FIG.180. The same patient shown in Fig. 178, illustrating how, despit the absence of three fingers, he was able to get a firm grip of his knife.

FIG. 181.-Apparatus to replace the knee strap used by the cobbler. This simple device enables the shoemaker who has lost a leg to work without inconvenience.

FIG. 182. A chair designed for patients suffering from an anchylosis of the left hip. (Biesalski model.)

(b) The agricultural subdivision, including dairying, is of particular importance, since here the hospital affords an unusual opportunity to increase the productive power of its inmates. The leader of this department should be thoroughly trained in the most modern methods of farming and should, of course, be of a sufficiently practical turn of mind to render his knowledge digestible for his pupils.

FIG. 183. A modified typewriter for the one-armed. The pedals are connected with the spacer and shift key.

Loss of a leg below the knee or shortly above does not incapacitate, nor does the loss of one hand, when the amputation has occurred below the elbow. Loss of the entire lower arm is a much more serious affair, but even under these conditions I have known of several men who have been able to continue as farmers, when equipped with a suitable artificial limb.

The business school with courses in bookkeeping, stenography, etc., is helpful not only to the artisan who is to become

In

a bookkeeper, but to the businessmen, salesmen, etc., who in this way increase their technical knowledge of business methods. Typewriting is a most effective form of mechanotherapy in certain injuries to the wrist and to the fingers. For the amputated, and for the patient whose hands have been severely crippled special devices are necessary. Fig. 183 shows a simple modification of the typewriter, in which the spacer and some of the other switches are attached to a pedal. case this device cannot be had, it is easy to improvise a strap attached to the spacer running beneath the patient's thigh. When fingers have been lost or cannot flex normally, pen and pencil can be modified on the same principle as the carpenter's tools shown in Fig. 177. Each patient should be regarded as a specific problem and no matter how great the pressure of medical duties, the physician must have time to consider the individual needs of each man.

For other patients, unsuited to the workshop or to the business school, who, because of the tedious convalescence, find that time hangs heavily on their hands, general culture courses are indicated. This part of the vocational department should be under the supervision of a well-trained teacher able to secure the coöperation of specialists in those subjects of interest to the patients.

One feature frequently omitted in reconstruction hospitals is the athletic department. It is almost as important for the purpose of physiotherapy as the workshop or the school room. Fig. 184 shows a game of hand ball in which all participants had suffered amputation of either leg or arm. Vigorous competitive athletics not only drive away the blues, but act as a beneficial form of mechanotherapy. I distinctly remember one patient whose shoulder had been stiffened by an ugly gunshot wound. I advised him to join his comrades playing ball. Within a week the shoulder was practically normal. Of course, vigorous athletics cannot be recommended for every patient, and in each instance a sufficient length of time must elapse after the wounds have healed before it is advisable. As in every other department of the hospital, careful medical supervision is necessary.

The third main division of the hospital, the administrative department, must assume not merely the functions usually assigned it in the ordinary hospital, but must include in addition to its staff of bookkeepers, stewards, etc., two other subdivisions.

The first has to do with military matters. A reconstruction hospital controlling several hundreds of men whose general health is excellent must be run with military discipline, other

FIG. 184. A game of volley ball, in which all the contestants had suffered amputation, either of leg or of arm. consciousness of self in the sport.

The men played with vim and lost all

wise the patients tend, in their exuberance, to become unmanageable. However sympathetic and kindly disposed the hospital authorities are, they must constantly bear in mind that the patients are still soldiers and that rigid discipline must be maintained. Rules regarding furlough, taps, etc., must be strictly obeyed as in a military camp and, if necessary, offenses must be punished. In addition to maintaining discipline, the military department has to do with the awarding of pensions, payment of salaries, and discharge from the army.

Of even more importance is the second subdivision, the employment bureau. It is manifestly unfair to discharge a

crippled soldier who has lost the use of a limb in the service of his country and allow him to shift for himself. The state is responsible not merely for the proper medical supervision, supplying a brace and giving the patient the necessary technical education, but it must also provide the crippled soldier with an opportunity to earn his livelihood. The employer, as a rule, looks askance at a cripple who applies for a job. The employment bureau must educate the public to the necessity of giving the crippled man a fair chance, and the pension must be so awarded that the discrepancy in salary between the cripple and the normal worker is balanced. In some of the belligerant countries the employers rapidly responded to the call and formed associations to assist the employment bureau in placing the crippled in advantageous positions. Economic necessity, too, will help educate the employer, for with the growing scarcity of labor, every individual, whether crippled or not, is bound to be sought after. The task will be made. easier by the state or local public employment agencies, some of which have already done work in this field.

The fourth and final department of the Hospital is necessary to correlate the three other divisions. It follows the hospital career of each inmate from the time of his admission until his discharge and sees to it that there is no duplication of effort or unnecessary delay. Its staff should consist of the heads of the other departments or their representatives and of a sufficient number of trained clerks. The patient is brought to this department as soon as he is admitted to the hospital. It decides upon the general course of treatment and refers the patient to the appropriate ward. Thus, for instance, assume that a number of wounded soldiers are admitted to the hospital. The first is amputated. He is examined by the medical officer in charge of amputations who decides whether the stump is suited to the application of an artificial limb, or whether operative measures or correction of contractures by means of splints are necessary. If these are not indicated, the patient is referred to the head of the bracemakers department who at once takes necessary measurements and determines the date for the delivery of the artificial limb. The clerks meanwhile have taken the personal record