himself alone, to eat with delicacy and grace, to write a perfect hand with more than the normal speed, and had passed the examinations qualifying him as a licensed teacher. He did all this without use of artificial limbs. I also had opportunity of meeting several other men with double amputations who used their stumps as skillfully as he.

FIG. 171.-A teacher, both of whose hands had been amputated when six years old. He had learned to be absolutely independent and had passed his examination entitling him to a teacher's license. Without artificial limb he could dress himself (the illustration shows him in the act of buttoning his collar), shave, eat with grace and assurance, write an unusually legible hand with more than normal rapidity, travel long distances alone, carry a suit case and pay his fares, just as the normal individual would. All this was done by careful education of the stump, which in his case had acquired almost the same sensitiveness as the tips of the fingers.

When, however, the stumps are so short that they cannot be brought together, then an artificial limb must be appliedeither the Carnes' arm (see Fig. 157), or Judge Corley's, since with sufficient training it enables the wearer to become a reasonably independent being, whereas without it he is absolutely helpless.

The double-amputated require a school all to themselves, especially devised clothing with snap-hooks instead of buttons, trousers so devised as to fit directly to a vest (see Fig. 172), etc. In no instance, however, should the individual be allowed to

FIG. 172. A patient with double amputation showing the vest_and trowsers designed by Spitzy and a type of artificial arm attachable directly to the clothing. Note the ring hanging down from the slit of the trowsers. By pulling this upward with the hook of the artificial arm, the trowsers are closed by means of a thin chain with interlocking teeth.

feel that his case is hopeless. Even in one pathetic instance in which in addition to the loss of both hands the patient had been blinded by the explosion, much was accomplished and he left the hospital ready to assume a post in the office of a large business establishment.

CHAPTER XI

THE AIMS AND ORGANIZATION OF THE
ORTHOPEDIC RECONSTRUCTION HOSPITAL

The effective treatment of the orthopedic cases referred to the Base Hospital demands a type of institution which hitherto has not existed. Its nearest analogue is the combination of Hospital and Home for crippled children, in which medical care is combined with vocational training. These institutions suggested the possibility of a similar type for the injured soldier. The necessity for a modification of the ordinary hospital is appreciated by all who, in reading the preceding chapters, have realized over how many months treatment must extend and how intimately the medical treatment is associated with the economic and sociological factors in the rejuvenation of the crippled soldier. The hospital should, in accordance with these varied aims, be divided into three main departments-the medical, vocational and administrative and a fourth to act as a kind of clearing house in which the proper correlation of the activities of the other departments can be secured.

The medical department has three subdivisions:

(a) The operating, in which not only the open operations but also the bloodless procedures, such as corrective plasters, etc., are performed.

(b) The department of physiotherapy. This includes not merely the usual massage, hydrotherapy, electrotherapy and thermotherapy, but also the gradual correction of deformities by means of the methods outlined on page 92 et seq. An important adjunct of physiotherapy is, what might be termed, "workshop therapy." In outlining the treatment of joint injuries I emphasized the advantages of the workshop over the usual forms of mobilizing apparatus such as the pendulum devices, Zander machines, etc. These contrivances are ex

ceedingly irksome both to patient and physician, and all too frequently defeat their own ends. The exercise which a patient gets in the workshop is on the contrary interesting and productive. If done under the proper guidance, the worker soon becomes enthusiastic and forgets the unpleasant symptoms in his desire to complete the allotted task. The physician must, of course, coöperate in every detail with the technician in charge of the shop. Thus for instance, he should suggest in the case of a patient, whose power of pronation and supination has been impaired, that such work as driving in screws, etc., should be tried; that for a patient whose right shoulder joint has been stiffened by adhesions, the opportunity should be given to saw and hammer. For injuries to the fingers, the finger work of the bookbindery and of classes in clay modeling are better suited. The latter, to my great surprise proved unusually popular among the soldiers under my charge, and much real artistic talent was brought to light in men, whose daily occupations gave no suggestion of their latent artistic capabilities. Practically for every type of injury an appropriate exercise can be found.

(c) The third subdivision of the medical department is devoted to the manufacture of artificial limbs and braces.

This work should, as I have tried to show in discussing the treatment of the amputated, not be left to the bracemaker alone, but should in all instances be under the supervision of the physician. Technical though the bracemaker's art is, it is, I think, far easier for the medical man to master its essentials than for the bracemaker to learn enough of anatomy, physiology, and pathology to ply his art with good result for the patient. Having the bracemaker's shop in the Hospital obviates the necessity of sending the patients away for fittings, and enables the physician to begin the manufacture of the splint while the patient is still in bed.

In constructing the braces much can be learned by consultation with engineers and other technical experts. In many respects bracemaking has lagged behind the age, and many tricks of the trade have been handed down from master to apprentice for hundreds of years without essential modifications. Of course, some of these are invaluable, whereas others,

when critically examined in the light of recent technical improvements, should be discarded. In another respect the bracemaking department is of unusual value. Even in times of peace the number of bracemakers scarcely suffices for the needs of the crippled. In times of war, when the number of amputated multiplies with enormous rapidity, it is absolutely impossible to find sufficient men versed in this branch to equip the crippled with suitable contrivances. By making the bracemakers' shop a division of the Hospital, the patients themselves can be taught to make their own splints; the mechanics are taught the metal work, the saddlers and cobblers, the leather technic.

For the amputated, particularly those living at a distance from the larger cities, it is absolutely necessary to be able to repair their own prosthesis. As already stated on page 199 it is customary in one of the largest European Reconstruction Hospitals to insist upon a 4 weeks' course in the bracemaker's shop for every amputated soldier and he earns his discharge only after he has satisfactorily demonstrated his ability to construct his own artificial limb.

In addition to these three main subdivisions of the Medical Department there are, as in every Hospital, specialists for the various incidental diseases likely to occur when any large body of men are grouped together.

The Laboratory should be supplemented by a research department, since the treatment of gunshot wounds has so many unique phases that only by careful experimental work can the surgeon hope to solve the many problems which present themselves.

The second main department of the hospital, the vocational, is intimately associated with the first, since the various courses, not only in the arts and crafts, but even in clerical work, such as typewriting, serve as medical therapy. It may be divided into five subdivisions:

(a) The Workshops.-These should be as numerous and as varied in type as possible, so that irrespective of the nature of the injury or of the previous occupation of the patient, something can be found for which he is fitted.