without iron. Of the actophosphatis 2 to 4 .c.), representing from the lime salt may be ee times daily. Of the tophosphatis cum ferro ay be given, each fluid gone grain of the ferabout one-fourth of the This medication was well-known fact that are among the workers , and that in the few they are tuberculous, f the rarest occurrence. ot that the ingestion or ne salts produces a tenready calcification of These salts given in h phosphates and iron ave a tonic effect and walls of the blood ves chotherapy. vill be more expedient cate institution for the treatment of the arOng our tuberculous solr this should be done in prium where the arrest as been obtained, must wisdom of the Surgeon staff. I'ersonally, I beecial institution would ble on account of the ect which the change the patient, but whatties may decide on this Emly convinced of the of the post-sanatorium tlined in the preceding are to say that on his life the one-time tuber thoroughly rehabilisoldier or sailor will be to the community. His t-sanatorium, and voca of the rehabilitation of the tuberculous soldier, Lieut. Col. E. H. Bruns* emphasizes the value of vocational training as a means to heighten the morale of the sanatorium patient. Massage, hydrotherapy, heliotherapy, and respiratory exercises as described will, by their stimulating and tonic effects, materially aid in bringing about mental as well as a physical improvement. I have frequently heard comments by medical officers, who had either honored me by listening to my lecture or had read it, to the effect that in their dealings with tuberculous soldiers they had encountered a considerable unwillingness to remain any length of time in the military hospitals. I can fully appreciate the difficulty of holding under restraint an arrested or nearly arrested case in a young man who has been away from home already for months or years. Infinite tact and diplomacy, the kindliest treatment, and persuasion, by holding before the soldier the danger of a relapse in tuberculosis, will be necessary to retain the homesick boy in the hospital. This is a particularly difficult task for the medical officer in charge because the patient cannot realize why, if he has attained an arrest of the disease, he should remain longer in the hospital or sanatorium. It is for this reason that I suggest special institutions for postsanatorium treatment to prevent relapses. The promotion from the sanatorium, where the patient has been sent when he was sick, to the post-sanatorium, preferably in a difierent locality, will have a wonderful psychological effect. The patient will see in his removal to the institution for post-sanatorium treatment an assurance of ultimate complete recovery, and the change *Bruns, E. H.: "Reconstruction and Rehabilitation of the Tuberculous Soldier." Journal A. M. A., 71:373 (August 3) 1918. 16 than the soluble lime prepara Psychotherapy. Whether it will be more e to have a separate institution post-sanatorium treatment of rested cases among our tubercu diers, or whether this should be the same sanatorium where th of the disease has been obtain be left to the wisdom of the General and his staff. I'ersona lieve that a special institutio be more desirable on accoun psychologic effect which the would have on the patient, t ever the authorities may deci point, I am firmly convince beneficial effect of the post-sa treatment as outlined in the pages. I venture to say th= return to civil life the one-ti culous, but now thoroughly tated, American soldier or sail indeed an asset to the commu sanatorium, post-sanatorium, without iron. Of the actophosphatis 2 to 4 .c.), representing from the lime salt may be ee times daily. Of the tophosphatis cum ferro ay be given, each fluid gone grain of the ferabout one-fourth of the This medication was well-known fact that are among the workers , and that in the few they are tuberculous, f the rarest occurrence. t that the ingestion or e salts produces a tenready calcification of These salts given in h phosphates and iron ave a tonic effect and valls of the blood ves chotherapy. ill be more expedient ate institution for the treatment of the arng our tuberculous sol- this should be done in prium where the arrest as been obtained, must visdom of the Surgeon staff. I'ersonally, I beecial institution would ole on account of the ect which the change the patient, but whatties may decide on this mly convinced of the of the post-sanatorium tlined in the preceding re to say that on his Life the one-time tuber thoroughly rehabilisoldier or sailor will be to the community. His -sanatorium, and voca of the rehabilitation of the tuberculous soldier, Lieut.-Col. E. H. Bruns* emphasizes the value of vocational training as a means to heighten the morale of the sanatorium patient. Massage, hydrotherapy, heliotherapy, and respiratory exercises as described will, by their stimulating and tonic effects, materially aid in bringing about mental as well as a physical improvement. I have frequently heard comments by medical officers, who had either honored me by listening to my lecture or had read it, to the effect that in their dealings with tuberculous soldiers they had encountered a considerable unwillingness to remain any length of time in the military hospitals. I can fully appreciate the difficulty of holding under restraint an arrested or nearly arrested case in a young man who has been away from home already for months or years. Infinite tact and diplomacy, the kindliest treatment, and persuasion, by holding before the soldier the danger of a relapse in tuberculosis, will be necessary to retain the homesick boy in the hospital. This is a particularly difficult task for the medical officer in charge because the patient cannot realize why, if he has attained an arrest of the disease, he should remain longer in the hospital or sanatorium. It is for this reason that I suggest special institutions for postsanatorium treatment to prevent relapses. The promotion from the sanatorium, where the patient has been sent when he was sick, to the post-sanatorium, preferably in a difierent locality, will have a wonderful psychological effect. The patient will see in his removal to the institution for post-sanatorium treatment an assurance of ultimate complete recovery, and the change *Bruns, E. H.: "Reconstruction and Rehabilitation of the Tuberculous Soldier." Journal A. M. A., 71:373 (August 3) 1918. from one institution to the other will be an important psychological factor in making him more willing to remain under medical supervision and guidance. Psychotherapy must always be considered part of the treatment of the tuberculous, no matter in what stage of the disease. Occupation therapy and vocational training as an aid to psychotherapy should begin while the patient with relative little activity, is still in bed. When by careful watching it is shown that light work for the hands, such as knitting, drawing, making bead, raffia, or reed work, or intellectual training, stenography, typewriting, etc., does not increase the temperature, these occupations will direct the thoughts of the patient from himself, which is always a great advantage. Even the arrested case needs to have his morale kept up and be constantly encouraged, and if he does not get the right attitude toward life, in which quite a number of the recovered tuberculous, both soldiers and civilians, fail, he must be taught this proper attitude. While still under sanatorium or post-sanatorium care the minds of the inmates must not have an opportunity to brood, and this can only be avoided by judicious occupation such as will be conducive to the individual's well-being. There must be a sufficient amount of work, rest, enjoyment, and the right kind of intellectual and spiritual pursuits to assure contentment. The true phthisiotherapeutist must also be a psychotherapeutist-a physician of the mind and soul as well as of the body. Choice of Occupation. When all of the measures just described-massotherapy, hydrotherapy, respiratory therapy, helio- and psychotherapy and the indicated medication have been applied for a number of weeks and the patient is considered as safe against any relapse as the physician's skill and his own personal train a ing and care can make him, there remains the necessity of selecting an occupation and environments for him that will tend to increase his chance of remaining well. This is a problem in itself and all I can say here is that in a general way the more the individuals who have passed through post-sanatorium treatment can be occupied outdoors, the less danger will there be of any renewal of the disease. At the same time we must bear in mind that there will be many who are neither temperamentally disposed nor physically fit to do agricultural or horticultural work, to raise chickens, drive trucks, become chauffeurs or outdoor salesmen, or be ticket choppers on elevated railroads. For those who have had the necessary training and are willing to occupy such or similar positions, which will assure outdoor life and at the same time enable them to make comfortable living, nothing better could be selected. But there will be many men who, prior to entering the Army, had been successful in pursuing trades or professions which demanded indoor life, for which they had been prepared by training and study and in which they made a very comfortable living. Such would wish, if at all possible, to return to their former occupations, and I am inclined to believe this can be done safely in many instances, provided the indoor office or workshop is sanitarily constructed and well ventilated, and the individual lives the most hygienic life possible at home. It is especially important for him to sleep in a well ventilated room with the windows wide open. Whenever it is possible, he should sleep outdoors on the porch, in a tent placed on the roof, in the garden or yard. For those living in city apartments or tenement houses, I would suggest the installation of the indoor window-tent, which I was privileged to devise for poor consumptives who had to be taken care of at home. *The simple window-tent is particularly useful in winter. It consists of an awning which, instead of being placed outside the window, is attached on the inside of the room, covering the head end of the bed, which is placed close to the window. The air from the room cannot enter or mix with the air in the tent. The person lying in the bed, which is placed parallel with the window, has his head and shoulders resting in the tent. The lower portion of the body, being indoors, is consequently warmer (Fig. 17). By following the description, it will be seen that the ventilation is as nearly perfect as can be produced with so simple a device. The tent is attached to the frame of an American window, without quite filling the lower half. A space of about 2 inches is left for the escape of the warm air in the room (Fig. 18). By lowering the window, this space can be reduced to 1 inch or less, according to the need. On extremely cold and windy nights there need not be left any open space at all above the tent frame. The patient's breath will rise to the top of the tent, the form of which aids in the ventilation. The tent is constructed of a series of four frames, made of steel rod suitably formed and furnished with hinged terminals; the hinges operate on a stout hinge pin at each end with circular washers interposed to insure independent and easy action in folding the same; the rod makes a stiff, rigid frame and insures its maintaining the original form. The frame is covered with thick yachtsail twill, fitting the frame and having elongated ends to admit of their being tucked in under and around the bedding to prevent the cold air from entering the room. After entering the bed the sleeper lowers the tent with the aid of a cord and a little pulley attached to the upper portion of the window. Shutters or Venetian blinds, whether attached on the inside or on the outside of the window, can be used as a screen to intercept the gazes of the neighbors and as a protection in stormy weather (Fig. 19). If the bed cannot be placed beside the window, which is the best way, it can be placed at a right angle to the window, but in that case it must have a low bed board or, better, it may be a metal bedstead. A piece of transparent celluloid is usually placed in the front of the tent serving as a window, through which the occupant can see what is going on in the room; but this, of course, is not necessary. During the daytime the window tent can be pulled up so that it will be out of the way (Fig. 20). in civil life was one in which he had been exposed to the inhalation of a great deal of dust or irritating gases, or to the extremes of cold and heat, night work or unusual physical strain, it will be wiser to choose another way for him to earn a living. Lastly, all soldiers and sailors discharged as arrested cases, whether or not they have had post-sanatorium treatment, should be impressed with the necessity of having the chest examined at least every three months for the first year or two, and later on semi-annually, so as to guard against any insidious recurrence of the trouble. Any intercurrent indisposition or actual disease of whatever kind should be considered important enough to have medical advice sought immediately. The recovered tuberculous soldier or sailor should be particularly careful in times of influenza and pneumonia epidemics. He should avoid overcrowded assemblies, keep his bowels in good condition, and above all guard against overfatigue. Let him abide by the simple rule never to continue to work physically or mentally when already tired from manual or brain labor and never to work to the extent of getting over-tired (acutely fatigued.) It is my conviction that the fatigue poisons are as much responsible for the prevalence of infectious respiratory diseases as careless sneezing and coughing. Whether the periodic examination of the discharged tuberculous soldier shall be done by the surgeon of the nearest military post, by a civilian practitioner, by a physician especially qualified and appointed by the government, or by the medical staff attached to the various tuberculosis institutions under the direction of the National Tuberculosis Association, is a matter which should be worked out carefully by the respective authorities. I offer this modest contribution to our government in the hope that it may |