War Surgery and Medicine
CHAPTER 24 — Occupational Therapy
The use of organised occupational therapy was almost entirely confined to mental hospital practice until the First World War, when its value came to be recognised in the treatment and rehabilitation of patients. Occupational therapy then came to be firmly established as a valuable form of therapy for sick and injured patients. For sick or nervous cases it involves treatment by mental or physical occupation, under the encouragement and direction of a trained observer, to hasten recovery and improve the mental state. It aims to divert the mind from anxieties and morbid fears, to improve effort and attention, and to awaken interest. For the wounded it aims at the restoration of impaired function of muscles, nerves, and joints to fit a patient to resume his normal activities. It endeavours to provide a progressive programme of mental, physical, and social activity according to the needs and capabilities of each patient. By achievement confidence is restored and recovery and rehabilitation hastened.
Diversional or prophylactic occupational therapy aims at diverting attention from a physical or nervous disability and directing interest towards some prescribed activity. Remedial therapy has these attributes also, but in addition is directed towards the restoration of a special function.
The type and range of part-time occupation useful in a base military hospital is considerable. Although no occupational therapists were posted to the staff of hospitals of 2 NZEF as such, each hospital soon developed an important department with talented rather than trained staff working under interested medical officers.
The first occupational therapy department was established at 2 General Hospital at Helwan in November 1940, and was promoted by Colonel F. M. Spencer and Major J. E. Caughey, both enthusiasts who made a notable contribution to 2 NZEF in this connection. The staff establishment did not allow for the posting of occupational therapists, but a call was made for voluntary workers from the civilian population, and this met with a ready response from American, Swiss, and English women, mostly from Maadi. There were up to twelve of them at different times, and one of them lent much equipment free of charge. Only a few had previous page 738 training, but all gave much time and devoted attention to the work in the hospital. They also aided the occupational therapy department financially. There was an initial grant of £10 from Red Cross funds, but thereafter the department became almost entirely self-supporting.
The work soon produced results. A large building at Helwan hospital was made available for a ‘workshop’ for walking patients, while many others were provided with diversional therapy at their beds.
By 1942 each hospital had an established occupational therapy department, operating under an NCO. With the arrival of the NZ WAAC (Medical Division) at the beginning of 1942 it was possible to expand the staffs of these departments by employing the nurses, some of whom displayed a particular aptitude for the work. On the hospital ships, too, this valuable work was developed. Materials were made available by the British Red Cross Society, and by the New Zealand Red Cross Society through its Commissioner in 2 NZEF. The Convalescent Depot made much use of occupational therapy of the more active type.
Occupational therapy thus came into its own. Having no official place at the beginning of the war, it came to be regarded as indispensable for the treatment and recovery of patients long before the end of the war, and some remarkable work was accomplished. The work expanded to such an extent that at 2 General Hospital in Italy at one stage there were four on the staff with an average of 280 patients a month, of whom 60 per cent were bed patients.
A review by Lieutenant-Colonel Caughey of the ambulatory patients who passed through the occupational therapy department at 2 General Hospital over two three-monthly periods indicated the class of patients who received therapy. During the period May to August 1941, 233 patients received treatment—14 psychotic, 50 psychoneurotic, 14 men with cerebral contusions, 45 orthopaedic cases, 110 general medical and surgical cases. Between October 1942 and January 1943, 174 patients attended for treatment—4 psychotic, 60 psychoneurotic, 54 orthopaedic, and 56 general medical and surgical cases.
In both series the largest group treated was made up of psychoneurotic patients, which included those with anxiety neurosis and hysteria. For these the treatment was both diversional and remedial. Some worked in the general occupational therapy room, but as far as possible they were set to work at carpentry or some outdoor occupation such as landscape gardening. From this group were drawn patients to assist in various departments of the page 739 hospital—engineer's shop, carpenter's shop, electrician's department, laboratory, linen store, pack store, clothing store, hospital library, canteen, etc. It was found that progress was usually good. The cases of anxiety neurosis and hysteria were set to work on various tasks as soon as they arrived in hospital, and, as far as possible, a programme was arranged for a full day's activity. Each morning a physical training class was held in the gymnasium under the direction of a patient.
For the psychotic group, occupation was invaluable as a form of therapy, the type of occupation being determined according to the mental state of the patient—in the excitable patient, a sedative type of occupation was most suited. If the restlessness was great, some plain painting was suitable work, or, for the less excitable type, tapestry or leather work was chosen. For those who were depressed, weaving or tapestry with bright elaborate designs helped to fix the attention and to bring about a change in the emotional tone. Concentration on close colourful work helped to divert the mind from depressive thoughts and anxieties. For the schizophrenic who was preoccupied with delusions and hallucinations, some occupation requiring close attention and concentration helped keep the mind in touch with reality.
With many cases of head injury with persistent cerebral contusion there occurred a superadded nervous factor which developed during the period of convalescence. To avoid this, it became the accepted practice to use occupational therapy as a prophylactic measure. Bed work was commenced soon after the initial shock had passed. Weaving or other simple activity was suitable, and this was continued until the patient was allowed up, when some light outdoor occupation could be commenced. With these cases in the early stages close detailed work, such as tapestry, or noisy work, such as carpentry, often induced headache and was best avoided until the tendency disappeared. Work which entailed postural changes, such as stooping, was best avoided on account of the sense of dizziness which so often followed.
Apart from acute illness with fever, toxaemia and marked debility, there were few contra-indications to diversional activities of some kind for a patient confined to bed. For those soldiers confined to bed for prolonged periods it was found that weaving, tapestry, and leatherwork were the most suitable occupations. Small hand looms were quite conveniently operated in bed and were valuable both as diversional and remedial activity.
Orthopaedic patients confined to bed for long periods in plaster required diversional activities, and in many cases remedial work was invaluable. Hand and wrist cases were helped by some activity page 740 such as weaving, tapestry, or painting. Lower-limb cases could be helped by a treadle fretsaw.
General medical and surgical cases required diversional activities while in bed, and active work to help them through the long periods of convalescence. Those with arthritis could have valuable remedial work for joints crippled by swelling and restricted movements. Occupation could prove invaluable for chronic dyspepsia, cardiac cases, and those with chronic pulmonary disease.
The general effect of well-organised occupational therapy within a hospital ward was impressive. Patients who had been dissatisfied and discontented became less irritable and contented, but to attain this it was essential that medical officers, sisters, nurses, and orderlies should play their part by co-operating with the occupational therapist in taking an active interest in the various activities of the patients.
Occupational therapy as a planned attempt, under skilled direction, to restore or improve in health, usefulness, and happiness those who were suffering from an injury, or who were recovering from sickness, more than proved its worth.
J. E. Caughey New Zealand Medical Journal, October 1943.