May I say a word at this point in regard to our large state sanatoria It is the policy in many to appoint one trained occupational therapeutist to organize and direct occupations, and at the same time to do the greater part of the teaching, assisted only by patients who have had little training, if any. If occupational therapy is to be of real value in these institutions, it is important that the director who is made responsible for this department should be given trained teachers to assist her as soon as she has secured equipment and materials to work with. Valuable helpers among the patients will develop in the course of time, but it is not in the best interests of the service to rely upon such assistance until the work is well established. Any patients who show promise of becoming teachers should be encouraged and given every opportunity for training. Some few here and there will prove capable of excellent work.

Occupational therapy calls for the very best trained teachers. The graduates of short courses who were admitted to the army service in such numbers were found to be insufficiently trained in most cases. This, fortunately, is now recognized and a longer and more thorough preparation is being required. The sick appreciate the skilled worker as quickly as anyone, and respond with satisfaction to a good teacher who knows the technique of the craft she teaches. Personality is, of course, of great importance, but in emphasizing this we have rather lost sight of the need for thorough technical knowledge.

Some crafts can be taught at the bedside, but it is more beneficial for the patients who are able to be up to go to workrooms specially provided for this purpose. These rooms should be light, sunny, and well ventilated, and warm in winter time. Let them be as pleasant and attractive as possible. A dreary basement room may have a depressing effect upon some patients that will counteract all the best efforts of a teacher. The subtle influence of a wellplanned room, pleasing in color and decoration, is something we cannot measure, but we know its importance. The equipment needs to be adequate and conveniently arranged, and the tools and materials must be good and carefully selected.

An effort is being made to improve the quality of the products of invalid occupations. The work is still so comparatively new in most sanatoria, that conditions favorable for its best development have not yet been provided. Occupational directors and teachers labor under such heavy difficulties that they cannot maintain high standards. They have too little time to prepare good designs and models, and in many cases lack the natural ability this requires, although they may be excellent teachers. We hope some day to have a designer with each group who will devote all her time to this side of the work. To get the best results from a curative standpoint, the things made should be good in form and color and design. Work badly planned and poorly executed reacts unfavorably upon the patient. Dr.

Hall, of Marblehead, has recently opened an experiment station to help us with this problem. A group of expert designers and craftsmen, "unhampered by the demands of teaching, will test materials and work out ideas and suggestions for hospital occupations." Collections of photographs and drawings, and loan exhibits of artistic handwork from the shops of master craftsmen, would help greatly in maintaining standards.

Which of the crafts should we choose for tuberculous patients? I believe that almost any of them may be taught with safety, provided the work is done under careful medical supervision, and by graded exercise. For bed patients, one would select something simple, which could be picked up for a few minutes at a time. We devise various shapes of cardboard looms, so light that the feeblest hands can hold them, on which are woven attractive bags of raffia, cotton, silk, or wool. Several types of bedside looms can be obtained to-day for the weaving of ties, belts, bags, table-runners, and such things. Some patients enjoy bead work, but it should not be given to any who are nervous. Knitting, crocheting, and tatting appeal to many. We use a variety of materials, from fine cotton for laces to a soft, thick roving for crocheting rugs. Men and boys like to make knotted string bags, belts, hammocks, and nets. They make the simple tools necessary for this work. Weaving reed baskets wins the interest of more patients than any other craft. Men, women, and children enjoy it. The results come quickly and are useful. If the teaching is good, it is one of the most restful of occupations. Many different things can be made-flower holders, trays and baskets of all sizes and shapes, and table lamps, or tall ones for the floor. Raffia and pine-needle basketry, and chair caning also are good. Tooled and cut leather work has almost unlimited possibilities for purses, billfolds, hand bags, belts, mats, book covers, and other useful articles. Toy-making affords an immense amount of fun, and quickens originality. Mr. Thatcher, of New York, has introduced the making of clever toys from old tin cans. If they are well designed and carefully made they are very much superior to most of the toys that can be bought to-day. Two of my patients are busy at present making kites. Others have made models for aeroplanes.

Weaving rugs, bookbinding, cabinet work, framemaking, carving, modelling, cement work and pottery, metal work and jewelry-these crafts offer an endless variety of interest. All are suitable for our purpose, if good judgment is shown in choosing the particular work that will best meet the needs of each patient. many of them as possible should be used in every sanatorium, but it is advisable to begin with one or two and add others as conditions are favorable.

As

There are many sanatoria too small to afford an occupational teacher. Nor must we forget the great number of tuberculous patients who (Continued on page 238)

Occupational therapy, or the use of occupation as a therapeutic measure, is not of recent origin, its value being recognized in the time of Galen, who said, "Employment is Nature's physician." It is, however, only of recent years that this form of therapy has developed to the point of general and successful applicability to the sanatorium treatment of persons ill with tuberculosis.

Of the four fundamental principles of curetaking rest, fresh air, proper food and graduated exercise-occupation is directly associated with the factors, rest and graduated exercise, and indirectly with the factor, proper food, through its influence upon digestion.

In the presence of active tuberculosis, rest is absolutely essential to successful treatment. It is the all-important element in the conservation of the patient's vitality and reserve force. The degree of rest possible to secure will depend upon the extent to which muscular activity may be minimized and mental contentment promoted. To meet the first requirement we have but to put the patient to bed; to meet the second is far more difficult, for it has to do with the psychic element of the man himself.

Mental contentment is not usually associated with mental inactivity. There are indeed few individuals who can truthfully answer, as did the fisherman on the dock when asked how he occupied himself when the fish were not biting. He replied, "I sit and think, but most of the time I just sit." Patients undergoing sanatorium treatment think, and the protracted period of cure-taking gives much time for thought. Just what those thoughts may be exert a profound influence upon the outcome of sanatorium treatment. Unfortunately, in many cases, undirected or misdirected thought results in disaster Introspection, exaggeration of the importance of personal ills and troubles, worry over financial difficulties, over home responsibilities, the uncertainty of the future, etc., are all examples of a mental state opposed to rest and a serious drain upon the vitality of the patient. It is in this type of case that the correct application of occupational therapy acts as a sedative to the entire nervous system, quieting the mind perturbed through worry and anxiety, lessening temperature and pulse rate, quieting the respiration, and thus promoting rest, the first and most important fundamental in the treatment of active tuberculosis.

A paper presented before the Nursing Section, Sixteenth Annual Meeting of the National Tuberculosis Association, St. Louis, April 24, 1920.

For the ambulant case, occupational therapy, with its endless variety of suitable occupations, proves ideal for the administration of graduated exercise. It is here that much care and skill is applied in the selection and dosage. The occupation must meet both the temperamental and physical requirements of the individual case, and the dosage medically prescribed, with exactness. Willing cooperation is the watchword of success rather than compulsion.

Indirectly suitable occupation favorably affects nutrition, through the preservation of a normal mental state. It is a well-known fact that excitement, anger, worry and despair destroy the appetite and inhibit digestion.

Aside from its therapeutic value, occupation possesses social and economic values scarcely less important. A Teuton proverb has it that "Idleness is the parent of all vice and evil," and a noted churchman once said. "The devil seeks the unemployed first of all." Certain it is that useful occupation increases self-respect and self-reliance, and fosters and preserves an inclination to labor and self-support.

Muirdale Sanatorium, at Wauwatosa, Wisconsin, has, since its opening in 1915, included Occupation in the daily program of cure-taking. We look upon this department at the present time not only as indispensable from a therapeutic standpoint, but also indispensable to the morale and discipline of the institution. Believing that the best therapeutic results cannot be obtained when financial profit to either invidual or institution is emphasized in its administration, occupation has been "put up" to the patient as a privilege rather than a duty, and a denial of rights to the workshops is considered a punishment. Our experience would seem to indicate that the success of occupational therapy in the sanatorium treatment of tuberculosis depends in the main upon the same factors that accompany the administration of any other therapeutic measure. It must be prescribed by the physician to meet the indications, administered in acceptable form and correct dosage, and carefully and intelligently supervised. If this is done we are firm in the conviction that occupational therapy is invaluable not only as an adjunct to the treatment of tuberculosis, but also as a means of returning to society a really better and more useful citizen.

We have at Muirdale an institution of 375 beds, and a section set aside for workshops. This section comprises eight or ten well-venti(Continued on page 238)

N the twenty-fourth of February, 1897, a scientist by the name of Dubard found a tumor in a carp that had been caught in a fish hatchery at Velars-sur-Ouche. He took the tumor for further study to Professor Bataillon; and, the following May eighth, Bataillon and Dubard, in association with a third investigator, M. Terre, told the Biological Society a story which initiated one of the most remarkable episodes in the history of tuberculosis.

They reported that the tumor, about the size of a pigeon's egg, had been situated in the fish's abdomen, and that it was not characteristically tuberculous, when viewed either with the naked eye or with the microscope. In one or two respects, however, it did suggest tubercle for instance, it contained giant cells; and, when properly stained, these giant cells exhibited numerous acid-fast bacteria* that looked exactly like tubercle bacilli.

The authors had cultivated these bacilli and had found their biological characteristics to be somewhat different from those of real tubercle bacilli. The carp bacilli grew more rapidly than the latter on the standard media. They also grew at temperatures which were entirely unfavorable to the development of tubercle bacilli. At ordinary room temperature they flourished best. Nevertheless, with great care they could be trained to grow slowly at the temperature of the body; and, as this happened, they then took on certain properties that were more peculiar to human tubercle bacilli.

Such was the gist of the first communication on the carp bacillus; in diseased tissue in a fish, diseased tissue which may or may not have been tuberculous, though the authors inclined to the opinion that it was, there were bacteria which had all the appearances and peculiar staining properties of real tubercle bacilli; and, although these bacteria had habits of growth that tubercle bacilli do not possess, they could be made to take on the cultural characteristics of the latter.

Now this was not the first time that acidfast bacilli had been seen in disease in lower animal forms than man, cattle, swine, hens, etc. In 1889 Sibley, working in Recklinghausen's laboratory in Strassburg, described having observed bacteria, which in every respect resembled human tubercle bacilli, in several tumors that he had found in a snake, a ringadder. Several years later Sibley reported

*See May, 1918, Essay.

similar observations which he had made on diseased tissue from a python. Meanwhile Shirley and Gibbs (1890) in a short contribution had mentioned detecting acid-fast bacilli in lesions in the livers of several pythons and boas. Sibley, as well as Shirley and Gibbs, were convinced that they had come across cases of tuberculosis in snakes and that the disease had been set up by tubercle bacilli. Shirley and Gibbs even hazarded the opinion that the snakes had become infected by feeding on material from tuberculous birds.

But Bataillon, Dubard and Terre were the first to isolate and cultivate acid-fast bacilli from diseased cold-blooded animals. And as soon as their work became known there opened up an unusually promising vista of new and fundamental studies to be made on the nature and prevention of tuberculosis.

More than one eminent authority had indulged in speculation concerning the genesis and evolution of tuberculosis throughout the world. By 1890 it was generally known that a variety of animal species became infected with tubercle, that the causative agent of infection was a very low form of vegetable parasite which had such unusual and peculiar properties as to put it in a class by itself, and that at least two types of this parasite-human tubercle bacilli and avian tubercle bacilli-were in existence. It was also taught that human tuberculosis, a disease as old as recorded history, was unknown among men who lived a nomadic life, and that we first become familiar with it after man has advanced a step in civilizationamong pastoral peoples who live in close association with their herds and flocks. Though too late to prove the inference by direct scientific observation, was it wholly improbable that man first acquired tuberculosis by contact with his cattle?

But if cattle tuberculosis antedated that of man, from what source did cattle first receive the infection? It must have been from still lower forms of life or through the medium of microorganisms which existed free in natureon plants, for instance, commonly used by cattle for food. Who could affirm that acidfast bacilli did not, either at some far anterior time or perhaps even at the present, exist widely distributed throughout the vegetable world? And, even though they were incapable of bringing about progressive tuberculosis in animals, could it not be possible that, if such bacteria really had being, they might enter the bodies of animals, remain and perhaps slowly develop there; and, by long-continued resi

dence in the animal body, gradually undergo such changes that they would be converted from non-pathogenic to disease-producing forms? Once pathogenicity, parasitism, were acquired the cycle of infection would take care of itself, as bacteria were passed on from animal to animal by contact.

And now Dubard's carp bacillus, apparently tubercle bacilli from what were apparently tuberculous masses in fish, had come; to forge one more link in the evolutionary chain of the most widespread of all infections and to give point and plausibility to speculations such as we have just set down.

But a still more remarkable discovery was hard at hand. Even before the existence of the carp bacillus had become common knowledge, the finding of acid-fast bacilli, free in nature and dissociated from animals, was announced.

Alfred Moeller is the man who had gone about the work of examining plants for tubercle bacilli or tubercle-like bacilli. He was a physician attached to the pioneer tuberculosis sanatorium, Brehmer's in Goerbersdorf; and in 1898 he reported having isolated acid-fast bacilli from several plants, but particularly from timothy grass. These acid-fast bacilli were not real and fully developed tubercle bacilli. They would grow much more rapidly than the latter. They would also develop well on media incubated at lower temperatures than that of the body. But, what was very suggestive and apparently ranked them closer than Dubard's bacilli to tubercle bacilli, was that like the latter they were also easily cultivated at body temperature, when they grew even more luxuriantly than tubercle bacilli.

But would they produce disease? Not in the sense that tubercle bacilli brought about lesion; that is, a very few timothy bacilli, inoculated into guinea pigs, would not originate a progressive cycle of lesions that led in time to an animal's death, a cycle which a few tubercle bacilli always initiated. Moeller had, however, tested the pathogenicity of the timothy bacilli, and reported that very large doses of the first culture from the grass, when inoculated into the abdomen of a guinea pig, brought about the typical lesions of tuberculosis which caused the death of the animal in from six to eight weeks. After the microorganisms had been cultivated for several generations on glycerin broth or glycerin agar, they were no longer pathogenic for laboratory animals. In Moeller's opinion, the timothy bacillus was to be looked upon as an acid-fast form, related to the tubercle bacillus, but of much less pathogenicity than the latter and, under natural conditions, harmless for man and the higher animals. The next year (1899) Moeller announced that he had found another type of acid-fast bacillus on timothy grass, a form which resembled his first timothy bacillus very closely, yet which had certain characteristics of its own, enough to stamp it with individuality and as a distinct variety. This new form he called timothy or grass bacillus II. Both types, I and II, he viewed as essentially non

pathogenic (that is, non non-disease-producing) acid-fast bacilli.

Here, then, was the entire evolutionary chain completed. Acid-fast bacilli did commonly occur in nature, on plants, grasses and vegetables. They looked exactly like tubercle bacilli and stained like them. They did not produce disease in the same way: yet, lacking further evidence, nothing could be more plausible than to imagine that, taken in with food by cattle, in some instances and for some unknown reason, they gained a foothold in these animals. Prolonged residence in the animal body had gradually brought about certain changes in their habits. They slowly lost their ability to grow at ordinary temperatures, so much so that at last the temperature of the animal body was strictly necessary to their development. Finally, as they had become evolved or transmuted into what we know as tubercle bacilli, they acquired parasitism; and attachment to animal tissues became necessary to their characteristic development to such an extent that, outside of the body, their cultivation had become a matter of great difficulty. After this had happened, tuberculosis of cattle was at last established: and with tuberculosis of cattle a fact, it was not difficult to assume how tuberculosis of man originated.

But how did tuberculosis arise in Dubard's carp? And whence came his bacilli?

In 1898 Dubard set forth further details of his story and gave his explanation. He said that in 1895, his father, while investigating the subject of artificial fertilization, cleaned out his tanks and put in eight carp which were left in a large brook. Here the carp passed a year with rainbow trout, but in the autumn of 1896 it was noticed that certain carp appeared sick. Their sides were sunken, their color darker and their abdomen distended. In all, six carp seemed to be affected, although, several years before, this same reservoir contained carp in good health and none had ever fallen ill before.

But it was discovered that a relative with pulmonary and intestinal tuberculosis had been accustomed to empty sputum and dejecta in this part of the brook. The spot where this happened was a little inlet where the lack of current attracted the fish. There was no doubt in Dubard's mind that the human tuberculous products had been ingested by the fish, and that several carp had thereby become infected. His carp bacilli, therefore, had originally been human tubercle bacilli, changed somewhat because of their sojourn in coldblooded tissues. Contrary to the evolutionary process of timothy bacilli to human tubercle bacilli, a change which represented an ascending devolopment, a more highly specialized differentiation from a lower form, Dubard conceived of his bacilli as having undergone a reversion to type. The transmutation in the carp was the opposite of evolution. Away from the warm-blooded animal and because of an adaptation to the bodies of the coldblooded fish, the bacilli had regained old habits of growth at low temperatures and a more luxuriant development.

A very few years later (1902-1903) medical annals recorded another startling discovery. F. F. Friedmann told of finding spontaneous tuberculosis in the lungs of two marine turtles that had died in the Berlin Aquarium. In one there was "tuberculosis of the entire right lung with large cavities"; in the other, "tuberculosis of both lungs with innumerable miliary tubercles and large caseous masses." In both were perfectly acid-fast bacilli which in size, form and arrangement could not be distinguished from human tubercle bacilli. The bacilli were not identical, in Friedmann's opinion, with Dubard's carp bacilli. He had cultivated them, and found them very close to human tubercle bacilli; yet, because of having resided in the turtles, changed in several important particulars from real bacilli. To use his words, they were "real, only wonderfully weakened tubercle bacilli" (echte, nur wundersam mitigierte Tuberkelbazillen). Whence did they originate? From an attendant who fed the turtles and who was suffering from a tuberculosis of both lungs. Here again the discoverer believed that he was in possession of acid-fast bacilli-of tubercle bacilli which, because of having resided in the coldblooded animal body had undergone changes which amounted to partial reversion to original type.

In 1904 Rupprecht brought forward still another form of acid-fast bacillus, isolated from a cold-blooded animal. In a frog he found what he interpreted as real tubercles and in these tubercles were acid-fast bacilli of much less marked acid-fastness than were Dubard's and Friedmann's bacilli. He, therefore, considered them a distinct variety.

There thus grew up a separate group of acidfast bacilli, made up of Dubard's carp bacillus, Friedmann's turtle bacillus, Rupprecht's frog bacillus and the several snake bacilli which were never isolated; and this group was variously called the cold-blooded tubercle bacilli or the pseudotubercle bacilli. The enormous amount of work that has been done on these, the numerous speculations and theories this work has engendered, the high hopes that it has aroused and the bitter disappointments that later investigations brought in their train, are all part of the tuberculosis story of the last quarter century, and will be touched upon in later sections of this essay.

Meanwhile, acid-fast bacilli were being found in other materials and places. As soon as the tubercle bacillus was discovered and the methods of detecting it in infected material became common knowledge, there naturally arose tremendous eagerness to bring together all the etiological evidence that was possible. The first most obvious and easiest thing to discover was where tubercle bacilli commonly occurred; for, thirty years ago, where tubercle bacilli lurked spelled where disease originated. Hands, lips, nostrils, beef, pork, mutton, eggs, milk, butter, cheese and the greatest variety of articles, all came under bacteriological examination. And at the time bacteriological examination meant for the most

part merely the microscopic inspection of a stained smear or section or swab of the suspected material; for, since, with one or two exceptions, tubercle bacilli were the only acidfast bacilli known, the detection of the latter was practically proof positive evidence of the presence of the former.

It became so common to find acid-fast bacilli, interpreted usually as tubercle bacilli, in butter, that, by the advice of public health authorities, butter as an article of diet bade fair soon to be taboo. But in the fruitful year of 1897, two observers, working independently of each other, reported finding in butter acid-fast bacilli which were not tubercle bacilli.

Petri was the first to announce the occurrence of non-pathogenic acid-fast bacilli in butter,-tubercle-like bacilli, growing rapidly at low temperatures and bringing about only minimal lesions when inoculated in large doses into guinea pigs; but the work of Lydia Rabinowitsch was the more complete and therefore the more convincing. Lydia Rabinowitsch had been a pupil of Koch and had also been connected with the Women's Medical College of Philadelphia. She examined 80 samples of butter obtained in the markets of Philadelphia and Berlin. In them she found no real tubercle bacilli, but in 28 per cent of the specimens she did discover acid-fast bacilli which were of questionable pathogenicity for guinea pigs and of none whatever for rabbits and white mice.

A number of other investigators reported similar observations later; and, besides the butter bacilli of Petri and of Rabinowitsch, the literature came to record those of Korn (two varieties) of Coggi, of Markl, of Binot, and of Maria Tobler (varieties I, II, III, IV and V of Tobler).

Moreover, in searching for acid-fast bacilli Alfred Moeller did not confine his attention to plants and grasses. In 1897 he isolated nonpathogenic forms from the dung of cattle and called this microorganism the Mist (dung) bacillus; and those familiar with the literature recalled that in 1892 Garth had seen similar acid-fast bacilli in cattle dung, while in 1895 Severin had observed the same forms in the dung of horses. Moeller also isolated nonpathogenic acid-fast bacilli from milk, a demonstration which pointed out that, before milk could be definitely proved to be tuberculous, something more than the mere detection of fuchsin-retaining rods in smears was necessary: animal inoculation must also be performed.

It thus became plain that, besides tubercle bacilli, we must also reckon with a number of practically harmless acid-fast bacilli which were widely distributed in nature. These fell roughly into three main groups: (1) those occurring free in nature, like the two types of timothy bacilli, isolated and described by Moeller; (2) those occurring in association with healthy animals, particularly cattle, like the dung bacillus, the milk bacillus and the several butter bacilli; and (3) those of the cold-blooded animals.