. Later exercise 
through normal occupations and recreations aids not only in functional 
but in psychologic rehabilitation. 
At first the spine is immobilized by a correctly applied extension 
plaster jacket, so that the lumbar portion of the spine cannot be flexed.8 
During this period normalizing activity should be planned for the 
patient, in order to prevent neurotic patterns from developing. 
Fig. 6.—The bicycle jigsaw is used to increase the strength of the flexors or 
extensors of the hip and knee. With special pedals and adjustable long and short 
shafts for the pedals and the seat the patient may pull the pedals around to 
increase flexion or push them for extension. 
When the jacket is removed, exercises to restore function may be 
used. Occupations center attention objectively and aid in vocational 
rehabilitation. 
Special information is necessary on referring cases of fracture (see 
the section on “Occupational Therapy and the Physician” for the 22 
general information necessary), such as the length of time and the 
position of immobilization, the type of union present, whether the part 
if still in a cast may be removed for exercise, the date of removal if a 
cast has been removed, whether the part if in a sling may be removed 
for exercise, whether weight bearing is permitted if a leg is encased 
and whether there is any complicating injury of a nerve. (See the section 
entitled “Injury of Peripheral Nerves” for information regarding a 
lesion of a nerve accompanying a fracture.) 
Purpose of Occupational Therapy.—In cases of dislocation occu- 
pational therapy serves to maintain motion and strength in uninjured 
parts, to promote circulation and nutrition of the injured part, to 
strengthen musculature around the joint which has been dislocated, to 
restore motion if stiffness has developed and to overcome the fear of 
recurrence of the dislocation. 
DISLOCATIONS 
In the opinion of Bohler 3 the treatment for dislocation after the 
necessary period of immobilization is “active exercise against resistance.” 
One of the most frequent dislocations is that of the shoulder. In 
considering dislocations of this type Watson-Jones 8 stated: 
All bandages and slings are discarded in three weeks and elbow and shoulder 
movements are regained by active exercise. There must be no passive stretch- 
ing ; this is the cause of permanent stiffness of the shoulder and of myositis ossi- 
ficans. There is no danger of permanent stiffness from three weeks of immobilization 
of the injured shoulder if full movement is retained in the distal joints and pas- 
sive stretching and manipulation under anaesthesia are avoided. Recovery is quite 
complete within a period of from five to eight weeks. 
Suggested Occupations.—Several occupations suitable for treatment 
in the order of their use are shown in figures 1, 2 and 3. 
Special Information Necessary on Referring Cases of Dislocation.— 
Certain special information (see the section on “Occupational Therapy 
and the Physician” for general information) should be included in the 
prescription, such as direction of dislocation, probability of recurrence 
and precautions regarding casts and slings, as discussed for fractures. 
STRAINS AND SPRAINS 
In general, the material presented under the heading Dislocations 
is applicable to strains and sprains. 
The injured part is immobilized, and activity is prescribed for 
uninjured parts. Later graded activity is prescribed for the injured 
joint. 
8. Watson-Jones, R.: Fractures and Other Bone and Joint Injuries, Balti- 
more, Williams & Wilkins Company, 1941. 23 
CONTRACTURES DUE TO BURNS 
Purpose oj Occupational Therapy.—In cases of burn occupational 
therapy serves to prevent contractures and to stretch those which have 
already occurred. 
Purpose oj Physical Therapy.—Physical therapy is directed toward 
softening tissue before active stretching by occupational therapy. 
Special Information Necessary on Referring Cases of Contracture 
Due to Burns.—Certain special information (see the section on “Occu- 
pational Therapy and the Physician” for general information) should 
be included in the prescription, such as date of grafts, when and how 
much stretching is safe and danger of irritation from tools or materials. 
Treatment should be carefully graded under a physician’s direction 
from active motion within the existing limits through active effort to 
stretching and forced stretching. (See the section on “Articular 
Limitation with Muscular Weakness” under the heading Principles of 
Treatment.) 
In treatment which is of necessity as long drawn out as that of 
contractures due to burns, occupational therapy is particularly essential. 
LACERATIONS OF TENDONS 
Purpose of Occupational Therapy.—In cases of lacerated tendons 
occupational therapy serves to encourage muscular response in the 
direction of the sutured tendon, to give graded stretching of the 
shortened tendon with motion in the opposite direction and to work for 
motion and strength in both directions. 
General Considerations.—Mason and Allen,9 in discussing the rate 
of healing of tendons, stated: 
(1) Tendon healing as measured by its tensible strength exhibits three phases: 
A. Phase of rapid diminution, which lasts about five days. 
B. Phase of increase in tensile strength up to a plateau, which it reaches about 
the sixteenth day. 
C. Second phase of increase in tensile strength, which probably starts between 
the nineteenth and twenty-first day and continues for an undetermined period of 
time. 
(2) Curves of tensile strength conform to phases observed in histologic process 
of repair: 
A. Phase of exudation and fibrinous union. 
B. Phase of fibroplasia. 
C. Phase of maturation or organizing differentiation. 
9. Mason, M. L., and Allen, H. S.: Rate of Healing of Tendons, Ann. Surg. 
113:424 (March) 1941. 24 
(3) Function to which the healing tendon is subjected is directly reflected in 
the curve of the third phase of healing. During the first and second phases it 
produces no effect unless it is so great as to cause marked separation. During 
the third phase of healing function accelerates the curve. 
(4) Function and motion during the first two phases of healing lead to increased 
reaction and to separation at the suture line [the italics are ours]. Restricted use 
of the tendon, started on about the fourteenth day and continued for one week, 
or preferably two, may be expected to lead to only a slight increase in reaction 
and to a rapid increase in tensile strength of the union. Active unguarded use 
even after three weeks of immobilization may be associated with stretching of 
the suture line and always leads to increase in reaction. 
Among the most frequently lacerated tendons are those of the wrist. 
Figure 5 demonstrates the position of mechanical advantage in regaining 
function following laceration of the extensor tendons at the wrist. 
INFECTIONS OF SOFT TISSUES 
In cases of infection complete immobilization should be observed to 
prevent spread. Even movements of unaffected joints in the same part 
should not be allowed until all danger of spread is over. Thus, physical 
therapy would be indicated before occupational therapy. 
Purpose of Occupational Therapy.—This depends on the resulting 
conditions, which in turn depend on the severity and duration of the 
infection. 
In all cases activity is given to increase circulation and nutrition. 
Muscular atrophy must be treated by graded resistive exercise for 
strength. 
Scar tissue or contractures from immobilization must be treated by 
exercise to stretch. 
(See the section on “Articular Limitation with Muscular Weakness” 
under the heading Principles of Treatment.) 
INFECTIONS OF BONES 
Immobilization looms large in the treatment of infection of bones, 
with the attendant implications of the needs for occupational therapy 
under these conditions, which have already been set forth. ( See section 
on “General Considerations” under the heading Orthopedic and Surgical 
Conditions.) These needs include graded occupational therapy to achieve 
general physical fitness and mental fitness and later to increase circula- 
tion and nutrition in the affected part and to return to normal function. 
Also occupational therapy in this connection may be regarded as 
control of activity. 
During the stage of active infection, when fatigue is an important 
factor, occupational therapy may promote rest and prevent restlessness. 
During convalescence occupational therapy provides controlled exercise 
of the affected part. 25 
Special information is necessary on referring cases of infection of a 
bone (see section “Occupational Therapy and the Physician” for general 
information), with special warning against fatigue and indication of the 
probable point of fatigue. 
HEAD INJURIES 
The paralysis which results from trauma of the cerebrum may be 
flaccid, with an absence of all deep tendon reflexes. Eventually an 
increase of tone develops in the muscles of the affected extremities. The 
commonest forms of trauma to the cerebrum are gunshot wounds and 
depressed or comminuted fractures of the skull. 
In cases of head injury there is usually a period of absolute rest 
required, with the patient under sedation if necessary. Later, when 
rest is still essential but when the acute state is past, occupational 
therapy may be used as a control of activity, and as a means of promoting 
rest and of preventing restlessness. 
As the patient begins to recover, voluntary power will return in the 
muscles of the hemiplegic extremity. At this time occupational therapy 
should be started. The patient’s help must be sought. He should be 
told that the ultimate degree of recovery of function depends to a great 
extent on his enthusiastic and persistent cooperation. The patient should 
be closely directed in his occupational therapy from the beginning. 
If the head injury has produced actual damage to the brain, the effect 
on muscular function will depend on the area damaged. (See the 
paragraph on loss of muscular control under the heading Symptoms 
Treated Through Occupational Therapy.) 
POST-TRAUMATIC HEADACHES 
Cairns 10 stated in part that there is no certain way of preventing 
post-traumatic headaches but that one can condition a patient to them by 
graded physical activity, combined with explanation and analgesic drugs 
when required. It is better policy to get the patient out of bed about 
a week after he has recovered full consciousness and then, without 
curtailing the time spent in the hospital, subject him to a graduated 
regimen of physical hardening. This can be done without increasing 
the frequency of post-traumatic headaches. 
Cairns emphasized the fact' that after the patient has returned to 
consciousness, the process of getting up should not be long delayed, and 
occupational therapy may be necessary, especially for patients in the 
armed services, who must be rendered fit for full duty before thev can be 
returned to their units. 
10. Cairns, H.; Rehabilitation After Head Injuries, Brit. J. Phys. Med. 5:84 
(May-June) 1942. 26 
INJURIES OF THE SPINAL CORD 
Davis,11 in considering the after-care of injuries of the spinal cord, 
stated that often the condition of the paraplegic patient is looked on by 
physicians as hopeless. Many times physical and occupational therapy is 
■carried out effectively until the patient is ambulatory, and then his further 
treatment is neglected. It is necessary to teach each patient to use his 
recovering muscles to the best advantage. 
In case of injury of the spinal cord the resulting paralysis should be 
treated according to the instructions given for injury of peripheral 
nerves. (See also the section on “Loss of Power Due to Injury of a 
Nerve” under the heading “Principles of Treatment.”) 
It is essential to institute occupational therapy in such a case from the 
first for the patient’s mental health. In case of a spinal injury fear may 
produce serious psychic complications. 
Specific information as to mental and physical factors is necessary on 
referring cases of injury of the spinal cord. 
Injury of peripheral nerves may require (1) an operative procedure, 
(2) protection and (3) physical and occupational therapy for preserva- 
tion and reeducation of specific muscles. (See “Loss of Power” under 
“Principles of Treatment.”) 
INJURY OF PERIPHERAL NERVES 
Occupational therapy for the affected part is not indicated until a 
rating of at least “poor” has been attained for all muscles and not then 
unless it can be specifically applied to obtain the desired exercise. (See 
the section on “Loss of Power Due to Injury of a Nerve” under the 
heading “Principles of Treatment,” also the section on “Adaptation of 
Activities to Meet Individual Needs” under the heading “Adaptation 
of Activities in Exercise.”) 
Davis11 stated, in part, regarding postoperative treatment: 
It is unfortunate that many times nerve ends are sutured and no thought is 
given to what we consider to be at least of as great importance, carefully 
supervised and persistent physical therapeutic after-care. If the paralyzed muscles 
are allowed to shorten and contract or the joints become ankylosed or fibrosed, 
it is of little value to have sutured a nerve and have its fibers regenerate. Every 
effort must be directed toward restoration of the normal physiological function 
of the paralyzed muscles. 
There is a definite increase of connective tissue in a muscle as early as three 
weeks after section of its nerve. Part of the late contractures are due to shrink- 
age of this newly formed, soft and extensible tissue. Active or passive movements 
of the muscle will stretch the developing connective tissue fibers so that when 
they shrink there may be less tendency to a contracture. 
11. Davis, L.; Principles of Neurological Surgery, Philadelphia, Lea & 
Febiger, 1942. 27 
Physical therapy should be carried out by individuals who fully realize the 
ease with which atrophied, denervated muscles may be injured by rough methods 
and fatigue. In a great many cases better results are obtained by simple devices 
and games which effect an unconscious and effortless exercise of the contracted 
muscles or ankylosed joints. We have found that most individuals require a 
definite goal to accomplish in each type of active exercise instituted to maintain 
their enthusiasm during the long period of physical treatment which is necessary. 
Regeneration of a nerve is a slow process, and exercise will pall on 
even those most anxious for recovery. If it can be adapted to construc- 
tive activities, the interest stimulus will relieve the tedium. Occupational 
therapy minimizes the possibility of a subconscious mental factor as an 
inhibitor of return of function. Occupational therapy for unaffected 
parts is strongly indicated from both the mental and the physical stand- 
point throughout the entire period of treatment. (See the section on 
“General Considerations” under the heading Orthopedic and Surgical 
Conditions.) 
Special information is necessary on referring a case of injury of a 
peripheral nerve (see the section on “Occupational Therapy and the 
Physician” for general information). 
Areas of sensory or trophic disturbance should be noted and pre- 
cautions taken regarding possible irritation or injury from tools or 
materials. 
AMPUTATIONS 
Purpose of Occupational Therapy.—In case of amputation occupa- 
tional therapy serves to minimize the shock produced by the trauma, thus 
preventing psychic complications; to help in mental and physical adjust- 
ment to the disability; to strengthen the muscles of the stump or the 
remaining adjacent parts, and to prepare the patient for vocational 
rehabilitation. 
The “Handbook on Amputations” 12 stated: 
Occupational therapy Is more interesting to the patient than formal gymnasium 
exercise and through games and work provides exercise for increasing the muscle 
strength in the stump. Such therapy is of great psychologic value because in the 
curative workshop the patient finds that he can work or play in spite of his 
disability, and he also' finds social contact with other handicapped persons. He 
becomes interested in what he is making rather than merely in exercises in which 
his attention is centered on himself. The occupational therapy technician must be 
given careful instruction as to which muscles of the stump require developing. 
Even with little equipment, the therapist can devise games that will not only 
amuse the amputee but also provide definitely useful exercise. 
Occupational Therapy for Arm Amputation Patients.—An inventive occupa- 
tional therapist can eliminate the necessity of waiting for provisional apparatus 
by making tools and devising methods for holding them even before temporary 
12. Handbook on Amputations, Prepared by the Council on Physical Therapy, 
Chicago, American Medical Association Press, 1942, p. 54. 28 
appliances can be secured for arm stumps. When the amputation has been 
through the forearm, the stump may be fitted with a leather cuff with a ping 
pong racket attached. Ping pong games played between patients fitted with similar 
appliances provide exercise which cannot be obtained by formal exercise and also 
result in a vastly improved mental state for the patients. 
Occupational Therapy for Leg Amputation Patients.—Many interesting games 
to be played before a leg stump is fitted with temporary appliances may also be 
devised by the occupational therapist. “One leg golf” is such a game and will 
help develop balance and confidence; it is particularly adaptable to large hospitals 
where there are a number of leg amputees in one ward. In playing the game 
the floor is marked into squares; the object is to kick around a wooden disk, 
6 inches [15 cm.] in diameter and 1 inch [2.5 cm.] thick, from one marked 
square to another according to numbers. Sides may be chosen according to the 
amount of support a player must use. For example, if a man using crutches is 
on one side, the other side could have two men without crutches. The player 
should be taught to fall so he won’t injure his leg, on his shoulder for example. 
Exercises and games may also be used to teach balancing and turning without 
crutches when the patient is using an artificial leg. For instance, this game 
devised from an exercise: The player walks oa a plank 12 inches [30 cm.] wide, 
2 inches [5 cm.] thick and 12 feet [360 cm.] long that is raised 6 inches from 
the floor. Points are deducted if the player loses balance so that he must grasp 
a rail placed near the plank. The patients may also be taught to play ping pong 
and golf. 
It is impossible in this short chapter more than to outline the exercise and 
occupational therapy program. An extensive and varied program can be devised 
by the physical and occupational therapy technicians who work together in 
planning the patient’s program. 
Special Information Necessary on Referring Cases of Amputation.— 
Certain special information (see the section on “Occupational Therapy 
and the Physician” for general information) includes whether the stump 
has healed, whether there is danger of reopening it, whether there is 
danger of irritation or infection and which muscles should be developed. 
HYSTERICAL PARALYSIS 
Hysterical paralysis may simulate a variety of conditions. It may be 
entirely of psychoneurotic origin, or it may be combined with some 
primary physical condition. But regardless of the fundamental cause, if 
it continues for any length of time, secondary changes in body tissues 
occur, combining circulatory changes with contractures. 
Shands 13 stated: 
The diagnosis of psychoneurosis should never be made until every effort to 
establish the presence of an organic lesion has been exhausted. The treatment 
of functional paralysis and deformity should be largely psychiatric. It is of 
fundamental importance that the confidence and active interest of the patient be 
secured. After this has been done . . . emphasis should be placed upon active 
motion and active correction. Occupational therapy will often prove of value. 
13. Shands, A. R., Jr.: Handbook of Orthopedic Surgery, St. Louis, C. V. 
Mosby Company, 1940. 29 
Occupational therapy would seem to be the most valuable factor at 
hand both in diagnosis and in treatment, since it strikes at the cause— 
psychoneurosis—and at the result—change in body structure. 
ARTHRITIS 
It is generally conceded that rest is necessary in the acute stage of 
arthritis—rest of the body as a whole, rest of the inflamed joints and 
mental rest. Physical rest depends on good circulation and maximum 
comfort of body and mind. Therefore, adequate means of producing 
complete rest must be instituted. 
In the subacute stage of the disease articular function and muscular 
power must be regained. The patient’s program should be so planned 
that there is a balance of complete rest with periods of prescribed activity. 
The period of convalescence is long and discouraging. Therefore, the 
plan of treatment must be such that it provides interests and emotional 
outlets and retains the patient’s confidence and cooperation. 
Among the measures of proved value recommended by the com- 
mittee of the American Rheumatism Association 14 are rest—general and 
local, prevention and correction of deformities, physical therapy, occupa- 
tional therapy and psychotherapy. 
The committee brought out the point that 
. . . in prescribing rest, intelligence and insight are necessary. Many patients 
say that all they do is rest. Examination of such patients, however, will fre- 
quently show that they are tense and their muscles are in more or less constant 
spasm. Many of them get only fitful hours of sleep: they are completely exhausted, 
physically and mentally. 
PURPOSE OF OCCUPATIONAL THERAPY 
In cases of arthritis occupational therapy serves the following ends: 
(1) Contributes to the program of rest during the period of acute 
articular involvement. Restlessness, anxiety and tension are reduced 
when the attention of the patient is centered objectively in constructive 
channels. 
(2) Contributes to the program of exercise during the subacute 
period. A carefully graded program of exercise preserves function or 
aids in the restoration of muscular power and articular mobility. 
(3) Adjusts the patient to a long time program of treatment 
preventing neurosis and unnecessary helplessness, furnishes a normal 
and satisfying means of self expression and aids in adjusting him to 
independence if he is physically able to return to work. 
14. Primer on Arthritis, Prepared by the Committee of the American Rheu- 
matism Association, J. A. M. A. 119:1089 (Aug. 1) 1942. 30 
Kovacs 15 stated: 
Extra rest for body and joints in positions favorable for general body mechanics 
is generally required; 10-20 hours of rather complete rest daily is recommended, 
but should not be overdone. Ambulatory patients with mild or moderate arthritis 
should be encouraged to work at non-traumatizing activity. Exercises should 
not be casual, but specified for the joints affected. Non-weight bearing, non- 
traumatizing exercises are preferred. 
TYPICAL DEFORMITIES IN CHRONIC ARTHRITIS 
Left to his own devices the arthritic patient is more comfortable 
when inactive, because he fears using painful joints. He usually 
assumes a poor posture with head forward, chest flat and the head of 
the humerus rotated inward and has little or no use of the intercostal 
muscles in breathing. The oxygen intake is cut down; circulation is 
retarded, and articular symptoms are therefore aggravated. In cases 
of arthritis good general circulation is of paramount importance to 
alleviate local symptoms. 
The articular position of comfort is flexion, and flexion deformities 
are frequent in the fingers, wrists, elbows, shoulders, hips and knees. 
Placing a pillow under the thigh with no support under the head of 
the tibia frequently leads to subluxation of the knee. Lack of proper 
support for the foot and pressure of bed clothes may result in rotation 
of the hips and drop foot. 
During the acute period of the disease adequate support should be 
given to prevent the aforementioned disabling deformities. 
If ankylosis is unavoidable, the affected joint should be fixed in the 
best position for functional use. 
Joplin and Baer16 stated: 
Rest, unquestionably, is the sheet anchor in orthopedic management of arthritic 
joints. Comfortable support to the affected part should be provided in a neutral 
position or in a position for optimum use should the joint eventually become lim- 
ited in motion or ankylosed. Active or guided motion (without injury) must be 
employed daily in an effort to retain as much motion as possible: [Activity 
prevents] the formation of adhesions within the joint [and] contractures of 
periarticular structures [and also provides] a stimulus to the articular cartilages. 
[The italics are ours.] 
15. Kovacs, R.: The 1942 Year Book of Physical Therapy, Chicago, The 
Year Book Publishers, Inc., 1942. 
16. Joplin, R. J., and Baer, G. J.: Treatment of Arthritic Joints, J. A. M. A. 
118:937 (March 21) 1942. 31 
OCCUPATIONAL THERAPY AS EXERCISE 
Comroe 1T stated: 
Early orthopedic management is an important phase of therapy in arthritis. 
The main aim of the orthopedic surgeon, in arthritis, is to preserve the function 
of joints or to restore such function if this has been impaired. He must con- 
stantly realize, however, that he is treating a patient and not merely several 
involved joints; in rheumatoid arthritis, particularly, it is true that the whole is 
greater than any of its parts. 
Because the arthritic patient is fearful of using painful joints, he 
needs a strong stimulus or incentive to exercise. Participation in 
carefully selected interesting activities provides this necessary incentive 
and stimulus. Attention is centered objectively, and he is more apt to 
relax and forget his fear of pain. The maximum of useful function is 
the goal in exercise. Activities providing not only the exact function 
desired but a coordinated use of the muscles and joints speed up return 
of function, as well as psychologic adjustment and socialization. 
Traut18 stated: 
Passive exercise being generally regarded as outlawed, exercise by occupation 
finds its natural place in the management of chronic and convalescent arthritis. 
Arthritis is a disease not only of joints but of the whole body. The mental 
attitude of the patient is of importance. For all these needs healing work is 
ideally suited. Instructions to physical therapists stress the unity of the whole 
joint mechanism; the joint, its capsule and the attacked ligaments, tendons and 
muscles. Again exercise-zvork cares for all these structures. [The italics are 
ours.] 
OCCUPATIONAL THERAPY AS A MEANS OF CONTRIBUTING TO 
PSYCHIC NEEDS 
The importance of the psychic factors in arthritis should receive 
consideration. Rheumatoid arthritis is a constitutional disease of the 
entire person with local disturbances and frequently occurs in high- 
strung, conscientious and overactive persons. Toxemia may definitely 
affect the nervous system of a patient and cause emotional disturbances 
which, in turn, retard physical recovery. 
An opportunity should be provided for wholesome emotional and 
spiritual outlets planned to meet the patient’s individual needs. Occupa- 
tional therapy can serve in a dual role by providing the desired physical 
exercise yet using interesting constructive activities which can give 
satisfying emotional outlets. This form of treatment is therefore one 
of the tools used by the physician in combating discouragement and the 
development of neurotic patterns. 
17. Comroe, B. I.: Arthritis and Allied Conditions, ed. 2, Philadelphia, Lea & 
Febiger, 1941. 
18. Traut, E. F.: What Every Occupational Therapist Should Know About 
Arthritis, Occup. Therapy 20:87-91 (April) 1941. 32 
SUGGESTIONS IN THE APPLICATION OF TREATMENT 
Wrists.—Deformity results from the overpowering pull of the flexor 
muscles. If dorsiflexion is impossible because of muscular atrophy, a 
cock-up plaster splint should be used. The angle of the wrist in dorsi- 
flexion should be about 30 degrees. This splint should be strapped to 
the forearm above the wrist in order that it not prevent further dorsi- 
flexion when muscular power returns. A patient doing craft work in 
this splint tends to pull away from it, thereby exercising the dorsiflexors. 
As soon as muscular power returns and dorsiflexion can be maintained, 
the splint is given up. 
Hands.—Ulnar deviation and subluxation of the fingers are frequent 
deformities. Splints for them have been described by Joplin and Baer.16 
The occupational therapist should use splints during the exercise period 
if they are needed in maintaining correct position of the fingers and 
thumb while exercising other joints. Ulnar deviation of the fingers 
should be guarded against. Working with the forearm supinated main- 
tains a good corrective position. 
Cramping and fine handiwork should be avoided if there are flexion 
deformities of the fingers. Activity requiring contraction of the muscles 
followed by relaxation is preferable to prolonged contraction, to avoid 
muscle fatigue. 
Elbows.—The usual deformity is flexion, as this is the position of 
greatest comfort. The elbow is under strain when a patient pulls himself 
up and holds onto tables, chairs or canes; trauma thus results, and the 
articular condition is aggravated. Exercises or activities to maintain or 
improve extension of the elbow and supination of the forearm are 
indicated. 
Shoulders.—There is usually a tendency to forward drooping, with 
internal rotation of the head of the humerus, and this combines with the 
flat chest and generally poor posture. Abduction and flexion of the 
upper arm are limited. The patient can compensate to some degree for 
an ankylosed shoulder by rotating the scapula and thereby obtaining 
motion of the upper arm. 
Upper Extremities.—Any activity should be directed to improving 
posture; flexion, abduction and outward rotation of the shoulder; flexion 
and/or extension of the elbow; supination of the forearm; extension of 
the wrist, and function of the fingers. Among suggested activities is knot- 
ting—tying sailors’ knots. This activity is as well suited as any craft to 
the many needs of the arthritic patient. It can be adapted to meet the 
necessary articular function and graded.in muscular power, and it controls 
and improves posture and expansion of the chest (see figure 1 [use of 
a sling suspension is not indicated] ). Carpentry and weaving, as well 
as many other crafts and games, may be adapted by the ingenious 
therapist. 33 
Hips and Knees.—Flexion deformities are frequent. Conservative 
methods of improving extension of the hip and the knee are usually 
instituted prior to more drastic methods. Non-weight-bearing exercises 
are used. The therapist with ingenuity and an understanding of function 
can construct knee push and other apparatus to improve muscular 
power and function which the patient can operate while in bed. The 
bicycle jigsaw with extra length seat shaft and pedal, as illustrated in 
figure 6, provides an excellent non-weight-bearing exercise for extension 
of both hip and knee. With the feet strapped on the pedals they may 
be pulled in reverse action for flexion or pushed in the usual manner 
for extension. Caution should be used to prevent exercising the exten- 
sors of the hip in a position of outward rotation. Exercise may be 
given prior to surgical treatment to improve muscular power and after 
such treatment to keep function mechanically restored. 
Ankles and Feet.—If there are deformities of the hips and the knees, 
there is a strain on the ankles and feet, producing pain and deformity. 
Pressure of bed clothes and lack of proper support for the feet cause 
a drop foot deformity. Regaining flexion of the ankles and toes is 
important, and non-weight-bearing exercise is indicated. Pedals with 
straps (fig. 6) make it possible to pull the pedals of the jigsaw in reverse, 
localizing action in the flexors. Wedges may be used to support the 
foot in a corrected position. 
Marble games and picking up marbles with the toes may be used for 
exercising the feet. 
SPECIAL REFERRAL INFORMATION 
The referring physician should provide the therapist with the follow- 
ing information: (1) type of arthritis; (2) stage of the disease, whether 
acute, subacute or chronic; (3) general cautions to be observed; (4) 
type and amount of activity indicated for specified joints; (5) length 
and frequency of exercise period; (6) special cautions to be observed, 
such as (a) joints in which function is to be avoided and (b) other 
physical factors which may have a bearing on the type or amount of 
exercise and materials used, such as cardiac involvement or allergies, and 
(7) useful information regarding the patient’s emotional adjustment and 
needs. 
CAUTIONS AND CONSIDERATIONS 
Exercise is not indicated during the acute period, while there is local 
heat in the joint and redness. The physician may allow exercise after 
the acute period in spite of existing swelling. 
The therapist must be on the alert to observe any recurrence of 
local heat and redness in the affected joints. The patient’s activity should 
cease at once, and the symptoms noted should be reported to the physician 
in charge. 34 
The amount of activity which the patient can tolerate in a given 
length of time, frequency of exercise periods and the muscular power 
expended should be carefully considered. The program of treatment 
must be so flexible that it can change at a moment’s notice, as the 
patient’s condition indicates. 
Work and rest should be balanced in a plan of exercise. Activity 
should be followed by complete relaxation. 
Exercise should stop prior to the point of fatigue or pain. Pain 
persisting for over an hour after treatment or increased pain the follow- 
ing day indicates overexercise. Active exercise should not be given if 
there is muscular spasm. 
Measures to correct subluxation of joints should be instituted prior 
to the effort to regain function. Functional alinement of the joints 
should always be maintained. 
Muscular atrophy from disuse is more readily corrected than atrophy 
resulting from injury of a nerve. 
Muscular power must be regained in order to force articular motion 
and to assist in counteracting adhesions. 
Exercise of involved joints in cases of osteoarthritis may be indicated 
to prevent secondary fibrositis and atrophy from disuse. Activities 
causing articular distress of more than half to one hour’s duration or 
causing increased stiffness should be decreased or discontinued. Spur 
formations may irritate soft tissue. 
Exercise should be so planned that the most necessary functions are 
concentrated on, that the best alinement for articular function is main- 
tained and that the patient and his work are in the best position for 
posture and function. 
Frequent and careful measurements of the treated joints, taken by 
either the physical therapist or the occupational therapist, make it pos- 
sible to record accurately the result of activity, whether it be gain or 
loss of motion. With this system loss of motion which may not be 
perceptible to the eye is detected. Gain encourages the patient and the 
worker and adds zest to the treatment. 
Summary.—Steinbrocker19 brought out the value of purposeful, 
interesting activities as a motivation in exercise: 
All exercise is given for the purpose of correcting deformity and improving 
the function of various parts of the body. Since progress is slow and the end 
to be obtained is often months in the future, the patient becomes restless, bored, 
and discouraged. To combat this and to continue with motion in the disabled 
joints, crafts and various manual skills can be utilized. 
19. Steinbrocker, O.: Arthritis in Modern Practices, Philadelphia, W. B. 
Saunders Company, 1941. 35 
There is no one activity that will suffice. There are innumerable 
occupations that can be adapted by an ingenious therapist to meet the 
functional needs of the patient, provide constructive interests, combat 
discouragement and prevent neurotic patterns from developing. 
The therapist dealing in this field should have ingenuity in devising 
special corrective equipment and should have adequate understanding 
of muscular and articular function. She should also be sensitive to the 
emotional needs of her patient and have unlimited patience in helping 
him adjust to the long period of pain and frustration. 
The end result of good treatment is a person fitted to take his place 
in the active world again. Skills should be discovered and fostered 
during the period of treatment, and the patient should be prepared for 
vocational training or placement if he is physically able to compete with 
normal persons. 
CORRECT POSITIONS FOR GENERAL RESTING, LYING IN A BED AND 
SITTING IN A CHAIR 
Rest is fundamental in the treatment of arthritis and should precede 
and follow exercise. 
Positions for Attaining Physiologic Rest.—This type of rest may be 
induced by the following positions: 
Supine Position: This position is to be assumed one half hour after 
meals. The patient lies on a flat, firm mattress or on the floor if the 
mattress sags. The pillow under the head is eliminated, the arms are 
placed at right angles from the body, with hands resting on the mattress 
in a medial position, and the chin is drawn in. A thin pillow or roll 
under the scapulas forces the chest high, and a thin pillow or roll under 
the head of the tibia creates slight flexion of the knees and prevents 
strain on the lower portion of the back. A support is necessary at the 
feet to prevent foot drop. Sandbags may be necessary to prevent rota- 
tion of the hips. 
This position should be approximated as nearly as possible. The 
patient who has been long bed ridden and has had several pillows under 
the head, producing flexion of the cervical portion of the spine and a flat 
chest, must be gradually adjusted to this hyperextended position, first by 
the gradual removal of the pillows under the head and eventually by 
adding the roll under the scapulas. If the articular limitation prevents 
the prescribed position of the arms, approximate the position as nearly 
as possible, making an effort to obtain outward rotation of the head of 
the humerus to force expansion of the chest. 
Prone Position: This position relieves the bedridden patient and 
may be adopted during a half hour of the rest period. A pillow is 
placed under the chest, and the arms are placed at right angles to the 36 
body, with the elbows flexed and resting on the mattress. A pillow 
under the lower leg assists in maintaining slight flexion of the knee 
and prevents a drop foot position. Sandbags may be necessary to pre- 
vent rotation of the hips. 
Position in Bed.—Recumbent Position: This position serves to 
prevent deformity and to improve general circulation. The following 
instructions should be observed: 
Make the mattress flat. Boards as a rule should be put under the 
mattress. 
Preferably eliminate a pillow under the head. A flat chest and 
slowing up of the circulation result if a pillow is used. 
Fig. 7.—Positions assumed in bed by the arthritic patient to obtain physiologic 
rest. A, the supine position. B, the prone position. 
Place a small pillow or roll under the head of the tibia. Subluxation 
of the knee frequently results from a pillow under the thigh. 
Train the patient to lie with his elbows and wrists extended to prevent 
flexion deformities. The arthritic patient frequently assumes a position 
in which he flexes elbows and wrists and rests them on his chest for 
comfort and body warmth. The pressure of the arms on the chest 
retards full inspiration and slows up circulation. 
Prevent outward or inward rotation deformity of hips by propping 
the legs in position with pillows or sandbags. 
Maintain a 90 degree angle of the ankles and prevent foot drop by 
using a heavy box or bricks at the foot of the bed to hold the feet at 
right angle and prevent pressure of the bed clothes. 37 
The occupational therapist should plan her equipment so that the 
patient who must lie flat on his back may maintain the good functional 
position which is illustrated (fig. 8 A). 
Sitting Position: Use a flat canvas or board back rest if possible. 
If a pillow is used it should be firm and extend from the hips to the 
shoulders. The chin should be in, the head back and the chest high. 
A firm pillow or roll under the head of the tibia to flex the hip and knee 
will prevent the patient from slipping down in bed and assuming a poor 
position. 
The patient who may sit up for his occupational therapy should be in 
the good functional position illustrated in figure 9 A rather than in a 
poor functional position. 
Fig. 8.—The recumbent position assumed in bed by the arthritic patient to 
prevent deformity and to improve general circulation. A, good position. B, poor 
position. 
Position in a Chair.—Whether a wheel chair or a regular chair is 
employed, it should have a straight back. While sitting up the patient 
should be erect with chin in and chest high. If a pillow is used, it should 
be below the shoulders so the head is not pushed forward and the chest 
flattened. The occupational therapist should see that the patient is seated 
correctly at work. 
Guide in Selection of Posture Chairs.—Support at the scapulas is 
essential. There should be a space between the top of the chair and the 
seat, so that the patient sits back in the chair. Slats, as shown in the 
illustration of bad seating (fig. 10 5), press against the pelvis, causing 
rotation and poor posture. 38 
“Absence of occupation is not rest, a mind quite vacant is a mind 
distressed” (Cowper, 1770). . 
TUBERCULOSIS 
Rest and exercise should be carefully prescribed for the tuberculous 
patient according to the needs of the patient and the stage of the disease. 
Occupational therapy plays an important part in adjusting a tuberculous 
patient to hospitalization from the day of his admission. It provides 
Fig. 9.—The functional position assumed by the arthritic patient sitting up in 
bed for occupational therapy. A, good position. B, poor position. 
Fig. 10.—The sitting position assumed in a suitable chair by the arthritic 
patient. A, good position in a well selected chair. B, poor position in a badly 
selected chair. 
definite and specific means for controlling and grading his physical 
activity and in replacing habits and attitudes which retard recovery and 
invite reactivation of the infection. It lays the necessary groundwork 
for training or employment after he leaves the hospital. 
Other contributing factors for the patient may be listed as follows: 
1. Occupational therapy may have a sedative effect on a restless patient. 39 
Activities using the processes of thought and the senses of sight and 
hearing may be instituted before the patient is ready for physical activity. 
2. The surgeon may utilize specific muscular exercise to restore muscular 
function after surgical treatment of the chest. 3. In the subacute stage 
graded activity is used to reestablish work tolerance. 4. The provision 
of suitable recreation, education and satisfying undertakings prevents 
neurotic and unhealthy mental attitudes from developing. 
5. Latent skills and potentialities may be discovered and developed in 
preparation for vocational training. 
6. The morale of the patient group is improved by the occupational 
therapy service in an institution. 
Other contributing factors for the hospital may be listed as follows: 
1. Occupational therapy increases the patients’ cooperation, which is 
essential in the treatment of this disease. 2. It lessens the number of dis- 
ciplinary problems, which complicate treatment and administration. 
Physiologic rest is essential in the cure of active tuberculosis. The 
human being, geared to physical and psychic activity, is often unable to 
make the transition to complete rest without assistance. To lie in bed 
is possible, but to be at rest requires cessation of psychic agitation, fear, 
anxiety, worry and boredom. Therefore, the patient’s content of thought 
must be directed in constructive channels, and mental relaxation must 
be obtained. This requires subtle and intelligent guidance on the part of 
all those who come in contact with the patient. The occupational thera- 
pist may be of great assistance in controlling mental activity by providing 
compensatory avenues of thinking, hearing and seeing to replace destruc- 
tive psychic activity. 
When the patient is ready to start a program of graded exercise, 
the physician should estimate the patient’s ability to exercise without 
fatigue. The effect of exercise on temperature, cough, sputum, hemop- 
tysis and weight must receive consideration. 
Exercise within the patient’s tolerance improves muscular tone, 
circulation, nutrition and the body functions. However, exercise to or 
beyond the point of fatigue lowers the patient’s resistance and is destruc- 
tive; although great caution should be used in prescribing and adminis- 
tering activity, its value if carefully prescribed is unquestionable. 
Occupational therapy offers an ideal method of inducing rest and of 
grading and controlling exercise. It is a pliable medium which can be 
quickly increased or decreased in extent and frequency of treatments, 
and its results can be measured by the patient’s clinical reaction. 
PROCEDURE 
The following procedure is suggested : 
1. Occupational therapy is prescribed by the physician. The pre- 
scription should indicate the length of time that the patient may be 40 
occupied and the amount of physical exercise that may be allowed. Any 
accompanying physical condition or psychologic or social factor should 
also be noted. 
2. The patient’s prescription should be changed whenever an increase 
or decrease of activity is indicated by his clinical reactions. 
3. The occupational therapist should keep a careful detailed record 
of the patient’s exercise and reactions. 
4. A complete program of occupational therapy not only aids in 
adjusting the patient to long convalescence and in providing a program 
of graded exercise but leads into vocational training and placement. 
Skills and aptitudes are fostered and an opportunity for study and train- 
ing is made available while the patient is hospitalized. The long period 
of convalescence can thus be utilized advantageously. 
5. On discharge the patient who can do only part time work under 
medical supervision should be assisted in finding this in a sheltered 
workshop. The patient who is homebound should be referred to an 
agency serving homebound persons. The patient who needs vocational 
training, further education or placement should be referred to the proper 
source of such help. The patient who is trained in the hospital to carry 
on intelligently and stay wdthin his physical limitations and who has been 
rehabilitated physically and vocationally is less likely to break down at a 
later date. 
PRESCRIPTION 
The classification and amount of exercise should be specified by the 
physician and should be increased or decreased according to the clinical 
reactions. All the patient’s activity should be considered as a unit. 
The prescription should also include a statement of the stage of the 
disease, the prognosis for recovery and any other physical complications. 
Suggested Classification for Exercise.—Exercise 1: This includes 
complete rest in bed, the patient to be fed and given personal hygiene by 
the nursing staff. 
Exercise 2: This includes rest in bed twenty-four hours a day. The 
patient may sit up to eat, but he is to be given complete nursing care 
and transported on a surgical cart. 
Exercise 3: This also includes rest in bed twenty-four hours a day, 
but the patient is allowed to take his own bath in bed. He is to be 
transported in a wheel chair and may sit on a bench or a chair in the 
corridor of the surgical floor and walk into the treatment room. He is 
permitted one-half hour of occupational therapy. 
Exercise 4: This is the same as exercise 3 except that the patient 
may go to the bathroom once a day and may sit in a chair beside the bed 
thirty minutes a day (fifteen minutes in the morning and fifteen minutes 
in the afternoon). He is to be transported in a wheel chair and is 
permitted one-half hour of occupational therapy. 41 
Exercise 5: The patient is allowed tray service and full bathroom 
privileges. He is to be transported in a wheel chair and is permitted 
one hour of occupational therapy in bed. 
Exercise 6: The patient is allowed tray service in the solarium or 
the dining room in his cottage, and he may walk to roentgen examination, 
treatment, etc. He is permitted one hour of occupational therapy in 
quarters and may use the telephone. 
Exercise 7: The patient may have street clothes. He takes all meals 
in the dining rooms and is permitted one hour of occupational therapy in 
the shop. He mgy attend church, movies and occupational therapy 
parties. He may visit other patients once a week, on Monday only. 
Regular visiting passes will be secured at the business office or in the 
cottages. 
Exercise 8: The patient is allowed to make his own bed and has one 
hour of occupational therapy but is not given ground privilege. (Ground 
privilege consists of walking for the time specified in each exercise within 
the limits allowed.) 
Exercise 9: This is the same as exercise 8 except that the patient is 
allowed one-half hour ground privilege in the afternoon. 
Exercise 10: The patient is permitted one and one-half hours of 
occupational therapy and has one-half hour ground privilege in the 
afternoon. 
Exercise 11: The patient is permitted two hours of occupational 
therapy and has one-half hour ground privilege in both morning and 
afternoon. 
Exercise 12: The patient is permitted three hours of occupational 
therapy and has one-half hour ground privilege in both morning and 
afternoon. 
Comment: Patients should consider assignment of exercise in accord- 
ance with this schedule as a medical prescription, which will aid as much 
in ultimate recovery as any drug or other medical measure. 
Suggested Activities.—Mental Activities Requiring No Physical 
Exercise: These include listening to radio programs selected or broad- 
cast by the hospital; reading with a book rest or being read to; looking 
at pictures, movies, etc.; studying, planning and dictating material, and 
playing guessing games. 
The patient should be helped to develop his mental resources to 
save his physical strength. His personality and social needs should be 
studied in order to help in his adjustment. ■ 
Physical Activities Adaptable to a Program of Gradual Exercise: 
These include light craft work, games and puzzles, educational work 
and prevocational activities. 42 
Socializing Activities: These are directed toward aiding in the 
adjustment of the patient after a long period of individual treatment and 
include group projects and parties, radio broadcasts and plays, games 
and recreations and work on the hospital publication. 
Problems Based on a Vocational Point of View: In planning voca- 
tions the following factors must be considered: the probable physical 
capacity of the patient, vocations from which once tuberculous patients 
are not barred by law, vocations in which there are local openings and 
vocations not requiring capital. 
Cautions.—With reference to occupational therapy the following 
precautions should be observed: 
1. The occupational therapist must be well trained, competent and 
experienced, 
2. For the patient’s and the therapist’s protection, she should have 
a physician’s signed prescription for treatment and for any changes in 
treatment. 
3. The program of occupational therapy should be carefully cor- 
related with other treatments and should be so pliable that it can be 
changed at a moment’s notice to meet the patient’s changing needs. 
4. Overstimulation, overexercise and fatigue should be guarded 
against at all times. That which will relax one patient may stimulate 
another. 
5. The materials and equipment used must be adapted to the treat- 
ment of tuberculous patients. Dust, lint, injurious gases and occupations 
causing strain to the thoracic muscles are to be avoided. 
6. Patients must be trained in the rules of good hygiene and required 
to practice them at all times. 
7. Direct sunlight for several hours will prove an effective germi- 
cide for equipment and materials. 
8. The therapist, for her own protection, should be required to 
observe rules of hygiene while working with patients. 
Comment.—Porter 20 stated: 
Physical idleness, which is a necessary part of early treatment of the disease, 
must find its therapeutic counterpart in carefully regulated activity designed to 
restore work habits and to recreate general work abilities. 
A well rounded program of medical supervision of the tuberculous patient 
has not reached completion until the patient has recovered sufficient work toler- 
ance to permit him to take his place in economic life where he is again able to 
be independent in a carefully selected occupation in competition with the able- 
bodied. 
Mental and physical activity provides a standard by which the physician can 
measure the patient’s work tolerance. Also, such activity, prescribed wisely, and 
20. Porter, E. B.: Vocational Therapy, Am. Rev. Tuberc. 45:392 (April) 1942. 43 
with the approval of the physician in charge, will, in most instances, contribute 
to speedier recovery than would be the case if the patient continued to carry on a 
life of comparative inactivity. 
A speedy return of the patient to suitable employment when physically ready 
may provide one important safeguard against the growth of conditions that bring 
about relapse and subsequent rehospitalization. 
For medical and economic reasons, therefore, rehabilitation in the sanatorium 
should occupy a place of major prominence alongside other techniques used in 
treatment. Thus the patient will derive maximum benefit from his sanatorium 
stay and a contribution will have been made to the total plan for returning the 
patient to a satisfactory status in the shortest period of time. 
The following schema represents the transformation of a patient 
with active tuberculosis to a rehabilitated independent citizen through 
the medium of a progress plan based on occupational therapy. 
Active Tuberculosis 
Care in Bed 
No physical activity; direct mental activity in aiding adjustment to 
hospitalization and treatment 
Slight and graduated physical activity for improvement of muscular 
tone; attention to general well-being and psychic well-being 
Inactive Tuberculosis 
Central Workshops 
Increased physical activity; group socialization; preindustrial training 
and measurement of work tolerance 
Discharge 
Vocational Training and Education 
Sheltered Employment 
At home 
In workshop 
Placement 
Follow-up: Medical, vocational, social 
CARDIAC CONDITIONS 
White 21 has said: 
Occupational therapy is one of the most important and useful measures at the 
disposal of the physician in the restoration of a cardiac patient to a fairly normal 
state of health after recovery from acute or subacute illness, and in combating 
the omnipresent cardiac neurosis which may appear alone or which may com- 
plicate true heart disease. 
Work is an integral part of the life of the normal man and woman; it should 
be maintained as a part of the life of those who have physical, or indeed mental, 
abnormalities so far as it is possible to do so. Of course during acute or sub- 
acute illness it is usually essential to impose absolute rest, though even then 
there are exceptions. During convalescence, however, work in mild degree often 
hastens a return to good health, and later, when it is possible, it is best to advise 
the resumption of full work when such work is not too strenuous or exacting, 
even though there remains permanent scarring of some part of the body. 
21. White, P. D.: Heart Disease, ed. 2, New York, The Macmillan Com- 
pany, 1937. 44 
Prescribing rest in bed does not necessarily bring about true physio- 
logic rest. Anxiety and boredom cause restlessness which is sometimes 
more vigorous and damaging than light exercise. 
PHYSIOLOGIC REST 
The occupational therapist’s first task is to induce mental and physical 
relaxation and rest through diverting the patient’s mind from his anxiety 
and guiding his thinking along healthy constructive channels. 
For example, when the therapist has become familiar with the 
patient’s interests, she can provide an outlet for him which does not 
require physical activity. Listening to radio programs, reading and 
dictating letters, studying and planning are a few of the activities that 
are used effectively to reduce restlessness and maintain mental health. 
GRADED EXERCISE 
During convalescence the physician may prescribe a program of 
graded exercise. Recreations and occupational activities are adaptable 
as a stimulus, as well as a control of activity. They are objective in 
character, and the neurotic patient, fearful of exercise, forgets himself in 
his interest in accomplishment. 
The amount and the duration of exercise can easily be controlled. 
Light activities requiring the use of the fingers only may first be used, 
then activities employing the forearm and the upper arm. As the 
improvement of cardiac condition permits, resistance and range of 
exercise are gradually increased from activities done in bed through ones 
carried out while the patient is sitting up to tasks done while he is 
ambulatory and so to shop work. 
PRESCRIPTION 
The classification and the grade of exercise should be specified by the 
physician. Exercises should be within the area of the patient’s tolerance, 
and the rate of increase in exercise should be specified by the physician. 
Overactivity should be guarded against at all times. 
The classification of exercise for tuberculous patients is adaptable as 
a means of prescribing activity for patients with cardiac condition (see 
page xxx). 
Leaman 22 stated: 
The functional capacity of the patient does not always determine the amount 
of physical activity which is permitted. There is frequently a difference between 
the amount of physical activity which the patient can undertake, in terms of his 
functional capacity, and that which he should attempt, in order to prevent further 
22. Leaman, W. G.: Management of the Cardiac Patient, Philadelphia, J. B. 
Lippincott Company, 1940. 45 
cardiac damage and bring about improvement. The recommendation as to physical 
activity is based upon both the amounts of effort possible without discomfort and 
nature and severity of the cardiac disorder. 
The proper form of occupational therapy can only be prescribed when a 
complete diagnosis of the patient is at hand and the functional classification 
determined; consequently it is one of the final considerations in treatment. 
FUNCTIONAL CLASSIFICATION OF PATIENTS WITH CARDIAC DISEASE 
Class I. Patients with Cardiac Disease and No Limitation of Physi- 
cal Activity.—Ordinary physical activity does not cause discomfort. 
Patients in this class do not have symptoms of cardiac insufficiency, nor 
do they experience anginal pain. 
Class II. Patients with Cardiac Disease and Slight Limitation of 
Physical Activity.—Patients in this class are comfortable at rest. If ordi- 
nary physical activity is undertaken, discomfort results in the form of 
undue fatigue, palpitation, dyspnea or anginal pain. Competition in 
athletics and other strenuous activity, even hurrying, are to be avoided. 
Activity should be graded according to cardiac tolerance. A vocational 
plan should be made according to the permanent mechanical involvement 
of the heart. 
Class III. Patients with Cardiac Disease and Marked Limitation of 
Physical Activity.—Patients in this class are comfortable at rest. Dis- 
comfort in the form of undue fatigue, palpitation, dyspnea or anginal 
pain is caused by more than ordinary activity. Occupational therapy is 
first used to induce rest from the cardiovascular standpoint, allowing 
the circulation to slow down and the reserve power to overcome infec- 
tions. By this means ultimate damage is minimized. Light activities 
and a program of graded exercise may later be indicated. 
Class IV. Patients with Cardiac Disease and Inability to Carry on 
Any Physical Activity Without Discomfort.—Symptoms of cardiac insuf- 
ficiency or of the anginal syndrome are present in patients in this class, 
even at rest. If any physical activity is undertaken, discomfort is 
increased. In this class as in class III, occupational therapy is used to 
induce rest, as well as to decrease anxiety and fear. The program is 
limited to mental activity and may prove of distinct value as a palliative 
measure. 
Comment.—Leaman 21 stated: 
Patients placed in Functional Group 4 can handle only the types of occupa- 
tional therapy that can be carried out at bed rest. Although these cases are 
allowed very little exertion, the mental rest that follows interest in some task that 
can be carried out for a few hours each day is a considerable aid to children and 
adults alike. If improvement permits advancement to Group 3, and finally to 
Group 2 and 1, the value of Occupational Therapy as a future means of earning 
a livelihood becomes important. 46 
For Class 3 and 4 patients confined to bed, various devices have been arranged 
to permit tasks requiring the use of the fingers only. Light bed boards may be 
used, or in some cases, where weaving is carried out, the apparatus can be sus- 
pended over the bed. Prolonged hospitalization permits training for occupations 
which require extensive apparatus, while patients who come in for shorter periods 
may be assigned to simpler tasks like basketry, cord and leather work. Women 
patients may, in addition, to any of these types of occupational therapy, renew 
their interest in different forms of needlework. 
Even in shorter illnesses, the psychotherapeutic value of some slight task 
assigned cannot be overlooked. The patient may be inclined to worry about his 
condition, the new surrounding may delay his convalescence, hence attempts should 
be made to interest him in some occupation as soon as his physical state permits. 
Occupational therapy, if intelligently supervised and directed by the 
physician, may be used as directly in treating the cardiac as the orthopedic 
patient. The prescription should be carried out by a competent and 
resourceful therapist, and this phase of the patient’s treatment should be 
correlated with his other treatment and activities. 
The entire plan of treatment should lead toward maximum physical, 
psychologic, social and vocational rehabilitation and should be carried on 
in such a manner as to elicit the patient’s hearty cooperation. 
The program should serve as an educational medium whereby the 
patient may learn to stay within his work tolerance, yet develop his 
resources for as useful and satisfying a life as possible. The program 
should be so planned that while meeting the need during acute illness, 
it is leading into a constructive plan for the patient’s future. 
NEUROPSYCHIATRY 
“Employment is nature’s best medicine and essential to human 
happiness” (Galen, 172 A. D.). 
PURPOSE OF OCCUPATIONAL THERAPY FOR NEUROPSYCHIATRIC 
PATIENTS 
In case of a neuropsychiatric disorder occupational therapy serves 
to train the disordered mind to maintain habits of normal activity and to 
reestablish mental and muscular coordination. 
Dr. William A. Bryan 23 stated that work, being reality, provides a 
powerful aid in keeping the patient in touch with his surroundings. Con- 
centration on a given task demands attention; absorption in a healthy 
activity tends to dispel disorganized thought. Once is aroused, 
new enthusiasms are created, courage takes the place of discouragement 
and the patient swings back toward the normal. If a psychosis has 
reached the point where a cure seems improbable, directed activity within 
the hospital provides a substitution which aids the patient toward a more 
comfortable adjustment to a long and indefinite period of hospitalization. 
23. Bryan, W. A.; Administrative Psychiatry, New York. W. W. Norton & 
Company, Inc., 1936. 47 
While there is little evidence that occupational therapy has a specific 
effect on a psychosis, there is much evidence to show that it has con- 
siderable influence on the personality of the patient. Therefore, the 
diagnosis should be considered only as it explains behavior patterns. 
Stress should be laid on personality problems and reactions. Efforts 
should be made from the start of the treatment to discover the “well 
part” of the patient and then through this avenue slowly and carefully 
to lead him through a transitional period from illness back to health. 
WAR NEUROSES 
In his Salmon Memorial lectures in this country in 1941 Dr. Robert 
Gillespie, psychiatric specialist with the Royal Air Force in England 
pointed out some interesting facts in connection with the so-called “war 
neuroses.” He stated that contrary to public opinion no new neurosis 
has been born of this war. In fact, because of the necessity of sustaining 
life under difficult circumstances there had been a noticeable decrease in 
civilian neuroses. Neuroses among men in the service were undoubtedly 
induced by their experiences, yet when the neurosis was thoroughly 
examined, the signs and symptoms were identical with those manifested 
by neuroses with which a psychiatrist is familiar in his daily practice. 
He stated that through his recent experiences in wartime England he 
had found that “the best way to prevent mental breakdown after tragic 
experiences is to keep people occupied(The italics are ours.) 
Army and Navy routine, through mass activity, may tend to stamp 
out all individualism and turn a man into a compliant machine, the duty 
of which is to obey orders and to cease acting on initiative. One of the 
first duties of the occupational therapist is to seek out what remains of 
individual thinking and acting in each patient, work to rehabilitate this 
and so fit the patient for reentry to an environment of individualistic 
existence. 
Of a group of neuropsychiatric patients showing similar signs and 
symptoms, few will respond to the same stimulus. With some patients 
it is necessary to apply many and varied stimuli before an association is 
formed and a reaction is brought about. Therefore, no rule can be laid 
down that any one activity will work equally well with each patient in the 
group, although the symptoms appear similar. For this reason, no list 
of activities can be given as specific cures for any given psychosis. 
Activities must be adapted from those available in the setup or in special 
cases from those that can be introduced into the organization. 
PROGRAM OF OCCUPATIONAL THERAPY FOR NEUROPSYCHIATRIC 
PATIENTS 
The program of occupational therapy outlined here for neuro- 
psychiatric wartime patients is based on the supposition that treatment 48 
will be instituted as soon as a patient reaches the base hospital. Early 
treatment of these patients will largely determine whether they will be 
discharged to further military duty or to an indefinite stay in an institu- 
tion or the treatment of prolonged psychiatric disorders. 
A program of continued treatment for neuropsychiatric patients 
should be developed on a basis of graduated activities, with therapeutically 
prescribed participation in hospital industries. Continued motivation 
through a varied program should be stressed to keep each patient as 
active as possible and aid in the prevention of deterioration. 
For acutely ill patients highly diversified, elastic and progressive 
programs should be arranged. The processes of the occupational 
mediums, no matter what form they take, should be so graded as to 
meet the needs of the highly intelligent, well educated, neurotic person, 
as well as those of the dull, withdrawn, unresponsive patient. In the past 
occupational therapy has been thought of in terms of arts and crafts. 
Today in its broader concept its program embraces any and all activities 
that in any way contain elements that have curative value. These 
activities may range in scope from the use of clay by the acutely ill 
person to arouse his interest and response to the fundamentals of life 
and thus give him his first step in a program of social rehabilitation 
through to highly intricate laboratory work, bookkeeping or other 
hospital industry or routine that may be utilized to fit a patient to take 
his place in the civilian world. Whether these activities take the form 
of handicrafts, gardening, recreation, music, dramatics, hobbies or 
participation in hospital industries, they are the tools with which the 
therapist administers her treatments. Standards of accomplishment as 
high as possible should be maintained in order that work habits and pride 
may be restored. However, the patient should never be sacrificed on an 
altar of perfection, which may be far beyond his native ability. 
Organized systematic work is better treatment than careless hap- 
hazard occupation. Every administrator is familiar with the grotesque 
ways of working which many patients adopt when permitted to work out 
their own methods—the patient who is placed in a work environment 
where activity is carried on in an orderly manner will respond better 
and derive greater benefit than one who is taken to a shop and permitted 
to do the work in his own way. On the other hand, the therapeutic value 
of the development of initiative and originality in the choice and execution 
of projects should be stressed. The patient should be urged to proceed 
as much as possible on his own, unless the activity chosen should in some 
way be detrimental to his progress. To prevent his use of initiative 
destroys the object of the whole program. 
In arranging schedules it will be found beneficial to give short con- 
centrated periods to each of a variety of activities rather than too long a 
period to any one activity. These wartime patients will at best be rest- 49 
less, and interest will be poorly sustained because of the memories of 
recent experiences. As soon as an activity begins to verge on the routine 
or can be accomplished automatically, attention weakens and the. activity 
ceases to be curative. While variety must exist, it is essential that the 
whole program be built up progressively; each new activity embracing 
new and more difficult processes. The new ideas and processes should 
be presented to the patient as rapidly as the therapist feels he can absorb 
them. 
The continued treatment program for the rehabilitation of the neuro- 
psychiatric wartime patient should embrace all the concepts outlined in 
the program of occupational therapy for the acutely ill service man plus 
such enlargement and variety as is needed to make a well rounded daily 
routine. 
In such a program consideration must be given to groups: first, 
the group who have some chance for recovery through continued treat- 
ment and, second, the group who must be trained to adjust to an 
indefinite period of hospitalization. In either case, morale must be 
maintained. The patient must be given repeated assurance that he has 
a chance for recovery or if not recovery assurance that his life in a 
sheltered environment will be full of interesting worth while activity. 
It must be pointed out to him, day after day if necessary, that participa- 
tion in the program outlined for him by his physician is the means 
toward this end. He must be made to feel that he is needed and his 
work of value, no matter how insignificant his share in the functioning 
of the hospital may seem. 
Constant activity and motivation are of the utmost importance in the 
treatment of the service man transferred from a base hospital to the 
psychiatric hospital for continued treatment. 
Habits are quickly and easily formed after admittance, and it is essen- 
tial that correct ones be formed as early as possible. Future reactions 
and results will be largely measured by the patient’s adjustment to the 
prescribed routine of the. first few weeks. 
In the large psychiatric hospitals activities of necessity are carried 
on in groups rather than as individual pursuits; therefore, it is all the 
more necessary that a well balanced program of work, recreation and 
social activity be prescribed for each patient. In this way it is possible 
to maintain some measure of individuality within the large group. 
These programs, in addition to offering variety of activity as near 
comparable to normal living as is possible in a sheltered environment, 
should be graded in effort and demand to meet the needs of the very ill 
patient with dull physical, emotional and intellectual responses as ade- 
quately as they do the needs of the well preserved mentally alert superior 
person. 
In order to determine what activities are indicated or contraindicated 
for a patient it is first necessary to find out as much about him as possible. 50 
This can best be determined through a series of tests given by the 
psychologist and the director of occupational therapy under the super- 
vision of the psychiatrist. 
These tests should be designed to determine the patient’s general 
vocational and avocational interests and his manual manipulation. On 
completion of the tests the psychologist and the therapist enter their 
findings on the prescription slip previously given by the psychiatrist. 
This slip is now returned to the psychiatrist, who after a study of the 
findings and an interview with the patient, assigns him to the treatment 
program which seems best indicated to help him. The prescription slip 
is sent back to the occupational therapy center with such instructions as 
are necessary, and the supervisor of the ward is notified of the patient’s 
routine. 
All programs should be well balanced, embracing equal proportions 
of work, rest, recreation and social activities. Stress is laid on the 
necessity of grading all activity to meet the needs and abilities of the 
patient, with plenty of opportunity for progression from one group to 
the next. It should be constantly kept in mind that the life within the 
sheltered environment should be patterned as closely as possible to 
normal life on the outside. 
Graded programs for continued treatment are institutional or com- 
munity in scope. The institutional programs include (1) socialization 
therapy, (2) both (a) occupational therapy—manual, recreational and 
academic activities—and (b) diversional activity, (3) industrial therapy 
and (4) association with hospital colonies. The community programs 
include (1) parole to sheltered workshops and (2) employment in open 
industry. 
Socialization Therapy.—This type of program (also known as a 
habit-training or a total push program) is administered by trained 
occupational therapists assisted by trained attendants. 
Type of Patient: Patients put on this program are dull, retarded, 
untidy and asocial. •* 
Object of Therapy: The program is intended to arouse within the 
patient an awareness of reality and to encourage normal reactions to 
normal stimuli. 
Program: The following daily program is suggested: 
6 A. M. Rising. The patients dress, wash, bathe and comb hair (under the 
direction of a selected attendant). 
7 A. M. Breakfast. Patients are seated at special tables and supervised in 
regard to table manners and amount of food. 
7:30 A. M. Personal hygiene. The patients cleanse teeth, comb hair and dress 
properly. 
8 A. M. Patients assist with the ward work, making their own beds and 
arranging the rooms under the direction of an attendant. 51 
9 A.M. Calisthenics under the direction of the physical director; out-of-doors 
exercise, walking, games or singing. 
9:30 A. M. Occupational therapy of such nature as the director may deem 
advisable. 
10: 30 A. M. Work put away, each patient assisting. 
10:45 A. M. Patients taken to the lavatory. Each patient combs hair, washes 
hands and prepares for dinner. 
11 A. M. Dinner for those patients served in the ward, followed by rest, smok- 
ing, listening to the radio and visiting with other patients. 
12 Noon Dinner for the rest of the patients at a special table in the main 
dining room. 
12: 30 P. M. Personal hygiene. Shave every other day. Hair dressing and mani- 
cure for women. 
1:30 P. M. Occupational therapy alternating with recreational therapy, including 
bus rides, gymnastic exercise, picnics, movies if possible and parties. 
3 ; 30 P. M. Patients taken to the ward. 
3: 45 P. M. Patients taken to the lavatory to practice personal hygiene and pre- 
pare for supper. 
4 P. M. Supper for those patients who eat in the ward. 
5 P. M. Supper for the other patients in the main dining room, followed 
by smoking, listening to the radio, games ancf reading. 
9 P. M. Retirement for the night. 
Manual, Recreational and Academic- Therapy.—This is administered 
by trained occupational therapists, volunteer assistants in occupational 
therapy and trained attendants in the occupational therapy center and 
in the wards. 
Type of Patient: Three types of patient are given this treatment: 
(1) mildly to fully responsive but unstable persons lacking initiative, 
ability to concentrate and adequacy in carrying on routine tasks without 
close supervision; (2) persons demonstrating through tests latent ability 
in handicraft or musical, dramatic, artistic or literary ability, and (3) 
persons interested in athletics. 
Object of Therapy: The object for each of these three types of 
patient, respectively, is as follows: (I) to assist the patient to maintain 
and help develop so far as possible what remains of normal thinking 
and acting and to train him to carry on simple routine tasks; (2) to assist 
and encourage a talented person to develop and utilize talents both for 
his own pleasure and for the benefit of the group, and (3) to assign a 
patient with definite athletic ability and interest to the recreational 
therapist to assist in recreational and athletic activities, including making 
and maintaining athletic equipment in the occupational therapy center. 
Program: The program carried on daily is as varied and progressive 
as it is possible to make it, including the following activities: major and 
minor crafts, repair work, dramatics, puppetry, gardening (vegetable 
and flower), flower shows, hikes, glee club, orchestra, choir, rhythm 
band, radio (active and passive participation), hospital publication. 52 
physical education and educational therapy, including courses in English, 
literature, science, history, languages, mathematics and business. 
Diversional Activities.—These activities are administered by volun- 
teer assistants in occupational therapy, the Gray Ladies of the American 
Red Cross and trained attendants under the supervision of trained 
occupational therapists. 
Workshop: It is quite necessary that adequate quarters be provided 
for shops or centers from which and in which these activities can be 
carried on. The size and arrangement of these must necessarily be 
dependent on the space available and the size and needs of the hospital. 
All hospital industries should be carefully analyzed to determine which 
are available and suitable for therapeutic uses. It is not possible .or 
necessary here to give a detailed description of a satisfactorily arranged 
shop with its full equipment, as these lists can be obtained from the 
American Occupational Therapy Association in New York. No matter 
what size or description of plant is available, it is quite necessary that 
masculine activities prevail, and the men should be made to realize that 
the shop is theirs. 
Psychology of the Shop: The atmosphere of the shop should be 
casual and informal; military discipline should be minimized. The 
therapist should be in charge to direct activities and maintain discipline. 
If she is the right sort of person there will be little need of disciplinary 
measures, and the patients will have a desire to attend the shop. Without 
this desire little good is accomplished. In addition to its material and 
functional use the shop should serve as a laboratory where the therapist 
can study the reactions, aptitudes, accomplishments and work habits of 
her patients. If she correctly evaluates, tabulates and presents her 
findings, they should be of value to the psychiatrist. Even though the 
shop presents a casual appearance, there should be a definite purpose 
behind each move, but the patient should never be allowed to become 
aware of this. He must not know that he is under close observation 
at all times and that the therapist, although urging him to use his initia- 
tive, is ready to step in and help before he reaches a point where failure 
and frustration may arise from his ignorance of what to do next. 
Type of Patient: The patients selected for diversional therapy include 
those for whom the chance for recovery seems remote and ones engaged 
in hospital industries or confined to bed who need diversion through 
simple handicrafts and games. 
Object of Therapy: The object of diversional therapy is occupying 
and maintaining interest in simple activities. 
Program: A daily program suggested for the wards includes simple 
handicrafts with repetitive motions, simple repair work from the hospital 53 
industrial units and games, letter writing, reading, listening to the radio 
(passive participation), translation, use of Braille, appreciation of radio 
programs, discussion of current events and social activities, including 
card and game parties, social dancing, music groups and community 
singing. 
Industrial Therapy.—This type of therapy is administered by the 
foremen in charge of various hospital industrial units under the super- 
vision of the psychiatrist and in collaboration with the director of occupa- 
tional therapy. 
Type of Patient; Such therapy may be prescribed for all types of 
patients capable of comprehending and following directions and possess- 
ing good work habits. 
Object of Therapy: The object of this type of therapy is to place 
the psychiatric patient in the industry most beneficial to him and to pro- 
vide developable and sufficient patient help to carry on the work of the 
various hospital industries. Participation in a program of hospital 
industries provides training of value after discharge. Industrial assign- 
ments should be on a part time basis to allow the patient to participate 
in other activities and to prevent the danger of his being placed in 
industry to get the work done without consideration of the therapeutic 
benefit of the placement. 
Program: The program includes part time assignments dovetailing 
with recreational and social activities. The following departments and 
units can be utilized to provide therapeutic activity: maintenance, 
engineering, farm and grounds, warehouse, culinary, housekeeping, 
janitor service, offices, barber shop, hydrotherapy, laboratory, phar- 
macy, roentgenology, shoe repair and other mending, sign painting and 
car maintenance. 
Association with Hospital Colonies.—These units are administered 
by trained personnel under the direct supervision of the commanding 
officer of the hospital. 
Type of Patient: Patients utilized in these colonies are active,, 
intelligent and trustworthy, with good work habits. 
Object of Therapy: The object of utilizing these units is to place a. 
patient possessing the required qualifications in a situation which is com- 
parable to open industry yet provides understanding supervision and ta 
test a patient’s fitness for return to home environment and open industry. 
Program: The daily program is designed according to the facilities 
available to keep the patient busy all day, thus affording a physical 
hardening process and developing self-reliance and initiative. It includes 
farmwork, chicken raising, and manual and mechanical activities involved 
in clearing land, establishing homesteads, etc. 54 
Parole to Sheltered Workshops Outside the Hospital.—These are 
administered by trained occupational and industrial therapists in collab- 
oration with social and rehabilitation agencies. 
Type of Patient: The patients admitted to these workshops include 
those ready for discharge but still needing supervision and understanding, 
especially in cities, before they are ready to return to open industry and 
those who are able to live comfortably at home but are not equipped 
either mentally or emotionally to enter open industry. 
Object of Therapy: The object of this program is to assist these 
patients to live adequately outside the hospital even for short periods 
and to prevent possible resort to house canvassing or begging. 
Program: The program involves simple industrial projects, such as 
furniture repair and other repairs similar to those made by the Goodwill 
Industries. 
Employment in Open Industry.—Object of Therapy: The object of 
this form of therapy is to return the patient to his former or to new 
employment in the community in some activity for which he has aptitude 
or training. The personnel of the hospital assist the patient in finding 
employment through permanently maintained contact with outside 
agencies. 
ACTIVITIES 
Because of the rapid turnover of patients in base hospitals, it is 
probably wise to have several long term projects on which any number 
of patients can work. These projects may take the form of repair work, 
as of shoes or hospital equipment; care of leather or athletic equipment; 
making of slippers for use in the wards or cases for storage pf rugs, and 
any number of other activities that may suggest themselves to the therapist 
after she has had an opportunity to learn the needs of the hospital. 
Kindwall24 stated in part: 
The exploratory, re-integrative, re-educational efforts of the psychiatrist and 
patient can be greatly facilitated by making it as easy and natural and meaningful 
as possible for the patient to work productively with those around him. Fortu- 
nately, experience seems to show that even in the neurotic, maladjusted person 
the element of imitation, or suggestibility, or herd-instinct, or identification, or 
whatever one may call the phenomenon, is not entirely dead, and that there is 
something contagious in the example of a group of people working for group 
purposes, when there is a need to be met. 
. . . . once the patient has been seduced by circumstances into manual 
activity of a socially useful kind, he will have taken a first unobtrusive, tentative 
step toward increased solidarity with the group. And that is the direction toward 
which are aimed all psychotherapeutic measures, whatever may be their technique 
and whatever they are called. 
24. Kindwall, J. A., and McLean, J. McG.: One Hand for the Ship, Occup. 
Therapy 20:223 (Aug.) 1941. 55 
Music and Recreation.—In discussing recreational therapy for 
mentally ill persons Davis 25 stated: 
It is fundamentally important for the therapist to understand that the patient 
will enter into the activity holding the greatest interest for him. This interest may 
be normal or abnormal and the therapeutic objective, reduced to its simplest terms, 
should be to substitute the strongest normal interests available in the particular 
situation to overcome the dream state or phantasy pre-occupations. Into this 
situation, both the active and passive aspects of recreational therapy may con- 
tribute a distinctive and effective appeal. By the evocation of elements of the 
primal and instinctive life of the individual as typified in play, the therapist is 
often enabled to elicit a favorable response when other agencies are ineffective. 
In passive recreational forms as well, the patients’ attention may become focused 
upon more wholesome trains of thought. Generally it will be found that the most 
antagonistic types will respond favorably to a highly diversified program of 
recreational therapy administered with careful reference to their physical, intelli- 
gence and personality levels. 
The importance of music as an aid in the adjustment and cure of 
neuropsychiatric patients cannot be too highly stressed. Altshuler28 
said: 
The therapeutic principle of music rests upon close affinity between the human 
organism and rhythm as well as upon the symbolism inherent in musical sounds. 
But the chief significance of music as a therapy, I feel, lies in the mechanics of 
the human brain and the way musical sounds reach and affect it. 
Music reaches the mind of the mental patient whose conscious reactions 
are so dulled that he cannot make a response to normal stimulus. It 
commands attention, and once attention is gained, it can by various 
devices be prolonged. Music is used to modify moods. It can be gaged 
to the speed and tempo of the overactive patient, then gradually slowed 
up to a more normal level with the resultant effect on the patient’s 
mood. Inversely, it can start at the tempo of the withdrawn, slowed-up 
patient and gradually be increased in speed, thus bringing the patient 
nearer a normal level of physical acting. Physically music produces 
changes in metabolism, respiration, blood pressure, pulse, endocrine 
activity and muscular energy. The rhythm of music tends to relax. 
Group Singing: This activity is at once stimulating and sedative, as 
well as being a definite socializing agent. Each person has a different 
reaction to a given piece of music. Patients should be carefully watched 
to determine which selections seem to have good and which bad effects 
on the group as a whole. Selections should be carefully chosen to avoid 
those that seem injurious. 
25. Davis, J. E., and Dunton, W. R., Jr.: Principles and Practice of Recrea- 
tional Therapy for the Mentally 111, New York, A. S. Barnes & Company, 1936. 
26. Altshuler, I. M.: Part of Music in Resocialization of Mental Patients, 
Occup. Therapy 20:75 (April) 1941. 56 
Dramatics.—Whether participation is active or passive, dramatics 
affords the patient an opportunity to work off tension, pent-up emotions 
and conflicts through projection of himself into the character which he 
plays. Many persons have the ability to write and produce plays. This 
should be encouraged. Frequently through a study of one of these plays 
or by watching its production the psychiatrist can find clues to some of 
the underlying causes of the patient’s difficulties. This is particularly 
true in psychodramatics. The patient watches a play in which he sees 
his own problems presented with a normal solution. He is invited to 
change the ending either in writing or by an impromptu act. His 
solution frequently is the answer to his problems. 
CONTACTING THE PATIENT 
It is better if a new patient is first brought to the shop after the 
class to which he is assigned has had an opportunity to get organized 
for its activities. There is confusion at the start of a class until the men 
have settled down to work, so it is better for the patient to see his first 
class with other patients absorbed in their various tasks. He is then 
inclined to feel that this is the customary routine and will be more likely 
to conform. The therapist, if she has the opportunity to talk uninter- 
ruptedly with the patient, can formulate her policies at once. The 
patient feels that here is a person who is interested in him and on whom 
he can rely. Thus his own self confidence is built up to the point where 
he can rely on himself. 
First contacts can usually be established by asking the patient to 
assist with some simple task that the therapist herself is doing. She 
can tactfully ask him to do the task and excuse herself to assist another 
patient. By the time she returns the patient has had an opportunity to 
see what the other patients are doing without being conspicuous. 
Persuasion is sometimes necessary to gain the patient’s cooperation in 
starting his program. The first project is always the most difficult, 
particularly with a patient who feels insecure and inadequate. Elated 
manic patients are usually eager to try everything in the shop. Dull 
withdrawn patients show little or no interest in any activity. The 
presentation of a project with simple processes well within the patient’s 
capabilities usually brings a good response as soon as the patient finds 
he can follow directions. He is then more eager to continue and takes 
pride in his accomplishments. First projects should embrace fairly 
rapid processes and technics to offset poorly sustained interest and 
attention. At this point the therapist has no idea of the patient’s 
abilities or limitations. Therefore, she cannot risk having him turn out 
a poorly made article, which would only lead to further discouragement 57 
and sense of failure. Success with the first project has more thera- 
peutic value than success with a later one.- The patient receives a 
distinct psychologic lift from his first real accomplishment. 
THE THERAPIST 
The therapist competent to handle groups of neuropsychiatric 
wartime patients should first be well trained in the presentation of the 
technics of the activities she uses for her tools. She should be able to 
approach her work with a clear understanding of psychiatric problems 
and have a good knowledge of the psychology of human relations. She 
should be between 25 and 45 years of age, have good health and be 
mature, emotionally stable, jolly and tactful, with the ability to respond 
quickly and adequately to emergencies. In addition, she must be alert 
to notice and evaluate changes in patients’ reactions and adjustments. 
She must have ingenuity and ability to adapt processes to the needs of 
the patient. She must have poise and self-confidence without egotism 
and must give the patient a feeling of security and support until he 
gains these for himself. 
THE PSYCHIATRIST AND THE OCCUPATIONAL THERAPIST 
The therapist should work directly under the supervision of a 
psychiatrist and should at all times be responsible to him. He should 
give her definite orders for results desired. After she has had an 
opportunity to observe the patient’s reactions and accomplishments, she 
should discuss a definite program for him with the psychiatrist. As the 
psychiatrist becomes familiar with the underlying difficulties of the 
patient, he can advise the therapist of facts which will be of help to her 
in the administration of the treatment. 
Frequent conferences between psychiatrists and therapists should be 
held for free discussion of patients’ problems and programs. The 
information on the prescription form and discussion of cases at con- 
ferences should be supplemented by frequent visits of the psychiatrists to 
the shop. 
Records and Reports oj the Occupational Therapist.—The psychiat- 
rist may wish to make his own personal observations on a patient at 
work in the shop, or he may wish to depend entirely on the reports sent 
to his office by the therapist. Observation of the patient’s response 
when he is objectively employed in a fairly normal situation may have 
decided value to the psychiatrist. A satisfactory weekly report can be 
worked out in code on the patient’s daily attendance sheet. For these 
code notes observations of reactions are made in three fields: (1) 58 
adjustment; (2) ability, accomplishment and work habits and (3) 
attendance. 
In each field qualities or reactions are rated as follows: 
A-excellent 90 to 100% 
B-good 70 to 89% 
C-fair 50 to 69% 
D-poor 49% or less 
A being evaluated at 100 per cent would be the basis from which 
positive desirable qualities or reactions would be rated downward to 49 
per cent or less into the negative or undesirable qualities or reactions. 
Adjustment: Observations are based on the following qualities : 
Desirable Undesirable 
Accessibility Inaccessibility 
Alertness Dulness 
Assurance Timidity 
Attentiveness Distractedness 
Calmness Agitation 
Clearness Confusion 
Cooperativeness Resistiveness 
Interest Indifference 
Reliance Fearfulness 
Responsiveness Muteness 
Sociability Seclusiveness 
Relaxation Tenseness 
Ability, Accomplishment and Work Habits: Ability. In rating the 
ability of patients it is necessary to give consideration to natural talents 
and to training and experience in creative activities. This is important, 
as a person with considerable ability and experience may because of 
illness be unable to produce results measuring up to his usual standard, 
with a resultant feeling of inadequacy. 
Accomplishment. This factor is usually dependent on application 
to a given task and is largely controlled by interest, ability to concentrate 
and energy drive. 
Work habits. These are somewhat controlled by the degree-of the 
patient’s illness but are more often dependent on habits formed in youth 
and frequently indicate the degree of success of the patient in his former 
employment situation. Observations in this field are based on: degree 
of ability, confidence in ability, constructive ideas, comprehension of 
directions, execution of directions, retention of directions, coordination 
or tremor, dexterity, imagination, industry or indolence, initiative, 
neatness, productivity, previous training and experience resourcefulness. 59 
BLINDNESS 
To take for granted that most of one’s necessary reactions are based 
on sight is erroneous. 
William James contended that the senses of hearing and touch are 
equally as important as vision and are, as a matter of fact, developed 
earlier in the evolutionary scale. As proof of this it is known that 
animals depend on their sense of hearing and of smell rather than on 
vision to warn them of impending danger. Schizoid patients have been 
known to reach a high degree of efficiency in needlework, weaving, etc., 
by using their sense of touch instead of sight. This is brought about 
through their desire to enjoy their own mental images rather than those 
which would be projected on their consciousness if their eyes were open. 
Within each person there seems to lie dormant a vast resource of 
potential abilities that through training could provide a satisfactory 
compensating agent to aid him newly blinded to greater independence. 
James further stated that it is difficult for a person living on one 
plane to understand and visualize completely life on another. There- 
fore, it is essential that persons working with newly blinded patients 
should have as complete knowledge and understanding of the world of 
the blind as it is possible to obtain without actually experiencing 
blindness. 
In the first World War it was the policy of the medical corps to 
place blind men who were adequate in their own daily life in the wards 
for patients with injured eyes to talk with them and prepare them for 
possible sightless futures. They accomplished much toward maintaining 
morale and developing within a newly blinded person self-respect, 
adequacy in small tasks and a desire to accept the prescribed program 
of training. 
Purpose of Occupational Therapy.—In cases of blindness occu- 
pational therapy serves to convince a newly blinded person that 
blindness does not mean incompetency; to contradict the belief that all 
is lost if vision goes; to prevent the development of a martyr complex 
and an attitude of “the world owes me a living”; to prevent depression 
due to shock of loss of sight; to develop the patient’s self-respect and a 
normal healthy attitude toward himself, his friends and his environment; 
to develop the patient’s confidence in himself and his ability to discuss 
future plans in a normal manner; to develop the patient’s ability to 
perform simple personal tasks adequately; to discover the patient’s 
aptitudes and develop them; to advise the type of vocational training 
to lead to economic independence; to acquaint the patient with various 
agencies, such as social activity clubs for the blind, Braille libraries and 
the Seeing Eye, and to educate the patient’s family and friends, when 
possible, in their attitude toward the blinded person. 60 
Prescription.—A general prescription plus added specific instructions 
pertinent to the case, such as psychologic viewpoint, must not be 
neglected in prescribing for a blind patient. 
Records.—General records should be kept plus specific reports on 
methods and mediums used and the progress of the patient. Definite 
reports are advised because of the possibility that they could be used 
later for research. 
Procedure.—The following procedure is suggested: 
Establish a relationship through visits with the patient even before 
the bandages are removed. 
Offer him encouragement and plan his program, treating this as a 
perfectly natural procedure. 
Give him training in the care of the person, in eating, etc. 
Aid the patient in orienting himself through sound, touch, etc. 
Urge his participation in games and tasks designed to develop 
initiative, erase fear and retain social contacts. 
Discover latent abilities of the patient and direct their development. 
Encourage the patient gradually and consistently to extend the con- 
tacts and scope of his environment. 
Introduce Braille, typing, etc. 
Build up the patient’s confidence to a point where vocational training 
can be started. 
Urging may and probably will be necessary to get the cooperation 
of patients in following through a prescribed program which should be 
presented with an attitude of “I take it for granted you are able to follow 
your prescription and will do it.” 
Native strength of character will be the determining factor in a 
patient’s response. 
Qualifications of a Therapist.—A therapist should be specially 
trained in subjects used in training blind persons, such as Braille, typing, 
etc.; adept with her fingers and possessed of an ability to make definite 
simple movements easy to understand and follow, and quiet, stable and 
steady, with a firm, yet “take it for granted the patient can do as 
suggested” attitude. She should possess a genuinely sympathetic 
nature, yet avoid any suggestion of pity and mushy sentimentality, and 
should have great patience and understanding and should instinctively 
know when to give praise and encouragement for honest effort. She 
should have an impersonal attitude when guiding fingers in new and 
difficult processes. 
Cautions.—Overactivity on the part of personnel should be avoided. 
Noise and commotion are confusing to newly blinded persons and tend 
to increase feelings of inadequacy. Do not permit persons of the 
“Pollyanna” type to visit the patients. Their forced cheerfulness is 
resented. 61 
Once furniture, tools, etc., have been located in the shop and the 
patients are aware of their placement, they should not be changed 
without informing the patients. 
ORGANIZATION OF AN OCCUPATIONAL THERAPY SECTION 
IN AN ARMY OR NAVY GENERAL HOSPITAL 
An occupational therapy section is established in an Army or Navy 
general hospital to provide functional and psychologic activity. It is 
prescribed for the purpose of hastening improvement or recovery from 
disease or injury. An occupational therapy unit to serve efficiently the 
full demands of a thousand bed hospital is dependent on the following 
factors: 
1. Properly qualified occupational therapists. 
2. Careful prescription and guidance of patients by the medical staff. 
3. Coordination of the occupational therapy department with all 
other hospital departments, particularly the physical therapy department 
in cases of orthopedic conditions. 
4. Adequate equipment and materials. 
5. Strategic location of central shops. 
6. Satisfactory prescription and record system. 
Pillsbury 27 stated: 
Occupational Therapy has already taken a prominent position in hospitals that 
deal with seriously injured patients. In the Army, Occupational Therapy Depart- 
ments have their widest field in the General Hospitals. It has been found that 
when Occupational Therapy is used in conjunction with Physio-therapy the patients 
recover function more rapidly than when Physio-therapy is used alone. The 
scope of Occupational Therapy in the Neuropsychiatric Sections is well-established. 
RESPONSIBILITY 
The occupational therapist is at all times responsible to the medical 
officer for following the prescription, keeping records and administering 
treatment. All patients are accepted for treatment and supervised by 
this medical officer who may wish to delegate responsibility for the 
treatment to orthopedic, psychiatric or general medical officers. 
To facilitate setting up the department, an initial appropriation for 
permanent equipment should be established. All purchasing is done 
through the medical supply officer. Materials standard to medical 
supply may be drawn from that source—i. e., furniture and fixtures, as 
is usually allowed in total hospital planning—and are not deductable 
from the allotment for occupational therapy. 
BUDGET 
27. Pillsbury. H. C., Brigadier General, M. C., U. S. A.: Personal communi- 
cation. 62 
ACTIVITIES USED AS THERAPY 
The form of treatment should meet the physical, psychologic or social 
need of the patient and be of sufficient interest to provide the necessary 
incentive. Occupations used include those work processes normal to 
men and if possible related to former or future employment. Carpentry, 
metal work, printing, etc., are adaptable as exercise and aid in psycho- 
logic rehabilitation. Interest in the activity must be great enough to 
stimulate the patient’s participation. 
GENERAL SETUP AND PHYSICAL PLANT 
The section is divided into the following units: the orthopedic shop, 
ward work, the psychiatric shop and other special shops. 
All patients for whom occupational therapy is prescribed are treated 
under the supervision of the occupational therapy medical officer. 
Division of the Services.—Orthopedic Shop: In this unit workshop 
activities are adapted to ambulatory patients for the specific effect on 
muscular and articular function. The orthopedic shop should be 
adjacent or close to the physical therapy unit. 
Open Ward Work: Light activity in the ward serves to restore and 
maintain the muscular tone and articular function of bedridden patients, 
patients in casts, patients with cardiac conditions, tuberculous patients 
and others needing this service. Such activity has a beneficial reaction 
which aids recovery. Storage space for materials used in open ward 
work should be provided at convenient intervals near the wards. 
Psychiatric Shop: This unit provides work activity for the purpose 
of sedation, stimulation, habit training, work adjustment, prevocational 
training and evaluation of reactions. Observations should be made 
available to the physician for his consideration in diagnosis and in 
planning for the patients. The psychiatric shop should be in the 
psychiatric section with facilities for segregation of patients. 
Other Special Shops; The operation of any special shops is 
dependent on the physical setup of the hospital. 
Setup for the Orthopedic Shop.—Activity in the orthopedic shop is 
coordinated with physical therapy and occupies a room close or adjacent 
to the physical therapy department. It is under the direct supervision 
of a medical officer, who heads both the physical therapy and the 
occupational therapy service. 
The plan of coordinated treatment is as follows: Physical therapy 
is prescribed as soon after the acute stage as possible; occupational 
therapy is added when active motion is indicated. This treatment is 
continued with increased grading of activity until the patient, having 
reached maximum hospital benefit, is discharged or transferred to a 63 
rehabilitation service. By this coordination of treatment, each depart- 
ment is able to handle a greater number of patients. Through such 
coordinated services more efficient total planning is possible for the 
patient. 
Equipment: The chief consideration in equipping an orthopedic 
shop is to have necessary equipment for graded activity in physical 
restoration. In general, such equipment would include (1) a complete 
supply of carpentry tools, for example, hammers and mallets of 
graduated weights; (2) a complete hand printing press outfit; (3) a 
bicycle jigsaw with orthopedic attachments; (4) work benches, tables 
and chairs of adjustable heights and sizes, and (5) other equipment 
according to needs of the patients. 
Setup for Open Ward Work.—The supply bases should be located 
at convenient intervals near the wards. When a patient becomes 
ambulatory, he is transferred from occupational therapy in the ward to 
the orthopedic or the psychiatric shop. 
Equipment: The equipment for work activity in the ward must of 
necessity be light in weight. The essential part of the equipment con- 
sists of overbed tables and frames that are adjustable to all positions 
and motions. 
Transportation of materials is facilitated by the use of converted 
surgical dressing carts. 
Setup for the Psychiatric Shop.—The psychiatric shop should be -a 
locked shop in a psychiatric ward, preferably in the convalescent unit. 
Groups of patients can be brought to this shop from other psychiatric 
wards. Individual work can be done in the wards whenever necessary. 
Purpose: Work in the psychiatric shop permits (1) stimulation or 
sedation of patients, depending on the prescription; (2) evaluation of 
patients through observation, and (3) maintenance of interest and 
reduction of restlessness of patients in a locked ward, as well as habit 
training, work adjustment and prevocational training. 
Precautions: The following precautions should be observed: 1. No 
patient is accepted for occupational therapy without a prescription and 
precautions signed by the psychiatric officer. 2. A trained corps man, 
or a specially selected one, must be in attendance at all times in the shop. 
Equipment: The equipment should consist of standard workshop 
tools and material which would provide for such activities as furniture 
repair, bookbinding, leather work, work in ceramics, painting and 
knotting and other equipment according to needs. 
Other Special Services.—In order to meet the special needs of 
tuberculous and other patients, special arrangements may be made as 
needed. 64 
VOLUNTEER ASSISTANTS IN OCCUPATIONAL THERAPY 
Volunteers may render valuable service and make it possible to 
extend the program of the occupational therapy department to include 
recreational and diversional activities for patients not needing the direct 
supervision of a medically trained worker. 
By regulation, all volunteer services within an Army general hospital 
are supplied by the Hospital Recreation Corps of the American Red 
Cross. Included in the training course given to volunteers is a program 
of diversional crafts which is operated under the supervision of the 
occupational therapy section. The value of diversional work should 
not be minimized. 
Supervision of Volunteer Service.—All volunteers doing ward 
crafts are directly under the supervision of the occupational therapy 
ward worker. 
Responsibility of the Trained Occupational Therapist: The therapist 
should (1) obtain approval from the ward surgeon before initiating 
diversional treatment, (2) transmit to the volunteer the necessary 
precautions and interpret the physical limitations in each case and (3) 
check each individual case and the form of diversion planned and aid 
in preparation before the volunteer goes to the ward. 
Responsibility of the Volunteer: The volunteer assistant should (1) 
clear every case first through the occupational therapist under whom 
she works, (2) review her list of patients and their activities each day 
with the occupational therapist in charge and (3) use her imagination 
and initiative in interesting the patients. EMERGENCY TREATMENT OF ACUTE 
WAR NEUROSES December 1943, Vol. 4, pp. 582-598 
Reprinted from War Medicine 
Copyright, 1944, by American Medical Association 
MANUAL OF EMERGENCY TREATMENT FOR 
ACUTE WAR NEUROSES 
LAWRENCE S. KUBIE, M.D 
NEW YORK 
Introduction 
TABLE OF CONTENTS 
Section I. The Acute War Neuroses 
Section II. Warning Signals of the Incipient Breakdown 
Section III. Preventive Therapy 
Section IV. Types of Acute Disturbance 
Section V. Emergency Measures After the Neurosis Is Established 
Step 1; Primary Treatment 
(a) Controlled Sleep 
(b) Physical Restoration 
(c) The Hold on Reality Through Companionship, Physical Contact, 
Games, Reading, Work and Talk 
Step 2 : Superficial Catharsis 
(a) Companionship in Isolation 
(b) “Gentling” 
(c) Catharsis 
(1) Release from Obsessive Waking “Nightmares” 
(2) Return to Sensations of Real Life 
(3) Release from Obsessive Feelings of Guilt 
(4) Relief of Rage 
Step 3: Prolonged Sleep Under Continuous Narcosis 
Step 4: Group Methods 
Step 5 : Deconditioning Procedures 
Step 6: Hypnonarcoanalysis and the Induced Hypnagogic Reverie 
Step 7 : Shock Treatment 
Most war neuroses begin as acute disturbances. Yet of the patients 
who have been in the care of the United States Veterans Bureau since 
the first World War, the majority are sufferers from chronic neuroses.1 
Adequate psychiatric treatment if administered promptly would have 
prevented the subsequent development of most of these chronic neurotic 
disabilities. Experience from the battle fronts of the present war 
indicates that from 70 to 80 per cent of acute neurotic battle casualties 
can be returned to active combat duty within a short time if they are 
treated at once. 
INTRODUCTION 
This is not true in every case, because in some men the stress of 
war precipitates a previously latent neurosis, which once established 
yields only to prolonged treatment. Precise statistics as to the percentage 
From the department of neurology, College of Physicians and Surgeons, 
Columbia University, and the Subcommittee on Psychiatry of the National Research 
Council, Washington, D. C. 
This paper constitutes a slightly expanded version of a chapter from the 
“Manual of Military Neuropsychiatry,” edited by H. C. Solomon and P. I. 
Yakovlev, to be published by W. B. Saunders Company. 
1. (a) Kardiner, A.: The Traumatic Neuroses of War, New York, Paul B. 
Hoeber, Inc., 1941. (b) MacCurdy, J. T.: War Neuroses, London, Cambridge 
University Press, 1918. 2 
of patients who can be saved by prompt care are not essential to the 
purposes of this manual, because, irrespective of such statistics, every- 
casualty should be given the benefit of prompt emergency care, in the 
hope that this may prevent subsequent chronic difficulties. 
Much of the emergency treatment of traumatic war neuroses, 
especially in the incipient phase, can be given by nonpsychiatric medical 
officers, by enlisted men of the medical corps, by line officers and by 
experienced noncommissioned officers. It should be administered as 
close to the front lines and as soon after the strain as possible. Even 
the more specialized forms of psychiatric treatment may be instituted 
close to the front line, although they can be completed only in the rear. 
The table of organization, therefore, should make adequate provision 
for mobile psychotherapeutic units which can be moved close to any 
area of active combat. At the same time, one must accept the fact 
that in modern warfare situations arise in which no treatment of any 
kind, medical, surgical or psychiatric, is possible. This occurs especially 
when for long periods isolated units fight in the face of heavy odds 
without any possibility of rest or replacement. The significance of this 
will become apparent in the subsequent pages. 
My colleagues and I must express our gratitude to the men of 
the Merchant Marine, and particularly to the men and officers of the 
National Maritime Union, for their cooperation in a study of the acute 
neuroses which arise in seamen of the Merchant Marine who have been 
subjected to bombing, torpedoing, shell fire, machine gunning and 
prolonged exposure in open boats. Any personal contributions to the 
principles of treatment described here rest largely on our study of this 
group of men.2 
For a survey of the literature, the interested reader is referred to 
Brown and Williams,3 Ebaugh and Johnson,4 Hoch,5 Kardiner,18 Miller,6 
Rees 7 and Salmon.8 
I. THE ACUTE WAR NEUROSES 
More frequently than is realized acute war neuroses develop grad- 
ually. Only in exceptional instances does a single overwhelming- 
catastrophe cause a breakdown with no preliminary warnings. The 
2. Margolin, S. G.; Kubie, L. S.; Kanzer, M., and Stone, L.: Acute Emotional 
Disturbances in Torpedoed Seamen of the Merchant Marine Who Are Continuing 
at Sea, War Med. 3:395-408 (April) 1943. 
3. Brown, M. W,, and Williams, F.: Neuropsychiatry and the War, New 
York, National Committee for Mental Hygiene, 1918. 
4. Ebaugh, F. G., and Johnson, G. S.; The Literature on Military Psychiatry 
Since 1938, Am. J. M. Sc. 201:905-918 (June) 1941. 
5. Hoch, A.: Recommendations for the Observation of Mental Disorders 
Incident to the War, Psychiatric Bull. 2:377-385 (July) 1917. 
6. Miller, E.: The Neuroses in War, New York, The Macmillan Company, 
1940. 
7. Rees, J. R.: Three Years of Military Psychiatry in the United Kingdom, 
Brit. M. J. 1:1-6 (Jan. 2) 1943. 
8. Salmon, T. W.; The Care and Treatment of Mental Diseases and War 
Neuroses (“Shell Shock”) in the British Army, New York, National Committee 
for Mental Hygiene, 1917; Recommendations for the Treatment of Mental and 
Nervous Diseases in the United States Army, Psvchiatric Bull. 2:355-376 (July) 
1917. 3 
rule is that collapse occurs only after cumulative stress. Paramount 
in this stress are the effects of fatigue and hunger, of incessant and 
increasing danger and of a series of repeated narrow escapes following 
one another in rapid succession. This was the story of Dunkirk and 
of every recorded experience in which men in large numbers have 
broken down suddenly. 
It takes time to recover from the effects of sudden danger. When 
the driver of an automobile has a narrow escape, he experiences a 
quick sequence of feelings: swiftly mounting tension which culminates 
in momentary terror, relief, elation, anger and sometimes tears. This 
is followed by a period in which he circles through these several 
emotions with lessening pace and intensity, until he finally settles on 
one, the choice of which depends chiefly on factors within the individual 
personality. After a variable time there will normally be a return 
to the emotional center of gravity of that particular person. 
But when one threat is followed at once by another, the disturbances 
become cumulative, because there is no interval in which the emotional 
reverberations can die out. Therefore ultimately a point is reached 
at which the compensating mechanisms break down and the sufferer 
becomes lost in a whirlpool of repetitive distress. Feelings, ideas and 
actions are drawn into this vortex, with the result that either directly 
or in some disguised form the patient spends his days and nights living 
as though he were engaged in an incessant struggle to escape from 
or master the original danger.1 
These cumulative experiences are typical of modern warfare and are 
a major cause of rapid breakdowns. When the moments of danger 
are more widely spaced, the same forces are operative, only more grad- 
ually and insidiously. The soldier with a “charmed life” knows that 
with every fresh escape his chances are less for the next. Consequently, 
each successive escape contributes to a secret mounting tension. 
At some point this becomes manifest. Usually the first sign is a 
specific disturbance of sleep, and it is precisely at this point that 
preventive measures can in many cases avert a breakdown if early 
warning signals are heeded. 
1. Sleep Disturbances and Nightmares.—The first warning of an 
incipient breakdown is usually a disturbance of sleep, which generally 
precedes changes in waking behavior.2 
II. WARNING SIGNALS OF THE INCIPIENT BREAKDOWN 
There is an increasing difficulty in falling asleep. Sleep comes 
slowly and with frequent sudden starts. These finally may make 
sleep impossible, or, after the subject has fallen asleep, similar starts 
may occur throughout the night. Again, during the process of waking 
gradually in the morning, the patient may leap from his bed and from 
the depths of sleep to stand wide awake in terror born of a preceding 
nightmare. 
The importance of this change cannot be overestimated. Darkness, 
immobility and quiet all lessen the hold on reality which activity provides. 
When the process of falling asleep is protracted and when sleep itself 4 
fluctuates fitfully, the sleeper is suspended in a half-sleeping, half-waking 
dream state (the so-called “spontaneous hypnagogic reverie”) in which 
reality is too remote to govern the processes of fantasy. Consequently, 
fantastic distortions occur as the mind automatically attempts to complete 
and thus to resolve the terrors and tragedies of the day. This produces 
terror dreams, in which the anxiety reaches such intensity that it 
wakens the dreamer, leaving him in a state of restless tension which 
may make it impossible for him to return to bed, much less to sleep, 
or even to remain alone. 
The more gradual the transition from waking to sleep (or back 
again from sleep to waking), the more opportunity there is for the 
occurrence of states in which relentless nightmares recapitulate the 
day’s experiences. Once this starts, it leads rapidly to fear of sleep 
itself and then to fear of the dark and lonely hours of the night. 
2. Daytime Startle States.—Once sleep is disturbed, fatigue increases 
rapidly, which gives rise to abstracted moments during the waking 
hours in which the patient lapses for an instant into a half-dissociated 
state. In such moments sudden movements, sudden noises or sudden 
lights cause a startled panic often accompanied by swift fragments of 
dreamlike imagery. As fatigue increases and as the moments of terror 
spread through the day, the patient becomes irritable and depressed 
and a sense of alienation from his comrades sets in. Thenceforth, fear, 
hate and loneliness gradually light up any latent neurosis which he 
may harbor. 
In an effort to struggle against this downward spiral, many men 
use alcohol. Unfortunately, however, alcohol is inadequate for this 
purpose. Unless taken to the point of profound intoxication, it tends 
to release and stimulate horror-born reveries instead of blotting them 
out. A more potent medicament than alcohol is needed. 
3. Other Warning Signals.—Many subtle changes in daily behavior 
may be noted as the inner tension mounts: e. g., an abstracted manner; 
a change in voice; changes in all the simple daily habits, of dress, 
expression, eating and drinking; tense and awkward movements; irri- 
tability ; seclusiveness; moroseness; erratic eating and drinking; incessant 
smoking, and excessive talkativeness or silence. These are hints which 
should lead to the institution of preventive measures, whether or not 
any change in sleep has been recognized. 
III. PREVENTIVE THERAPY 
So far as the soldier who succumbs to an acute combat neurosis 
is in some obscure way “weaker” than or different from his comrades, 
preventive measures would have to begin in the nursery or even earlier. 
So far as such patients are less whole hearted in their devotion to the 
cause for which they are fighting, prevention becomes a matter of 
morale, and everything that is conducive to high fighting morale should 
lessen the incidence of such disorders. 
However, since any man may break under sufficient stress, no matter 
how great are his inherent endowments and no matter how high his 5 
morale, prevention must depend ultimately on the recognition of incipient 
stages and on the steps which can be taken to stave them off. It is 
this which deserves to be called preventive therapy. 
From the military point of view both morale and preventive therapy 
are of utmost practical importance. Flowever, since this manual is 
addressed primarily to medical officers, who have little opportunity 
to influence the psychologic preparation of troops for combat, only 
the second issue will be considered. 
Three measures are of primary importance in the preventive therapy : 
First, since the most vulnerable moment in the incipient phase is the 
transition between waking and sleeping, it is vital to-make that transi- 
tion as nearly instantaneous as possible. Second, one should aim to 
secure a profound sleep of unvarying depth throughout the night. 
Third, it is important to bring the patient as swiftly as possible through 
the transition from deep sleep to full alertness. These measures reduce 
the disturbing influence of terror dreams and involuntary reveries. The 
steps involved are as follows: 
1. Officers and men should be taught that disturbances of sleep 
are important. They should be told to note if men are falling asleep 
slowly; if they complain of disturbing dreams and reveries while falling 
asleep; if they drop off only to waken with a start; if they waken 
repeatedly during the night; if they have recurrent dreams and night- 
mares; if they waken slowly and heavily in the morning, and, finally, 
if they have disturbing or fearful dreams or fantasies during the process 
of waking. 
2. At the first serious indication of any of these difficulties men 
should be given a combination of two sedatives, one which is absorbed 
rapidly and acts rapidly and another which is absorbed slowly and the 
action of which is sustained. For this purpose we have used a com- 
bination of sodium seconal and barbital or of a bromide and chloral 
hydrate. It is better to give too much than too little. Only if there 
is a possibility that the soldier may have to fight during the night should 
this medication be withheld or the dosage reduced. 
The dosages are as follows: 
Capsules to contain „ 
Gm. or Cc. 
Grains 
Sodium seconal 
0.097 
1^ 
Barbital 
0.324 
5 
One to three capsules to be taken on retiring 
Chloral hydrate .... 
or 
6 • 
100 
Sodium bromide .... 
6 
100 
Syrup of orange q.s. ad 100 3 ounces 
Use 1 to 3 teaspoons on retiring. 
3. In order to keep men anchored in reality as they doze off and 
again as they waken, where possible there should be a low light in the 
sleeping quarters throughout the night and a psychiatrically trained 
member of the medical corps in attendance. 
This is important because in the hypnagogic reveries which occur 
during the after-reaction to severe stress, early childhood fears of the 6 
dark and of being alone are reactivated. A dim light and the presence 
of an adult who is awake lessen these terrors. This simple precaution 
becomes of increased importance for patients whose disturbance goes 
beyond incipient manifestations. 
4. When the spontaneous return from sleep is slow and troubled, 
it is important to waken a man swiftly, by letting bright illumination 
into the sleeping quarters, by shaking him gently but firmly while talking 
to him and laughing with him and by giving him a cold drink or black 
coffee almost as his eyes open. Once he is awake, amphetamine sulfate 
(10 mg. or more) and sometimes thyroid to 1 grain [0.03 to 
0.06 Gm. ]) will help to bring him to a level of alertness which will 
protect him from drifting off into dreamy reveries in which the pressure 
of his anxieties can again become disturbing. The use of a stimulant 
as he wakens to balance the nocturnal sedative and to lessen momentary 
dissociated lapses is especially valuable in the prodromal phases. Once 
the full-fledged disturbance has arisen, such stimulants must be used 
with caution, although even here they can be of greater value than 
is realized. 
5. In the prodromal phase, whenever there is a respite from active 
combat, the day should be divided between planned activities and planned 
periods of rest. Silent rest periods, however, can themselves cause 
trouble, because of disturbing reveries. Therefore, during any period 
of relaxation, attention should be kept anchored and the men should 
be kept interested, amused and relaxed with music, singing, reading, 
radio and movies. All available forms of useful active work in groups 
should be interspersed with such periods of rest. 
Close to the front it may be impossible to take such precautions. 
Inexorable circumstances are rare, however, and an ingenious and 
determined medical officer, if he knows his men and realizes the necessity 
for such preventive measures, can save lives and breakdowns by 
insisting on short interludes from combat duty for men who are 
showing early signs of accumulating tension and by instituting preventive 
measures such as those mentioned. 
Acute war neuroses may take many forms, which vary greatly in 
severity. These can be grouped under the following categories, which 
are modified from Miller 6 and Kardiner la (Babinski and Froment,9 
Mitchell10 and Porter 11 have presented contrasting viewpoints which 
are of historical interest) : 
IV. TYPES OF ACUTE DISTURBANCES 
1. Simple exhaustion, from which the patient recovers promptly with 
sleep and food. 
9. Babinski, J. F. F., and Froment, J.: Hysteria or Pithiatism and Reflex 
Nervous Disorders in the Neurology of the War, London, University of London 
Press, 1918. 
10. Mitchell, S. W.; Morehouse, G. R., and Keen, W. W., Jr.; Reflex Paralysis, 
Circular no. 6, Surgeon General’s Office, March 10, 1884, Washington, Surgeon 
General’s Office, 1884. 
11. Porter, W. T.: Shock at the Front, Boston, Atlantic Monthly Press, 1918. 
Porter, W. C.; Novak, J. G., and Lemkau, P. V.: Therapeutic Considerations 
for Army Psychiatrists, Mil. Surgeon 92:372 (April) 1943. 7 
2. State of more severe exhaustion, with inability to rest or sleep. 
3. Overwhelming exhaustion, complicated by varying degrees of 
starvation, avitaminosis, dehydration and acidosis, with or without 
wounds, infection, fever, burns, concussion or blast injuries. 
4. Confusional states, varying from mild low grade disorientation, 
with rapidly alternating levels of clarity and confusion, to profound 
delirious reactions, with total disorientation, severe emotional distur- 
bances, hallucinations and stupor. 
5. Diffuse dissociated states: amnesias, fugues, somnambulistic wan- 
derings, trancelike “twilight states,” pseudoconvulsive states and states 
of immobility which may for a period resemble cataleptic and catatonic 
reactions. 
6. Localized dissociations: hysterical paralyses, hysterical spasticities, 
tics, tremors, ataxias, vertigo and hysterical sensory disturbances 
involving distance receptors, skin receptors or internal sensory functions. 
7. Acute anxiety states of widely varying severity. These may 
be (a) diffuse and continuous, (b) episodic or (c) “phobic,” in that 
they are precipitated only in certain special situations. 
8. Acute emotional eruptions which swing swiftly through the 
whole gamut of fear, rage, tears and elation. These may occur in a 
setting of confusion and delirium (category 4) or of transitory diffuse 
dissociations (category 5). 
9. Visceral disturbances. These may involve, for instance, (a) the 
heart, i. e., “soldier’s heart,” effort syndrome or neurocirculatory 
asthenia; (b) the respiratory system, with typical air-hunger and 
dyspnea; (c) the gastrointestinal system, with hysterical vomiting, 
any degree of dyspepsia, one of the ulcer syndromes or severe and 
debilitating diarrhea; (d) the genitourinary system. 
10. Acute psychotic and psychopathic disturbances; (a) profoundly 
retarded depressions; (b) hypomanic or manic excitements; (c) para- 
noid states, with or without megalomania, more or less systematized 
suspiciousness, explosive rages, and insubordination and rejection of all 
military regulation and commands; (d) schizoid trends, with seclusive- 
ness, ideas of reference, typical delusions and acute hallucinatory 
experiences. 
The most frequent disturbance is the simple state of acute anxiety, 
with hypersensitivity to sudden noise, motion or bright lights, aimless 
restlessness, diffuse emotional discharges and an inability to escape 
into sleep at night or to find rest or relaxation during waking hours. 
It is possible to describe the emergency care which is ideal for 
each of these conditions. In practice, however, what can be done 
will be determined more by the personnel available and by the exigencies 
of the local situation than by the severity or nature of the neurotic 
disturbance. Thus, a particular patient may need to be encouraged 
to blow off steam. Yet if a display of emotion will disturb other troops 
and if it is impossible to isolate him, his need will have to be sacrificed 
to the well-being of his companions. In treating any individual soldier, 
the possibilities of “emotional contagion” must constantly be borne in 8 
mind. This, again, demands a nice balance between protecting the 
group by the isolation of the disturbing individual and aiding the 
individual by companionship. Similar considerations apply to morale 
in the wards and to the handling of patients during the process of 
transfer. These will be discussed somewhat more fully in the section 
on “Methods of Group Treatment.” 
V. EMERGENCY MEASURES AFTER THE NEUROSIS 
IS ESTABLISHED 
For practical reasons the emergency measures after the neurosis is 
established divide into two major groups, according to whether or 
not frank psychotic trends are manifested early. Otherwise, the basic 
principles of emergency treatment are identical in the care of all. 
The psychotic casualty becomes accessible to treatment only after 
he has spent some time in the peace and security of the rear. Before 
he reaches this haven, however, and during the process of his evacua- 
tion, most of the emergency measures for the care of acute neurotic 
upsets can be used. As a matter of fact, in the turmoil and haste 
of the combat zone it is quite impossible to differentiate emergency 
measures to meet the precise requirements of different clinical syn- 
dromes. At the front there is no time for intensive investigation of 
individual cases, and, even if there were, different neuroses at their 
onsets may resemble one another closely. Therefore emergency psy- 
chiatric care must consist of measures which have a chance to be 
effective quickly in the majority of cases, irrespective of the finer 
clinical differences which may arise later. For clarity in presentation, 
these emergency measures will be described as a series of seven major 
steps, but these steps should be thought of both as overlapping and 
as taking place progressively from areas of active combat through 
every stage in the process of evacuation to rehabilitation hospitals. 
The first steps can be used at any point from the front lines back, 
wherever and whenever a few days of continuous contact with the 
patient is possible, whereas the later steps can be undertaken only in 
special hospitals. 
Despite the fact that this is primarily a manual of emergency care, 
the later steps are included because men with acute neuroses sometimes 
are evacuated promptly by plane, with the result that when the initial 
forms of treatment prove ineffective the more specialized later steps 
must be used as emergency measures to cut short malignant trends 
and to transform the condition into one which is accessible to simpler 
procedures. 
Step 1: Primary Treatment.—In the initial phases of illness the 
sufferer from an acute neurotic disturbance has three basic needs, and 
so far as conditions allow these needs should be met at once: 
(a) Controlled sleep. Everything which has been said concerning 
disturbances of sleep in the incipient phases applies equally to the 
developed traumatic neuroses. 9 
The same medications are indicated (page 586). 
The patient should be precipitated into sleep as swiftly as possible 
in a dimly lit room. 
He should sleep as deeply and evenly as possible throughout the 
night. 
When time comes for him to waken, he should waken or be 
awakened swiftly. 
As far as possible, he should not be permitted to be alone during 
any phase of sleep. 
Once awake, he should be kept alert with coffee, amphetamine 
sulfate, constant companionship, talk and useful vigorous activity. 
(b) Physical restoration. Physical restoration begins with use of 
a soft, readily assimilable diet of high caloric value, containing abundant 
fluids, salts and vitamins. The vitamin content of the diet should be 
supplemented with large doses of vitamin concentrates, to make sure 
that lowered thresholds of response are not complicated by the effects 
on nerve trunks and on calcium metabolism12 of a relative vitamin 
deficiency. 
(c) Hold on reality, through companionship, physical contact, games, 
reading, work and talk. When a break threatens, a sense of friendly 
solidarity with others is craved and needed, in order to displace the 
loneliness, fear and hate, the “kill or get killed’” of battle. So far as 
possible, therefore, a man who is in this state must not be left alone 
and should be given as much friendly companionship as he can use. 
He must be made to feel the presence of others through every physical 
sense—the sound of voices, the grip on the arm or shoulder and the 
easy rivalry of games. Reading aloud in a group is better than reading 
silently and alone. The same is true of music and singing, as well 
as of work. Patients should be detailed to chores in small groups— 
never to solitary tasks. 
This regimen alone, consistently applied, may dissipate a beginning 
illness. However, when a patient’s discomfort persists in spite of it, 
further special procedures become necessary. 
The methods discussed thus far depend on no psychiatric subtlety. 
To a large extent they can be administered by all medical officers, line 
officers, enlisted men of the medical services and experienced non- 
commissioned officers. Inevitably, however, as these simple common- 
sense procedures are carried out, among any group of casualties some 
will show more serious symptoms, the therapeutic handling of which 
requires a greater measure of psychiatric judgment. The method which 
becomes necessary at this point can be roughly characterized as one 
of “superficial catharsis.” 
Step 2: Superficial Catharsis.—Most emotionally disturbed patients 
try to hide their feelings. When this effort fails, one sees all degrees 
of anxiety, with shaking, shivering, chattering, starting, dashing away 
12. Sargant, W.: Physical Treatment of Acute War Neuroses, Brit. M. J. 2: 
574-576 (Nov. 14) 1942. 10 
to hide, sweating, vomiting, urinating and voiding of feces. The 
patient may become lost in depression with suicidal tendencies, or he 
may swing to wild and meaningless gaiety. More rarely, anger and a 
diffuse combativeness and truculence occur. Frequently there will 
be a rapid circling through the whole gamut of emotions. Either in 
the midst of these emotional outbursts or in the quieter interludes, 
there may be an uncontrollable need to talk obsessively and endlessly 
about home and family, about recent experiences, about the men who 
have been killed, about the conduct of officers, etc. Since human 
beings like to blame their troubles on superiors or on subordinates, 
pet hates and resentments will be heard frequently. The proper handling 
of such emotional outbursts can make a profound difference in the 
course of the illness. Wherever local conditions permit, therefore, 
the following procedures are recommended; 
(a) Companionship in isolation. The disturbed patient should be 
isolated from other patients so as not to communicate his upset to 
them. Some one should be assigned to him as a companion in his 
isolation. On this companion, then, will devolve the duty of handling 
the patient’s outbursts in as therapeutic a fashion as possible. 
(b) “Gentling.” Such a patient should never, under any'circum- 
stances, be shamed, reproved, intimidated or bullied. He should not 
be shouted down, argued with or corrected. Neither, on the other 
hand, should one assent to or acquiesce in unfounded and excited state- 
ments, in the hope that this will prove “soothing.” Quiet, serious, 
attentive listening, with a reassuring grip on arm or shoulder, and 
an occasional seemingly irrelevant suggestion that the man walk around, 
take a drink of water, eat something, smoke—these are the only 
responses which are safe at this point. This is because the conscious 
outpourings of the patient have only a dreamlike relationship to the 
underlying sources of his discontent, and to allow oneself to be drawn 
into an argument in the midst of such a disturbance is about as useful 
as to argue with a dreamer in the midst of his dream that the lion 
he is dreaming about is not there. On the other hand, silent, attentive, 
friendly listening, which sets no obstacle to the stream of thought and 
speech, plus a gradual diversion into simple activities can bring many 
patients back to contact with the immediate realities of their situation. 
(c) Catharsis: Moreover, in many instances the skilful listener 
can do more than this. 
(1) Release from the obsessive waking nightmares. There may 
be an insistent preoccupation with harrowing recent experiences. This 
may be expressed frankly in terms of battle situations, or it may be 
translated into the dangers of ordinary civilian life. For instance, a 
man who was rescued from a lifeboat after weeks of exposure had 
somnambulistic waking nightmares which dealt not with the sea, not 
with the torpedoing of his tanker, not with burning oil but with 
wholly imaginary fights on the edges of cliffs or at open windows in 
high buildings. Like a child who wakens from a nightmare only to 
remain in a daze of terror until comforted by his parents, the soldier 11 
needs some one who by his presence rather than by words gives 
him the secure feeling of reality which alone can penetrate his terrifying 
dreams and reveries. He must be made to feel the safety of his com- 
rades as well. He needs to be reminded of such simple facts as that 
men who have died are no longer suffering. In short, he needs to be 
helped to bring his incomplete dreamlike fantasies to a close, so that 
gradually he can regain his hold on reality. 
(2) Return to sensations of real life. This hold on reality must 
be strengthened by use of every sensory pathway. This is why there 
is comfort in a friendly touch, in the familiar sounds of camp and 
kitchen, of voices and words and tunes, in the familiar smells of cooking 
and in the taste of water and food. These familiar sensations are paths 
back to reality out of the nightmare and fog of battle, and companionship 
helps unobtrusively to supply these steadying experiences. 
(3) Release from obsessive feelings of guilt. Closely related to 
this is another recurrent theme that requires an understanding ear and 
an occasional appropriate word. This is the fantastic sense of guilt 
that haunts many survivors of terrifying experiences. A feeling of guilt 
over real mistakes is understandable, especially if these increased the 
danger or cost the lives of other men. More obstinate, however, is the 
feeling that to have survived at all was somehow at the expense of 
those who were lost. In his own eyes this patient is the murderer of 
his comrades. This feeling is particularly striking among survivors of 
catastrophes at sea, but it has also been noted regularly among sur- 
vivors of land and air combat which was not purely individual. 
Here again the patient’s feeling of guilt must be heard with respect, 
without assent and yet with no attempt to brush it aside or to laugh 
it off. Indeed, when a man is haunted by images of the sufferings of 
others yet cannot formulate for himself his feeling of responsibility, 
it will help him to have some one else put his groping feelings of guilt 
into words for him. Quietly and gently one can say: “You seem to 
feel as if you were responsible for their death. We often feel that 
way if we come through when others die. I know how you feel.” 
Simple words repeated quietly and patiently many times and provoking 
no argument about whether the man’s guilt is justified can gradually 
discharge much of this pent-up anguish. Such relief can ensue, however, 
only when the source of the guilt feelings lies predominantly in the 
present situation. Reassuring words will fall on deaf ears when such 
feelings have their origins in buried hatreds which are remote from 
the war situation and which have been relit by the recent combat 
experiences. When this is true, the therapeutic effort becomes only a 
diagnostic test and its failure indicates that a more profound neurotic 
problems remains to be dealt with and that the soldier should be invalided 
to the rear. 
(4) Relief of rage. There may be rage against officers, against 
fellow soldiers, or against subordinates. This may present difficult 
problems; but here again through an attitude of sympathetic and under- 
standing listening the man must be made to feel that he has a right 12 
to his feelings, whatever they are. This must precede any effort to 
correct a mood. Particularly when one is dealing with rage, it is 
important to listen with sympathy many times before risking a demurrer 
to the least of the patient’s charges. 
When applied by psychiatrically untrained personnel, superficial 
catharsis can legitimately attempt to go this far but no farther. When 
this succeeds, it provides an essential emotional and ideational relief. 
Such treatment remains deliberately superficial, but it is a necessary 
preliminary to any further release of feeling. Deeper levels of catharsis 
can be undertaken only by technically trained psychiatrists, working 
far from the scene of battle. When the ancient storehouse of infantile 
rage and terror has been mobilized by the war experience to such a 
degree that buried fantasies of injury and mutilation are set in motion, 
these can be relieved only by providing the patient with an opportunity 
to ventilate these historically old and symbolic meanings of current 
experiences. This should be attempted only by persons who have 
special training and experience in the technic requisite for such work 
(pages 593 to 597). 
Step 3: Prolonged Sleep Under Continuous Narcosis.13—There 
can be no question that the acute war neurosis can be greatly relieved 
if the patient can be made to sleep so deeply that at no point is his 
sleep interrupted by the intrusion of disturbing nightmares or obsessional 
horror reveries. If it is to be effective, however, such treatment cannot 
be halfhearted. The narcosis must be profound and must be sustained 
at least for several days, with all of the dangers which this entails. 
This may create serious nursing problems in the maintenance of nutrition, 
cleanliness and general physical well-being of the patient. Such nursing 
problems can be adequately met only in rehabilitation hospitals. It 
will be obvious that continuous narcosis cannot be employed in any 
situation in which the subjects may suddenly be called on to fight or 
where the mobility of modern war may necessitate their quick removal. 
Many different medicaments have been recommended and many 
combinations. It is not possible to choose among these, since no observer 
has reported comparative statistics, based on large numbers of'patients, 
on the relative merits of different medicaments. Among those recom- 
mended are the following; 
(1) Soneryl (n-butylethylbarbituric acid) in 6 grain (0.39 Gm.) 
suppositories, up to 20 grains (1.30 Gm.) per day. 
(2) Solution of somnifen (equal parts of diethylamine salt of 
diethylbarbituric acid and allylisopropylbarbituric acid) 2 cc. (0.19 Gm. 
13. (a) Bleckwenn, W. J.; Narcosis as Therapy in Neuropsychiatric Con- 
ditions, J. A. M. A. 95:1168-1171 (Oct. 18) 1930; (b) Production of Sleep and 
Rest in Psychotic Cases: A Preliminary Report, Arch. Neurol. & Psychiat. 24: 
365-372 (Aug.) 1930. (c) Miller,6 pp. 231 et seq. (d) Sargant, W., and Slater, 
E.; Acute War Neuroses, Lancet 2:1-2 (July 6) 1940. (d) Sargant.12 (e) 
Slater, E.; Sargant, W.; Debanham, G., and Hill, D.: Treatment of War Neurosis, 
Lancet 1:107-109 (Jan. 25) 1941. (/) Acute War Neuroses, editorial, New 
England J. Med. 223:431-433 (Sept. 12) 1940. 13 
of the drug per cubic centimeter) intramuscularly, up to 60 cc. per day; 
and supplemented with paraldehyde y2 fluidrachm (1.8 cc.) in capsules, 
repeated as often as needed. 
(3) Paraldehyde, 10 to 15 cc. with elixir of orange and cracked 
ice by mouth as required or in olive oil per rectum. 
(4) “Twilight sleep”: scopolamine hydrobromide, %50 to %0o grain 
(0.4 to 0.6 mg.) with % to y grain (0.01 to 0.015 Gm.) of morphine 
sulfate, to be repeated within one and one-half to three hours). 
(5) Hyoscine, %50 grain (0.4 mg.) with phenobarbital, \y2 grains 
(0.1 Gm.) intramuscularly each four hours (Mira). 
(6) Sodium amytal, 3 to 6 grains (0.2 to 0.4 Gm.) intravenously 
each four hours. 
(7) Barbital sodium, 10 grains (0.61 Gm.) by mouth, each three 
to four hours. 
(8) Phenobarbital sodium, J/2 to 2 grains (0.03 to 0.12 Gm.), by 
mouth, each three to four hours. 
Whatever the drug or combination of drugs, the aim should be 
to achieve at least twenty hours of sleep out of each twenty-four during 
the period of treatment. It should be possible to rouse the patient to 
eat four full meals each day, with adequate administration of fluid and 
adequate elimination. 
At the end of the period of continuous sleep the medication should 
be reduced gradually, with a gradual return to full 'activity. 
In the event of collapse, 1.5 to 3 cc. of a 25 per cent solution of 
nikethamide (pyridine-3-betacarboxylic acid) should be given intra- 
venously as an antidote to any of the barbiturates and as a respiratory 
stimulant. Coffee, amphetamine and intravenous injections of dextrose 
or plasma may also be necessary on occasion. Respiratory stimulation 
by inhalation of mixtures of oxygen in carbon dioxide may also be 
helpful, in emergencies. 
Step 4: Group Methods.—When many fall ill, methods of treatment 
for large groups are inevitably sought.14 The methods used include 
group lectures, exhortation through speeches, placards and illustrated 
posters, repeated playing of specially prepared phonograph records,15 
group hypnosis and a more or less systematic mutual analysis by 
members of the group.16 
The present state of knowledge with respect to group psychotherapy 
has been admirably reviewed recently by Thomas,17 with an excellent 
14. Blair, D.: Group Psychotherapy for War Neuroses, Lancet 1:204-205 
(Feb. 13) 1943. Jones, M.: Group Psychotherapy, Brit. M. J. 2:276-278 (Sept. 5) 
1942. 
15. Snowden, E. N.: Mass Psychotherapy, Lancet 2:769-770 (Dec. 21) 1940. 
Miller,6 p. 146. 
16. Schilder, P.: The Analysis of Ideologies as a Psychotherapeutic Method, 
Especially in Group Treatment, Am. J. Psychiat. 93:601-617 (Nov.) 1936; Results 
and Problems of Group Psychotherapy in Severe Neuroses, Ment. Hyg. 23:87-98 
(Jan.) 1939. Wender, L.: Group Psychotherapy: Study of Its Application, 
Psychiatric Quart. 14:708-718 (Oct.) 1940. 
17. Thomas, G.: Group Psychotherapy: A Review of the Recent Literature, 
Psychosom. Med. 5:166-180 (April) 1943. 14 
introduction to the literature. No detailed reports are available on the 
application of this principle to the acute war neuroses. It is a reasonable 
avenue of approach to explore further. 
Group methods, however, include more than formal instruction of 
the patients concerning the nature of their problems and of their neuroses. 
It includes everything which influences the morale of a ward. It implies 
the watchful eye on the disturbing or disgruntled patient and his in- 
fluence on others. It includes direct and open handling of the shame of 
being afraid. During the process of transferring troops, and especially 
of evacuating them to the rear, it involves the protection of these casual- 
ties against the sense of shame which grows in them as they leave the 
battle zone for the security of the base and begin to realize that they are 
being invalided out of the fight without a visible wound. At this point, if 
they are herded together and set apart as a group of suspects, their 
morale deteriorates rapidly, and within a few weeks what began as a 
curable acute neurosis may become a rigid, well defended chronic struc- 
ture. Therefore, during transfer of patients only those should be handled 
as a group apart who are relatively unaware of their surroundings or 
who are disturbing to others. Those who can maintain a fairly smooth 
front should be handled along with all other casualties, and their morale 
can often be improved by setting them to work assisting in the transfer 
of persons who carry the more visible scars of battle. 
Step 5: Deconditioning Procedures.—The principle of decondition- 
ing has long been recognized in the experimental laboratory. Its most 
recent demonstration is in the brilliant work of Masserman.18 Its prac- 
tical feasibility and therapeutic value in the treatment of acute war 
neuroses has yet to be fully demonstrated. 
Preventive deconditioning is already being used in the training of 
troops for special operations through exposure to “live bullets,” shrapnel- 
free land mines and the like. It would seem reasonable to expect that if 
men in training are led repeatedly through situations which mimic closely 
the sights, sounds and smells of actual battle it may be possible to de- 
sensitize them to the stress which lies ahead. Similarly, once men have 
broken under that stress, it would seem reasonable to suppose that 
similar procedures could break down the links between these sights and 
smells and sounds and the superimposed terror-states and thus return 
the soldier to his desensitized condition. 
An extensive trial of deconditioning procedures is being conducted 
in the southern Pacific by Commander Uno Helgesson (MC), U.S.N.R., 
in what is called the “Battle Noise School.” Men who have broken 
under the stress of battle and who show acute hypersensitivity to noise 
are carried gradually through situations in which in trenches, dugouts 
and foxholes they are subjected to mock strafing, land mine explosions 
and simulated dive bombing attacks, with complete protection from any 
possibility of physical injury. The results of these important experiments 
are not yet available; but the preliminary impression of observers is that 
18. Masserman, J. H.: Behavior and Neuroses: An Experimental Psycho- 
analytic Approach to Psychobiologic Principles, Chicago, University of Chicago 
Press, 1943. 15 
this will prove to be a valuable method if and when it is applied promptly. 
It may be curative in many cases, and at the same time it may serve to 
weed out patients in whom the neurotic roots go deeper than the recent 
combat experience. 
Step 6: Hypnonarcoanalysis and the Induced Hypnagogic Reverie. 
—Even prior to World War I it was known that in certain types of 
mental and emotional disturbances the recovery of the patient depended 
at least in part on the recovery of forgotten memories. Hypnotism had 
been used for that purpose in the treatment of multiple personalities and 
of hysterical amnesias. The psychoanalytic technic of free association and 
interpretation had been used to penetrate to vital information covered 
by the amnesias that arise in infancy and early childhood. States of 
hypnagogic reverie had been used for this purpose, sporadically and with- 
out systematic investigation, by Silberer,19 of Vienna, by Boris Sidis,20 
of New York and Boston, and by Rorschach.21 
During the first World War, psychiatrists were confronted with large 
numbers of acute neuroses induced by experiences which were partly 
covered by amnesia. Efforts were made to penetrate this amnesia by 
bringing together in various ways hypnotic technics, psychoanalytic 
technics and the hypnagogic reverie. Among the contributors in this 
field were notably Hadfield 22 and Eder 23 in England and Simmel24 in 
Berlin. Many others made significant contributions (see Miller 6 for a 
bibliography). Under the exigencies of war, however, methods had to 
be improvised rapidly, and from existing reports it is not easy to com- 
pare the various approaches used and their relative efficacy in meeting 
identical or different clinical problems. It is all the more unfortunate 
that in the decades that have intervened since World War I the possi- 
bilities of this fusion of methods were not systematically explored until 
the last few years. 
Nevertheless, the work which has been done justifies a few conclu- 
sions : 
(a) That a skilful and experienced hypnotist can in time induce 
states of hypnotic dissociation, with somnambulistic and regressive phe- 
nomena, in a larger proportion of subjects than was formerly realized.25 
19. Silberer, H.: Berichte (iber eine Methode, gewisse symbolische Halluzina- 
tions-Erscheinungen hervorzurufen und zu beobachten, Jahrb. f. psychoanal. u. 
psychopath. Forsch. 1:513-525, 1909. 
20. Sidis, B.: An Experimental Study of Sleep, J. Abnorm. Psychol. 3:1-32, 
63-96, 170-207, 1908-1909; An Experimental Study of Sleep, Boston, R. G. Badger, 
1909. 
21. Rorschach, H.: Assoziationsexperiment, freies Assoziieren und Hypnose im 
Dienst der Hebung einer Amnesic, Cor.-Bl. f. schweiz. Aertze 47:898-905 (July 14) 
1917. 
22. Hadfield, J. A.: (a) War Neurosis, Brit. M. J. 1:320-323 (March 7) 1942; 
(b) Treatment by Suggestion and Hypno-Analysis, in E. Miller,6 chap. 7, pp. 128- 
149. 
23. Eder, M. D.: War Shock: The Psychoneuroses in War Psychology and 
Treatment, London, William Heinemann, Ltd., 1917, p. 154. 
24. Simmel, E.: Psychoanalysis and the War Neuroses, London, International 
Psychoanalytic Press, 1921, p. 59. 
25. (a) Kubie, L. S., and Margolin, S. G.: The Process of Hypnotism and the 
Nature of the Hypnotic State, Am. J. Psychiat., to be published. (b) Hadfield.226 16 
(b) That a wide variety of sedative drugs can be used to render ac- 
cessible to hypnotism an additional percentage of subjects who cannot 
otherwise be hypnotized.26 
(c) That the induction of hypnotic phenomena in patients under 
sedation can be done rapidly and by technics sufficiently simple to be 
learned readily.27 
(d) That the hypnotic state can be used most profitably not as the 
basis for direct suggestions in an effort to force symptoms to disappear 
but as a technic for the exploration of unconscious historical material, 
both remote and recent, which bears on the illness.28 
(e) That the recovery of amnestic material under hypnosis can be 
achieved through the use of free associations and states of hypnagogic 
reverie. In some cases it proves helpful to supplement this with 
automatic drawing and automatic writing and a controlled regression 
to earlier age periods. No generalizations are possible as yet as to the 
frequency with which these technical adjuvants are needed or the type 
of case in which they are necessary. 
(f) In many instances the hypnagogic reverie alone, without the 
production of a full hypnotic state, suffices to recover the important 
amnestic material.29 
(g) The hypnagogic reverie can be induced (a) by simple suggestion 
of total relaxation,30 (b) by simple suggestions plus the rise of sedative 
drugs, (c) by rhythmic, monotonous auditory stimuli,31 such as a 
metronome or bell,20 or by use of amplified breath sounds.29a,b 
(h) The amnestic material which is recovered by various 
devices will sometimes be direct and accurate recollections of recent 
traumatic personal experiences; but on other occasions the data will 
be subjected to fantastic and dreamlike elaborations and to condensa- 
tion with material from early years. These productions are quite as 
valuable as the simpler historical information, but in the unraveling of 
such data technical experience with interpretation of dreams is essential. 
26. (a) Hypnotics in Psychotherapy, editorial, Brit. M. J. 1:865-866 (May 25) 
1940. (6) Hadfield.22b 
27. Gill, M. M., and Brenman, M.; Treatment of a Case of Anxiety Hysteria 
by an Hypnotic Technique, Employing Psychoanalytic Principles, Bull. Menninger 
Clin. 7:163-171 (Sept.) 1943. 
28. Sargant.13d Slater.13® Footnote 13 f. 
29. (a) Kubie, L. S., and Margolin, S. G.: A Physiological Method for the 
Induction of States of Partial Sleep, and for Securing Free Associations and Early 
Memories in Such States, Tr. Am. Neurol. A. 68:136-139, 1942; (b) An Apparatus 
for the Use of Breath Sounds as a Hypnagogic Stimulus, Am. J. Psychiat, 
to be published; (c) footnote 25 a. (d) Kubie, L. S.: The Use of Induced 
Hypnagogic Reveries in the Recovery of Repressed Amnesic Data, Bull. Menninger 
Clin. 7:172-182 (Sept.) 1943. 
30. Jacobson, E.: Progressive Relaxation, ed. 2, Chicago, University of Chicago 
Press, 1942. 
31. Lovell, G. S., and Morgan, J. J. B.: Physiological and Motor Responses to 
a Regularly Recurring Sound: A Study in Monotony, J. Exper. Psychol. 30:435- 
451 (June) 1942. 17 
(f) Finally, whatever the method used, whether it is hypnosis alone, 
hypnosis under narcosis or hypnagogic reveries with or without narcosis, 
the recovered material must be fully fused with its appropriate emotional 
content and with normal waking consciousness. This is achieved by 
carrying the patient through the procedure not merely once but several 
times within the course of a fortnight, by reworking the same material 
with the patient as he emerges from the hypnoid or hypnagogic state, 
by discussing the material with him freely at subsequent interviews 
and by having the patient associate freely to the material in undis- 
turbed states of consciousness during the intervals between the hypnoid 
or hypnagogic sessions. 
These various procedures for the exploration of unconscious proc- 
esses are at present the chief weapon on which psychiatrists rely in 
their treatment of the acute war neuroses. They have various purposes; 
(1) to allow the subject to express feelings which he may be dimly 
aware of yet afraid to express; (2) to allow the subject to become 
aware of feelings which he may have buried so completely as to be 
totally unaware of them but which may nonetheless disturb him; 
(3) to allow the subject to express these deeply buried and uncon- 
scious feelings; (4) most important, to penetrate into the amnesic areas 
of the subject’s psychologic processes in order, in a sense, to arouse 
and “waken” that aspect of the personality and those mechanisms of 
control which were rendered inaccessible by the traumatic experiences. 
A list of medications which have been recommended by various 
workers in this field follows: 
1. Sodium amytal,82 3 grains (0.18 Gm.) by mouth every three 
to four hours. 
2. Sodium amytal, dissolved in distilled water, administered intra- 
venously at the rate of 1 grain (0.06 Gm.) per minute, the total not 
to exceed 7y2 grains (0.48 Gm.). 
3. Sodium amytal, given intravenously as in 2, followed at half- 
hour intervals by amphetamine sulfate, 10 mg. intravenously, to a 
total not to exceed 30 mg. 
32. Bleckwenn, W. J.: The Use of Sodium Amytal in Catatonia, A. Research 
Nerv. & Ment. Dis., Proc. 10:224-229, 1931. Harris, M. M., and Katz, S. E.: The 
Effect of the Administration of Sodium Amytal and Sodium Rhodonate on Mental 
Patients, Am. J. Psychiat. 12:1065-1083 (March) 1933. Herman, M.: The Use 
of Intravenous Sodium Amytal in Psychogenic Amnesic States, Psychiatric Quart. 
12:738-742 (Oct.) 1938. Horsley, J. S.: Narco-Analysis, Lancet 1:55-56 (Jan. 4) 
1936. Lindemann, E.: The Psychopathological Effects of Sodium Amytal, Proc. 
Soc. Exper. Biol. & Med. 28:864-866 (June) 1931; Psychological Changes in 
Normal and Abnormal Individuals Under the Influence of Sodium Amytal, Am. J. 
Psychiat. 11:1083-1091 (May) 1932. Lindemann, E., and Malamud, W.: Experi- 
mental Analysis of the Psychopathological Effects of Intoxicating Drugs, ibid. 
13:853-881 (Jan.) 1934. Lindemann, E., and Finesinger, J. E.: The Effect of 
Adrenalin and Mecholyl in States of Anxiety in Psychoneurotic Patients, ibid. 
95:353-370 (Sept.) 1938. Palmer, H. D., and Braceland, F. J.: Six Years’ 
Experience with Narcosis Therapy in Psychiatry, ibid. 94:37-57 (July) 1937. 
Sullivan, D. J.: Psychiatric Uses of Intravenous Sodium Amytal, ibid. 99:411- 
418 (Nov.) 1942. Footnote 26 a. 18 
4. Simultaneous intravenous injections of 0.2 to 1.0 Gm. of sodium 
amytal and 10 to 30 mg. of amphetamine sulfate. 
5. Pentobarbital sodium in 2.5 per cent solution injected intra- 
venously at the rate of 1 cc. per minute. 
7. Pentothal sodium, 0.25 to 0.4 grains (0.015 to 0.026 Gm.) 
intravenously slowly.34 
6. Evipal sodium, j/2 grain (0.03 Gm.) by mouth.33 
8. Delvinal sodium (sodium 5-ethyl-5- [1 -methyl- 1-butemyl] bar- 
biturate) narcosis, plus 10 to 20 mg. of amphetamine sulfate intra- 
venously. 
9. Scopolamine hydrobromide, %00 to y150 grain (0.6 mg.) with 
% to grain (0.01 to 0.015 Gm.) of morphine sulfate, not to be 
repeated within one and a half hours for the smaller doses or within 
three hours for the larger doses. 
The use of narcotics in this fashion is contraindicated for any 
debilitated patient and for any patient suffering from severe cardio- 
respiratory involvement or hepatic disease. 
As an antidote, 1.5 to 3.0 cc. of a 25 per cent solution of nikethamide 
intravenously is recommended. 
As to procedure, in general, with all methods of intravenous admin- 
istration of the barbiturates it is advisable to dilute the drug in a larger 
volume of distilled water than that provided in the ampule which is 
supplied with the drug. During the process of solution most of these 
drugs are somewhat unstable. Therefore they should be shaken gently 
and injected promptly. The outer limit for the stability of the solution 
is usually set at about thirty minutes. Naturally, no preparation should 
be injected if any precipitate remains undissolved. 
The injection should be made extremely slowly. Some authors 
recommend that the patient be asked to count slowly during the injection, 
the injection being stopped at the point at which the counting first 
shows incoherence and an attempt made to hold the patient at this 
level by interrupting the injection and adding more as needed. Efforts 
to maintain rapport should precede the injection and should continue 
during the injection and throughout the phase of narcosis. 
Other workers recommend putting the subject soundly to sleep 
and then attempting to establish rapport with him only as he is waking 
from this sleep. 
No fixed rules can be laid down in this matter, but the former method 
seems to me to have definite advantages. 
33. Campbell, A. M. G.: Sodium Evipan as an Aid to Psychotherapy, Guy’s 
Hosp. Rep. 88:185-198 (April) 1938. Stungo, E.; Psychological Investigation 
by Means of Evipan Sodium, M. Press 197:382-386 (Oct. 26) 1938; Evipan 
Hypnosis in Psychiatric Outpatients, Lancet 1:507-509 (April 19) 1941. 
34. Wilde, J. F.: Narco-Analysis in the Treatment of War Neuroses, Brit. 
M. J. 2:4-7 (July 4) 1942. Hadfield.22 19 
Step 7: Shock Treatment.—It may seem inappropriate to consider 
any form of shock treatment as an emergency measure in the manage- 
ment of the acute traumatic war neuroses. Let it be said at once, 
therefore, that the value of shock treatment has yet to be demonstrated 
conclusively and that its field of application is probably limited. Never- 
theless, there is at least one theoretic reason for including this method 
in this discussion, and there are at least a few situations in which 
it may be a method of choice. 
The theoretic basis lies in the fact that many of the phenomena of 
the acute war neuroses appear to be acute states of partial dissociation, 
which precipitate the patient into a waking nightmare from which he 
cannot be roused. Such persons may be inaccessible to any contact, 
even under narcosis, but can sometimes be brought into rapport either 
by inducing sustained periods of hypoglycemia35 without coma or 
convulsions or by one or two electric shock treatments. If these 
methods are to be used at all, they should be used as soon as the state 
is recognized and before it has established itself as chronic.36 
This is not the place for a discussion of the technic of shock treat- 
ments. They should be administered only by persons who are familiar 
with them.37 A few general considerations should be borne in mind. 
(a) Of the various forms of shock treatment, that employing 
metrazol would seem to be least appropriate for this particular purpose. 
It would seem inhuman and of doubtful therapeutic value to subject 
a patient whose illness has resulted from the accumulation of undis- 
charged terror to the extremity of fear and apprehension which gen- 
erally occurs between the injection of the metrazol and the onset of 
the convulsion. Furthermore, the psychomotor restlessness and excite- 
ment which usually follow the convulsion may last for hours and may 
be complicated by severe vomiting, cardiac complications and fractures. 
Even though some of these disadvantages can be partially controlled 
by the use of curare 38 and various sedative drugs,39 the procedure is 
never freed of its subjective terror by anything less than a general 
anesthesia,40 and the method creates complex nursing problems which 
seriously limit its usefulness in military neuropsychiatry, except per- 
haps in rehabilitation hospitals. 
35. (a) Bennett, C. R., and Miller, T. K.: Observation on Treatment of Mental 
Cases with Sub-Shock Doses of Insulin, Am. J. Psychiat. 96:961-966 (Jan.) 1940. 
(b) Robinson, G. W., Jr.: Treatment of Delirium Tremens with Insulin in Sub- 
shock Doses, ibid. 97:136-151 (July) 1940. 
36. Good, R.: Convulsion Therapy in War Psychoneurotics, J. Ment. Sc. 87: 
409-418 (July) 1941. 
37. Jessner, L., and Ryan, V. G.: Shock Treatment in Psychiatry: A Manual, 
New York, Grune & Stratton, Inc., 1941. 
38. Bennett, A. E.: Curare: A Preventive of Traumatic Complications in 
Convulsive Shock Therapy, Am. J. Psychiat. 97:1040-1060 (March) 1941. 
39. Harris, M. M.; Horwitz, W. A., and Milch, E. A.: Regarding Sodium 
Amytal as a Prognostic Aid in Insulin and Metrazol Shock Therapy of Mental 
Patients (Dementia Praecox), Am. J. Psychiat. 96:327-353 (Sept) 1939. 
40. Neustatter, W. L., and Freeman, H.: Prevention of Fear in Cardiazol 
Therapy by Preliminary Anesthesia with Cyclopropane or with Nitrous Oxide, 
Lancet 2:1071-1072 (Nov. 18) 1939. 20 
(h) Insulin shock is a more flexible device 41 and offers certain 
advantages as well as certain disadvantages. Grave disadvantages are 
the facts that it is a slow process, that it too is followed by a prolonged 
hyperreactive phase and that it needs much supervision. On the other 
hand, the severity of the reaction can be controlled at any moment, and 
it is possible to induce prolonged states of hypoglycemia with coma 42 
but without convulsion,35b during which a patient may become accessible 
and in which significant memories can sometimes be recovered.43 From 
this point of view it is worth further investigation, even if because of 
practical military exigencies it is not the optimal method of producing 
the convulsive shock itself. 
(c) Electric shock would seem to have many significant practical 
advantages,44 although its therapeutic efficacy in these situations remains 
undetermined. It is reasonable to raise the question whether the 
retrograde amnesia so often induced by electric shock may interfere 
with its therapeutic value and contribute to an elaboration and extension 
of the amnesic problem of the traumatic neurosis itself. This can be 
determined only by experience.45 
Electric convulsive therapy is usually produced by an alternating 
current. The faradic shock method described by Berkwitz46 would 
have certain practical advantages near the front, since the source of 
energy need be only a 6 volt dry cell battery. Furthermore, it is a 
less drastic form of shock treatment in that no convulsion is induced. 
Its therapeutic value remains to be demonstrated. 
41. Polatin, P.; Spotnitz, H., and Wiesel, B.: Ambulatory Insulin Treatment 
of Mental Disorders, New York State J. Med. 40:843-848 (June 1) 1940. 
42. Cleckley, H., and Templeton, C. M.: Prolonged Coma in Insulin Therapy 
of the Psychoses, Am. J. Psychiat. 97:844-857 (Jan.) 1941. 
43. Bychowski, G.: Psychoanalyse im hypoglykamischen Zustand, Internat. 
Ztschr. f. Psychoanal. 23:540-547, 1937. 
44. Strauss, E. B., and Macphail, A.: Treatment of Outpatients by Electrical 
Convulsant Therapy with Portable Apparatus, Brit. M. J. 2:779-782 (Dec. 7) 
1940. 
45. Polatin, P.; Strauss, H., and Altman, L. L.: Transient Organic Mental 
Reactions During Shock Therapy of the Psychoses: A Clinical Study with Electro- 
encephalographic and Psychological Performance Correlates, Psychiatric Quart. 
14:457-465 (July) 1940. 
46. Berkwitz, N. J.: Faradic Shock Treatment of “Functional” Psychoses: 
Preliminary Report, Journal-Lancet 59:351-355 (Aug.) 1939; Faradic Shock in 
Treatment of Functional Mental Disorders: Treatment by Excitation Followed by 
Intravenous Use of Barbiturates, Arch. Neurol. & Psychiat. 44:760-775 (Oct.) 1940. 
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