UC-NRLF THE er-Allied Conference on the After-Care of Disabled Men SECOND ANNUAL MEETING Held in London, MAY 20th to 25th, 1918. Reports Presented to the Conference. LONDON: PUBLISHED BY HIS MAJESTY'S STATIONERY OFFICE. 1918. Price Five Shillings Net. THE INTER-ALLIED CONFERENCE ON THE AFTER-CARE OF DISABLED MEN SECOND ANNUAL MEETING Held in London, May 20 to 25, 1918. Reports Presented to the Conference. *.** ' i i i * > LONDON : PRINTED BY HIS MAJESTY'S STATIONERY OFFICE. 1918. Price Five Shillings Net. CONTENTS. TABLE OF CONTENTS. PAGE. Programme of the Conference 5 List of Official Delegates 7 Committee and Officers of the Conference 10 Prefatory Note by the EDITOR ... 12 Foreword by JOHN GALSWORTHY, Esq 13 Reports and Summaries Presented to the Conference 18 SECTION 1. Pensions and Allowances. Pensions and Allowances, by Lieut.-Col. Sir A. GRIFFITH-BOSCAWEN, M.P. ... 18 Canadian Pensions, by Major HUME BLAKE, O.M F.E. See Appendix. Pensions, &c., in France, by M. LEFAS (Depute) 25 Italian Official Report on Provision for the Disabled 31 Problems as to War Pensions in Italy, by Avvocato GIOVANNI GIURIATI, Major. See Appendix. Pensions and Allowances, by Dr. MARCEL STASSEN, Belgian Army ... 47 The Work of Local Committees, by W. E. HINCKS, Esq. 60 State Insurance of Disabled Men in Italy, by Avvocato FOSCOLO BARGONI 71 International Protection for the Disabled, Avvocato GENNARO LAGHEZZA, Lieut.-Col. 83 SECTION 2. Training. The Training of Disabled Sailors and Soldiers, by Major MITCHELL, C.B.E 96 Re-education of Disabled Men, by DK. BOURRILLON, President of the Permanent Committee Ill Re-education of Disabled Men, by DR. LE BKUN 124 The American Y.M.C.A. and the Disabled, by J. GUSTAV WHITE, Esq. 129 Technical Re-education in Italy, by Professor GIOVANNI CHEVALLEY. 139 Technical Re-education; in Italy, by Frofpssov LEVI 150 The Training of the 'Disabled Canadian "SoMier, by Major R. T. MACKEEN .'. ; ; 157 The Training of the' Disabled South' A'frican Soldier and its Lesson, by Lieut.-Colonel THORNTON, O.B.E., South African Medical Corps 165 Schools and Methods of Re-education, by M. ALLEMAN 171 Handicraft in Re-education, by THE ARTS AND CRAFTS SOCIETY ... 179 Agricultural Re-education of the Disabled in Italy, by Professor MARIO GUSMITTA 183 Outlines of Scheme for Training and Employment of Disabled Men, by K. S. DICKINSON, Esq 205 Employment, by the Ministry of Labour 211 After-Training and Its Results, by Mrs. WOOD 221 State Provision for the Placing of Wounded Soldiers in Italy, by Avvocato DIEGO MARTELLO 226 The Work of Local Italian Committees for the Employment of Soldiers after Re-education, by Signora OLGA MONSANI ... "236 SECTION 3, A. Medical Treatment, the Blind and the Deaf. PAGE. Homes for Recovery of Shell Shock Cases, by Sir JOHN COLLIE ... 242 Organisation of Military Neurological Assistance in Italy, by Professor EUGENIO MEDEA 246 Military Neurological Centres in Italy, by Senator GOLGI, Professor in the University of Pavia 251 The Neuro-Organic Section of the Neurological Centre at Pavia, by Professor GUIDO SALA 255 Better Treatment of War Neuroses, by Lieut.-Col. SPRINGTHORPE, Australian Medical Service 258 The Care of the Tuberculous Soldier, by Major P. H. S. HARTLEY, C.Y.O., R.A.M.C 266 The Blind, by Sir ARTHUR PEARSON, Bart., G.B.E 277 Treatise of the Blind, by Dr. LAVINIA MONDOLFO 283 The Deaf, by Major DUNDAS GRANT, M.D., F.R.C.S 312 After-Care ot the Ultra-Disabled in Italy, by Professor ETTORE LEVI 323 Should Treatment be compulsory, by Dr. A. BASSETTA. See Appendix. SECTION 3, B. Surgical Treatment. Cinematic Amputation, by Dr. GINO FIERI, Captain, Italian Royal Medical Corps... ... 338 Cinematic Amputation, by Professor V. PUTTI 341 A New Process for Cineplastics, by Professor AUGUSTO PELLEGRINI... 342 Functional Exercising of Mutilated Legs, by Dr. A. BASSETTA. See Appendix. A New Ergograph for Mutilated Forearms, by Dr. A. BASSETTA. See Appendix. The Speedier Treatment of Cases of Amputation of the Arm, by Dr. MARTIN 347 Fitting and Adjustment of Artificial Limbs, by Colonel T. H. OPENSHAW, C.B., C.M.G., F.R.C.S. ... ' 356 The Limbless, by Sir WILLIAM MACEWEN, F.R.S., LL.D 367 The Test of the Real Value of Artificial Legs, by Dr. MARTIN ... 376 New Ideas on Post-operation Treatment and Earlier Use of Prothesis, by Dr. MARCEL STASSEN, Medical Director, Port Villez ... 384 The Present Position of Prothesis in Italy, by Professor RICCARDO DALLA VEDOVA, University of Rome 390 The Vitalising of the Prothesis, by Professor GIULIANO VANGHETTI... 394 Prothesis for Manual Labour, by Professor RICCARDO GALEAZZI, Lieut.-Colonel, Italian Royal Medical Corps. See Appendix. Constructive Drawings of the Prothesis, by Professor RICCARDO GALEAZZI. See Appendix. Military Orthopaedic Surgery, its Scope and Aims, by Colonel Sir ROBERT JONES, C.B. See Appendix. Functional Restoration of the Wounded, by Dr. DELREZ 399 Functional Re-education : Preliminary Considerations, by Major W. G. TURNER, M.C , C.A.M.C., and Major G. W. F. BOYER, C.A.M.C. ... * 408 Medical Gymnastics and Medical Gymnasts, by Professor A. DE MARNEFFE 415 Treatment of Wounds by Continuous Bath, by Major LINDSAY SANDES, M.A., M.D., S.A.M.C 435 Operations on Peripherie Nerves, by D^ G. VERGA .., 441 A 2 APPENDIX. Papers delayed in transmission. PAGE. Canadian Pensions, by Major HUME BLAKE, O.M.F.E. 445 Problems as to War Pensions in Italy, by Avvocato GIOVANNI GIURIATI, Major 451 Should Treatment be compulsory, by Dr. A. BASSETTA 479 Functional Exercising of Mutilated Legs, by Dr. A. BASSETTA ... 484 A New Ergograph for Mutilated Forearms, by Dr. A. BASSETTA ... 488 Prothesis for Manual Labour, by Professor RICCARDO G-ALEAZZI, Lieut-Colonel, Italian Royal Medical Corps 491 Constructive Drawings of the Prothesis, by Professor RICCARDO GALEAZZI 514 Military Orthopaedic Surgery, its Scope and Aims, by Colonel Sir ROBERT JONES, C.B. 519 OFFICIAL PROGRAMME FOR THE ALLIED CONFERENCE ON THE AFTER-CARE OF DISABLED MEN, MAY 20th TO 25th INCLUSIVE. Monday, %0th May. Delegates and guests to be in their places not later than 11.15 a.m. at the Central Hall, Westminster. 11.30 a.m. Opening ceremony by H.B.H. the Duke of Connaught. 12 noon. Opening of the Exhibition. Presentation of Delegates from Allied Foreign Nations. 12.30 p.m. Visit by Their Majesties the King and Queen, 2 to 8 p.m. Exhibition open to the Public. 2.30 to 7.30 p.m. Cinema Lectures by British and Allied Representatives. (For details, see List at entrance.) Tuesday, 21s May. 10 a.m. to 12.45 p.m. Section Meetings. (For details, see Lists at entrance.) 10 a.m. to 8 p.m. Exhibition open to Public. 2.15 p.m. Visits to Roehampton, Richmond and Walton- on-Thames by Allied Delegates in three parties. 2.30 to 7.30 p.m. Cinema Lectures by British and Allied Representatives . 7.30 p.m. Dinner at the Mansion House to Allied Delegates. Wednesday, 22nd May. 10 a.m. to 12.45 p.m. Section Meetings. (For details, see Lists at entrance.) 10 a.m. to 8 p.m. Exhibition open to Public. 2.15 p.m. Visits to St. Dunstan's (Blind) and Golders Green (Shell-Shock Recovery Home) by Allied Delegates in two parties. 2.30 to 7.30 p.m. Cinema Lectures by British and Allied Representatives . Thursday, 23rd May. 10 a.m. to 12.45 p.m. Section Meetings. (For details, see Lists at entrance.) 10 a.m. to 8 p.m. Exhibition open to Public. 2.15 p.m. Visit to Shepherd's Bush and Battersea War Pensions Committee by Allied Delegates in two parties. 2.30 to 7.30 p.m. Cinema Lectures by British and Allied Representatives. Ifi.i24 A 3 Friday, 24/i May. 10 a.m. to 12.45 p.m. Section Meetings. (For details, see Lists at entrance.) 10 a.m. to 8 p.m. Exhibition open to Public. 12 noon. Final closing of the Conference by H.E.H. the Duke of Connaught. 2.30 to 7.30 p.m. Cinema Lectures by British and Allied Representatives. Afternoon Entertainments to Allied Delegates by Sir William Younger. 7.15 p.m. Official Dinner to Allied 'Delegates at Ritz Hotel. Saturday, 25th May. Visit to Brighton by Allied Delegates, leaving Victoria about 10 a.m. 10 a.m. to 8 p.m. Exhibition open to Public. 2.30 to 7.30 p.m. Cinema Lectures by British and Allied Representatives. E. A. 8T ANTON, Lt.-Col., Secretary-General . CORRECTED LIST OF DELEGATES, BELGIUM. Le Lt.-General MELIS. M. Le Ministre BRUNET. M. le Senateur THIEBAULT. M. le Senateur LE CLEREG. Le General DERUETTE. M. le Docteur .LE BRUN. M. le Docteur WAFFELAERT. M. le Docteur STASSEN. M. ALLEMAX. Major HAINAULT. FRANCE. M. le Depute METIN. M. le Docteur LEFAS. M. le Docteur BOURRILLON. Mme. BARTHEZ. M. VALLON. M. CHARLES KRUG. M. le Docteur CAUYY. M. le Docteur NOYE-JOSSERAND. M. le Docteur GOURDON. M. le Docteur YILLARET. M. le Docteur RIPERT. Mme. la MARQUISE DE NOAILLES. ITALY. Col. Sir F. DE FILIPPI, K.C.I.E. Professor ENRICO BURCI. Major Dr. GIOYANNI CELY1. Professor GIOVANNI LORIGA. Cavaliere PARDO. Lt.-Col. Dr. GIACOMO POMA. Lt.-Col. Comm. GENNARO LAGHEZZA. Major GIOYANNI GIURIATI. Paymaster ROBERTO SANDIFORD. Lt. NERINO RASPONI. Professor Lt.-Col. RICCARDO GALEAZZI. PORTUGAL. Surgeon-Colonel JOSE GOMEZ RIBEIRO. Surgeon-Major ANTONIO DE COSTA FERREIRO. Surgeon-Captain JOSE PONTES. SERBIA. Colonel SUBOTITCH. Miss DICKINSON. Mr. LAZAR BOGUICEYITCH. Dr. Y. STOKITCH. Dr. G. DJOURITCH. SIAM. WILLIAM ARCHER, Esq., C.M.G. PHRA-SAN-PACKITCH PREECHA. 165242,000 UNITED STATES. Mr. P. B. KENNEDY will not attend. Captain PHILIP WILSON, of the American Bed Cross and of the United States Public Health Department, will be present. Surgeon W. C. BUCKEB, U.S. Public Health Service. Mr. JEFFEBSON CAFFBET. Miss G. HABPEB. Major JOEL E. GOLDTHWAITE. Mr. GEOBGE E. VINCENT. Mr. J. WHITE. Professor SELSKEAM GUNN. Mr. NOBTON C. ADAMS. Captain PHILLIP WILSON. Surgeon W. C. BUCKEB. Mr. WALTEB C. PAGE. CANADA. The Hon. Sir E. KEMP, K.C.M.G. The Hon. Sir A. PEBLEY, K.C.M.G. Lt.-General Sir B. TUBNEB, V.C., K.C.B., K.C.M.G. Major-General FOSTEB, C.B. The Hon J. S. McLENNAN. Major B. T. MCKEEN. Colonel MACLABEN, C.M.G. Lt.-Colonel FINDLAY. Mr. W. GBIFFITHS. Major W. G. TUBNEB. The CHIEF COMMISSIONEB, Canadian Bed Cross-. Lt.-Col. McCOMBE, C.A.M.G. AUSTBALIA. The Hon. J. C. MANIFOLD, M.P. The Bt. Hon. A. FISHEB, Colonel MUBDOCK. Lt.-Col. SPBINGTHOBPE. Surgeon-General FETHEBSON. Surgeon-General Sir NEVILLE HOWSE, V.C., K.C.B. SOUTH AFBICA. Lt.-Col. WABD, D.S.O., S.A.M.C. Lt.-Col. THOBNTON, O.B.E, S.A.M.C. Major G. SANDES, S.A.M.C. NEW ZEALAND. The Hon. Sir THOMAS MACKENZIE, K.C.M.G. Brigadier-General RICHARDSON, C.M.G. Colonel the Hon. R. HEATON RHODES. INDIA. F. S. STEWART, Esq. Surgeon-General Sir B. HAVELOCK CHABLES, G.C.V.O. "NEWFOUNDLAND. The Bt, Hon. Lord MOBBIS, K.C.M.G. EBBATUM. Sir JOHN COLLIE, C.M.G., M.D., Director of Medical Service to the Ministry of Pensions, has, through a regretted in- advertence, not been correctly designated. DELEGATES TO THE ALLIED CONFERENCE. Foreign Countries. BELGIUM. M. le Lt. -General MELIS, Inspector General of Belgian Military Medical Services ; President of the Belgian Delegation. M. le Senateur THIEBAUT, [Representative of the Ministry of War on the staff of the Military Institution for Maimed and Injured. M. le General-Major DEEUETTE, A. B.C. to the King, of the Belgians ; Commandant of the Military Institution. M. le Dr. LEBEUN, Senior Medical Officer; 2nd Class Director of the Military Institute of St. Adresse. M. le Dr. WAFFELAEET, Chief of the Surgical Service Hospital de Bonsecours at Eouen. M. le Dr. STASSEN, Eegimental Medical Officer, and Chief Surgeon at Port-Villez. M. ALLEMAN, Chief of the Educational Staff, Port-Villez. M. le Major HAINAUT, Headquarter Staff, attached to Ministry of War. M. le Ministre BEUNET, Treasurer of Permanent Allied Com- mittee ; Member of the Chamber. M. HENRI LE CLERCQ, Secretary to the Ministry of Interior. FEANCE. M. ALBEET METIN, Depute ex-Minister of Labour. M. A. LEFAS, Depute. M. le Docteur BOUEILLON, President of the Permanent Inter- Allied Committee. M. LUGIEN MARCH, Vice-President of the Permanent Inter- Allied Committee. M. CHARLES KEUG, Secretary General of the Permanent Inter- Allied Committee. Madame BAETHEZ, Member of the National Office. M. VALLON, Sous-Chef de Bureau Ministry of the Interior. M. le Medecin-Major de Premiere Classe JEANBEAU, Professor in University of Montpellier, attached to Service de Sante. Monsieur le Medecin Major NOVE-JOSSERAND, Chief of the Centre de Physitherapie , Lyons. Monsieur le Docteur GOUEDON, Director of the Technical School for the Disabled at Bordeaux. Monsieur le Docteur QUISERNE. 16524 A 4 ITALY. Professor ENEICO BUKCI, Ministry of War. Major Dr. GIOVANNI CELVI, Ministry of War. Lt.-Col. Dr. GIACOMO POMA, Ministry of Marine. Lt.-Col. Commendatore GENNARO LAGHEZZA, Ministry of Marine. Professor Commendatore GIOVANNI LORIGA, Ministry of Commerce and Labour. Major GIOVANNI GIURIATI, Ministry of Pensions. Cavaliere GUIDO PARDO, Italian Government Commissioner, London. Paymaster ROBERTO SANDIFORD, Royal Italian Navy, Secretary of the Delegation. SERBIA. Colonel SUBOTITCH, Chief of the Serbian Military Medical Service. Miss DICKINSON, Serbian Red Cross. SIAM. WILLIAM ARCHER, Esq., C.M.G., Counsellor of the Legation. PHRA-SAN-PACKITCH PREECHER, First Secretary of Legation. PORTUGAL. Surgeon Colonel JOSE GOMEZ RIBEIRO, Chief of the Portuguese Ex. Force, Military Medical Service. Surgeon-Major ANTONIO AURELIO DE COSTA FERREIRO, Director of Institute for Disabled Sailors and Soldiers. Surgeon Captain JOSE PONTEZ, of Institute for Disabled Sailors and Soldiers. UNITED STATES. Mr. JEFFERSON CAFFREY. Miss G. HARPER, American Red Cross. Mr. NORMAN C. PAGE. Major JOEL E. GOLDTHWAITE, Member of Inter- Allied Committee representing War Department. Mr. GEORGE E. VINCENT, representing the Rockefeller Foundation. Mr. J. GUSTAV WHITE, representing American Y.M.C.A. Dr. LIVINGSTONE F ARRANT, Representative of Ministry of Interior. Mr. MORTON C. ADAMS, Representative of Labour Depart- ment. 9 Overseas Dominions. AUSTEALIA. The Hon. J. C. MANIGOLD, M.P. The Et. Hon. A. FISHEK, High Commissioner. Colonel MUBDOCK, A.A.M.C. Lt.-Colonel SPBINGTHOBPE , A.A.M.C. Surgeon General FETHEBSON, Director General A.A.M.C. Surgeon General Sir NEVILLE HOWSE, V.C., K.C.B. CANADA. The Hon. Sir ALBEET E. KEMP, K.C.M.G., Minister of Militia. The Hon. Sir GEOEGE PEELEY, K.C.M.G., High Com- missioner. Lt.-General Sir E. TUBNEB, V.C., K.C.B. , K.C.M.G. Major-General FOSTEB, C.B. The Hon. J. S. McLENNAN, Senator. Major E. T. McKEEN. Colonel McLABEN, C.M.G. Lt.-Colonel FINDLAY. Mr. W. GEIFFITHS. Major W. G. TUENEE. The CHIEF COMMISSIONEE, Canadian Bed Cross. Lt.-Colonel McCOMBE. INDIA. F. S. STEWAET, Esq. Surgeon General Sir E. HAVELOCK CHABLES, G.C.V.O. NEWFOUNDLAND. The Eight Hon. Lord MOEEIS, K.C.M.G. NEW ZEALAND. The Hon. Sir THOMAS MACKENZIE, K.C.M.G. Brigadier-General EICHAEDSON, C.M.G. Colonel Hon. E, HENTON EHODES. SOUTH AFEICA. Lt.-Colonel WAED, D.S.O., S.A.M.C. Lt.-Colonel THOENTON, C.B.E., S.A.M.C. Major G. SANDES, S.A.M.C. 10 GENERAL COMMITTEE. The Et. Hon. JOHN HODGE, M.P., Minister of Pensions (Chairman). Lt.-Colonel Sir A. GEIFFITH BOSCAWEN, M.P., Parlia- mentary Secretary to the Ministry of Pensions (Vice-Chairman). Et.'Hon. Sir MATTHEW NATHAN, G.C.M.G. Lt.-Colonel E. A. STANTON, C.M.G. C. F. A. HOAEE, Esq. Major MITCHELL, C.B.E. Lt.-General T. H. J. C. GOODWIN, C.B., C.M.G. , D.S.O., Director-General of Army Medical Service. Surgeon-General Sir MICHAEL W. RUSSELL, K.C.M.G., C B 'General Sir GEO. M. BULLOCK, K.C.B. Sir ALFRED PEARCE GOULD, K.C.V.O. Colonel Sir EOBT. JONES, C.B: Sir JOHN COLLIE, M.D. Major P. H. S. HARTLEY, C.V.O., M.D. EOBT. FOX-SYMONS, Esq., M.E.C.S., L.E.C.P. Major DUNDAS GRANT, M.D. C. HUBERT BOND, Esq., M.D., Board of Control. Sir CYRIL JACKSON, K.C.B. Sir HENEY P. HARRIS, M.P. Sir CHAS. NICHOLSON, Bt., M.P. The Hon. Sir ARTHUR STANLEY, M.P. Sir ROBERT HUDSON. The LORD CHAENWOOD. Sir C. A. MONTAGUE BARLOW, M.P. JAMES W. B. HODSDON, Esq., M.D. Sir THOMAS OLIVER, M.A., M.D. Sir JOHN SAMUEL, K.C.B. Sir WM. MACE WEN, F.E.S., LL.D. Sir BERKELEY MOYNIHAN, C.B. Col. J. LYNN THOMAS, C.B., C.M.G. Sir GEO. BEATSON, K.C.B., M.D. C. J. MATHEW, Esq., K.C., C.B.E. Sir HY. NORMAN, M.P. Sir FEED. TAYLOR, M.D. GEOEGE J. WAEDLE, Esq., M.P. Sir RICKMAN J. GODLEE, Bt., K.C.V.O., M.D, Sir A. PEARSON, Bt., G.B.E. The Et. Hon. the LOED MAYOE OF LONDON. Sir WM. SOULSBY. C.B., C.I.E. Surgeon-General Sir WILLIAM NORMAN, K.C.B, " E. MARRIOTT COOKE, Esq. H. D. EOBEETS, Esq. 11 OFFICERS OF THE CONFERENCE. Chairman, The Bight Hon. JOHN HODGE, M.P. Vice-Chairman, Lt. -Colonel Sir A. GRIFFITH BOSCAWEN, M.P. Secretary-General, Lt. -Colonel STANTON, C.M.G. Hon. Sec. of Exhibition, H. D. ROBERTS, Esq. Editor of Reports, Lord CHARNWOOD. Interpreters : Monsieur MONCEAU. W. L. DUNLOP, Esq. Lady SCOTT. OFFICERS OF SECTIONS. Section 1. Pensions, dc. Chairman, Sir A. GRIFFITH BOSCAWEN, M.P. Vice-Chairmen, C. J. MATTHEW, Esq., K.C., C.B.E., and Professor ENRICO BURCI. Section 2. Training. Chairman, Sir CHARLES NICHOLSON, Bart., M.P. Vice-Chairmen, Major MITCHELL, C.B.E., and M. le Docteur BOURRILLON, President of the Permanent Com- mittee. * Section 3 A : Medical Treatment, dc. Chairman, Lord CHARNWOOD. Vice-Chairmen, Sir JOHN COLLIE and Surgeon-Colonel JOSE GOMEZ RIBEIRO (Chief of Medical Services, Portuguese Ex. Force). Section 3 B : Surgical Treatment. Chairman, Sir H. P. HARRIS. Vice-Chairmen, Sir ARTHUR PEARCE GOULD, K.C.V.O.. and Le General MELIS (Chief of the Belgian Military Medical Service) . 12 PREFATORY NOTE BY THE EDITOR. BY JOHN GALSWORTHY, ESQ. The Editor thinks that special acknowledgment is due to the speed and efficiency with which the printers have carried out their task under the great difficulties which at the present time beset such work. His thanks are due also to the many writers of papers who have taken great trouble to let him have their papers early, and to Professor Pardo, of the Italian Government Commission in London, for his energy in revising the translation of the many valuable papers received from Italy. In order, however, to make certain that this volume should be completed in time for the Conference, it has been necessary to adhere strictly to the rule that no papers should be printed unless they were received type-written, and in the case of the two or three papers last received it has been impossible for the printers to submit proofs for correction. Moreover, in revising proofs containing technical terms of surgery or medicine it has not always been possible to secure correction by an expert hand, nor has it in the case of all such terms been possible to ensure uniformity of spelling. The Editor trusts that the contributors of surgical and medical papers will not find their contributions to the Conference much disfigured from this cause. He hopes, too, that the contributors of papers written in , or translated into ,. French will forgive those slight disfigurements of their writings which the publication of them in this country, under the pressure of haste, has made almost inevitable. The following papers have been grouped according to the Sections of the Conference at which they respectively seemed suitable for discussion ; and in each group the papers are arranged in an order in which it is likely to be convenient to take them , so that in general papers dealing with the same subject may be found together. The results of this (or any other) classification will in some cases be arbitrary. Thus, for example, the reports sent by the Italian Government officially have been kept together under the Section dealing with Pensions and Allowances, though they cover a much wider ground. Again, a paper (on Operations on the Periphenic Nerves) placed at the end of the Section dealing with Surgical Treatment will be found to be closely related in subject to the papers on nerve cases wjiich are classed under Medical Treatment. 13 FOREWORD. BY JOHN GALSWORTHY, ESQ. The Angel of Peace, watching the slow folding back of this darkness, will look on an earth of cripples. The field of the world is strewn with half -living men. That loveliness which is the creation of the aesthetic human spirit ; that flowering of directed energy which we know as civilisation ; that manifold and mutual service which we call progress all stand mutilated and faltering. As though, on a pilgrimage to the dreamed-of Mecca, water had failed, and by the wayside countless muffled forms sat waiting for rain ; so will the long road of mankind look to-morrow. In every township and village of our countries stricken heroes of the war will dwell for the next half -century. The figure of Youth must go one-footed, one-armed, blind of an eye, lesioned and stunned, in the home where it once danced. The half of a generation can never again step into the sunlight of full health and the priceless freedom of unharmed limbs. So conies the sacred work. For what Youth has done, for what it will yet do before the long gale blows away over sea and sky, shall not Youth be praised for ever ? Can there be limit to the effort of gratitude ? Niggard- liness and delay in restoring all of life that can be given back is sin against the human spirit, a smear on the face of honour. Love of country, which, like some little secret lamp, glows in every heart, hardly to be seen of our eyes when the world is at peace love of the old, close things, the sights, sounds, scents we have known from birth ; loyalty to our fathers' deeds and our fathers' hopes ; the clutch and kiss of Motherland this love sent our soldiers and sailors forth to the long endurance, to the doing of such deeds, and the bearing of so great and evil pain as can never be told. The countries for which they have dared and suffered have now to play their part. I have seen those countries nearly all and something from each of special charm or wonder lingers yet in memory. Only the son of his country knows the hidden heart of her ; but for the eager stranger other lands have faces and voices which tell him odd truths, show him grave beauties. France ! The country of the long romance ! Who can see France ar^d not love her the land with the mysterious smile, with the clear thoughts and the gay, unconquerable, self -seeing spirit? France, the eternal type of Mother-country she surely will not fail her sons who serve and suffer. Italy, whom the gods love, and chose, I think, for the land where Beauty should be embalmed for ever, so that man might look on it age after age and drink of inspiration she will not forget to fill again the 14 lives of her wounded children with hope and usefulness. And the Little Country, trodden and ravished none in the world had quite her teeming energy she will be last of all to let the stricken go down their days drained of strength and interest. And all our own far sister lands, having each her special flower of promise ; having , all , the clear eyes and adventuring hearts of the young. To their pride of new race it will seem intolerable that their best and bravest should go starved of help and oppor- tunity. Sooner would an Arab's hospitality fail than the free- masonry of the new worlds neglect their maimed heroes ! And India, the wonder-land. She, too, will care for her^ children. And this Britain of ours ! Shall the work of restoration fail with us? Unthinkable! The draft will be honoured, the debt paid, so far as such a debt can be repaid. America, too, I know, new as yet to this conflict and the wreckage thereof. Of that great, warm-hearted nation I prophesy deeds of restoration, most eager, most complete of all. The conscience of to-day is burdened with a load well-nigh unbearable. Each hour of the sacred work unloads a little of this burden. The Conference in Paris last year, and this Conference in London, were summoned that the countries who stand shoulder to shoulder in the fight may stand shoulder to shoulder also in the task of remedy, profiting by each other's success, avoiding each other's failures ; that the whole field of recovery may be surveyed ; the holy purpose of this crusade of healing be fortified in the hearts of all who serve ; and a sign made manifest to the peoples of each country that the debt due is remembered. To lift up the man who has been stricken on the battlefield, restore him to the utmost of health and agility, give him an adequate pension, and re-equip him with an occupation suited to the forces left him that is a process which does not cease till the sufferer fronts the future keen, hopeful and secure. And such restoration is at least as much a matter of spirit as of body. Consider what it means to fall suddenly out of full vigour into the dark certainty that you can never have full strength again, though you live on twenty, forty, sixty years. Though you have the soul of a hero, the flag of your courage may well be down half-mast ! Apathy that creeping nerve disease is soon your bedfellow and the companion of your walks. A curtain has fallen before your vision ; your eyes no longer range. The Russian " Nichevo " the " what-does-it-matter?" mood besets you. Fate seems to say to you : " Take the line of least resistance, friend you are done f or ! " But the sacred work says to Fate : ' ' Retro- Satanas ! This comrade of ours is not your puppet. He shall yet live as happy and as useful if not as active a life as he ever lived before. Do your worst ; you shall not crush him ! We shall tend him fft>m clearing station to his last hospital better than wounded soldier has ever yet been tended. In special hospitals, 15 orthopaedic, paraplegic, phthisic, neurasthenic, we shall give him back functional ability, solidity of nerve or lung. The flesh torn away, the lost sight, the broken ear-drum, the destroyed nerve, it is true, we cannot give back; but we shall so re-create and fortify the rest of him that he shall leave hospital ready for a new career. Then we shall teach him how to tread the road of it, so that he fits again into the national life, becomes once more a workman with pride in his work, a stake in the country, and the consciousness that, handicapped though he be, he runs the race level with his fellows, and is by that so much the better man than they. And beneath the feet of this new workman we shall put the firm plank of a pension." The sacred work fights the creeping dejections which lie in wait for each soul and body, for the moment stricken and thrown. It says to Fate : ' ' You shall not pass ! ' ' And the greatest obstacle with which it meets is the very stoicism and nonchalance of the sufferer. To the Anglo-Saxon, especially, those precious qualities are dangerous. That horse, taken to the water, will too seldom drink. Indifference to the future has a certain loveability, but is hardly a virtue when it makes of its owner a weary drone, eking out a pension with odd jobs. The sacred work is vitally concerned to defeat this hand- to-mouth philosophy. Side by side in man, and especially in Anglo-Saxon, there live two creatures. One of them lies on his back and smokes ; the other runs a race ; now one, now the other, seems to be the whole man. The sacred work has for its end to keep the runner on his feet ; to proclaim the -nobility of running. A man will do for Mankind or for his Country what he will not do for himself ; but Mankind marches on , and Countries live and grow, and need our services in peace no less than in war. Drums do not beat , the flags hang furled , in time of peace ; but a quiet music is ever raising its call to service. He who in war has flung himself, without thought of self, on the bayonet and braved a hail of bullets often does not hear that quiet music. It is the business of the sacred work to quicken his ear to it. Of little use to man or nation would be the mere patching-up of bodies, so that, like a row of old gossips against a sunlit wall, our disabled might sit and weary out their days. If that were all we could do for them, gratitude is proven fraudulent, device bankrupt ; and the future of our countries must drag with a lame foot. It seems, to one who has watched, rather from outside, that restoration worthy of that word will only come if the minds of all engaged in the sacred work are always fixed on this central truth : ' ' Body and spirit are inextricably conjoined ; to heal the one without the other is impossible." If a man's mind, courage and interest be enlisted in the cause of his own salvation, healing goes on apace, the sufferer is remade. If not, no mere surgical wonders, no careful nursing, will avail to make a man of him again. Therefore I would say : " From the moment he enters hospital, look after his mind and his will; give them food; 16 nourish them in subtle ways, increase that nourishment as his strength increases. Give him interest in his future ; light a star for him to fix his eyes on. So that, when he steps out of hospital, you shall not have to begin to train one who for months, perhaps years, has been living, mindless and will-less, the life of a half- dead creature." That this is a hard task none who knows hospital life can doubt. That it needs special qualities and special effort quite other than the average range of hospital'devotion , is obvious. But it saves time in the end, and without it success is more than doubt- ful. The crucial period is the time spent in hospital ; use that period to re-create not only body, but mind and will-power, and all shall come out right ; neglect to use it thus, and the heart of many a sufferer, and of many a would-be healer, will break from sheer discouragement. The sacred work is not departmental ; it is one long organic process from the moment when a man is picked up from the field of battle to the moment when he is restored to the ranks of full civil life. Our eyes must not be fixed merely on this stressful present, but on the world as it will be ten years hence. I see that world gazing back, like a repentant drunkard at his own debauch, with a sort of horrified amazement and disgust. I see it impatient of any reminiscence of this hurricane ; hastening desperately to recover what it enjoyed before life was wrecked and pillaged by these blasts, of death. Hearts, which now swell with pity and gratitude when our maimed soldiers pass the streets , will, from sheer familiarity, and through natural shrinking from reminder, be dried to a stony indifference. " Let the dead past bury its dead " is a saying terribly true, and perhaps essential to the preservation of mankind. The world of ten years hence will shrug its shoulders if it sees maimed and useless men crawling the streets of its day, like winter flies on a window pane. It is for the sacred work to see that there shall be no winter flies. A niche of usefulness and self-respect exists for every man, however handicapped ; but that niche must be found for him. To carry the process of restoration to a point short of this is to leave the cathedral without spire. Of .the men and women who have this work in hand I have seen enough in France and in my own country, at least to know their worth, and the selfless idealism which animates them. Their devotion, courage, tenacity, and technical ability are beyond question or praise. I would only fear that in the hard struggle they experience to carry each day's work to its end, to perfect their own particular jobs, all so important and so difficult, vision of the whole fabric they are helping to raise must often be obscured. And I would venture to say : " Only by looking upon each separate disabled soldier as the complete fabric can you possibly keep that vision before your eyes. Only by revivifying in each separate disabled soldier the will to live, can you save him from the fate of merely continuing to exist." 17 There are' wounded men, many, whose spirit is such that they will march in front of any effort made for their recovery. I well remember one of these a Frenchman nearly paralysed in both legs. All day long he would work at his " macrame," and each morning, after treatment, would demand to try and stand. I can see his straining efforts now , his eyes like the eyes of a spirit ; T can hear his daily words : " II me semble que j'ai un pen, plus de force dans mes jambes ce matin, Monsieur!" though, I fear, he never had. Men of such indomitable initiative, though not rare, are but a fraction. The great majority have rather the happy-go-lucky soul. For them it is only too easy to postpone self-help till sheer necessity drives, or till someone in whom they believe inspires them. The work of re-equipping these with initiative, with a new interest in life, with work which they can do, is one of infinite difficulty and complexity. Nevertheless, it must be done. The Great Publics of our Countries do not yet, I think, see that they too have their part in the sacred work. So far they only seem to feel : " Here's a w r ounded hero; let's take him to the movies, and give him tea!" Instead of choking him with cheap kindness, each member of the public should seek to re- inspire the disabled man with the feeling that he is no more out of the main stream of life than they are themselves ; and each , according to his or her private chances, should help him to find that special niche which he can best, most cheerfully, and most usefully fill in the long future. The more we drown the disabled in tea and lip gratitude the more we unsteel his soul, and the harder we make it for him to win through, when, in the years to come, the wells of our tea and gratitude have dried up. We can do a much more real and helpful thing. I fear that there will soon be no one of us who has not some personal friend disabled. Let us regard that man as if he were ourselves ; let us treat him as one who demands a full place in the ranks of working life, and try to find it for him. In such ways alone will come a new freemasonry to rebuild this ruined temple of our day. The ground is rubbled with stones fallen, and still falling. Each must be replaced ; freshly shaped, cemented, and morticed in, that the whole may once more stand firm and fair. In good time, to a clearer sky than we are fortunate enough to look on, our Temple shall rise again. The birds shall not long build in its broken walls, nor lichens moss it. The winds shall not long play through these now jagged windows, nor the rain drift in, nor moonlight fill it with ghosts and shadows. To the glory of man we will stanchion, and raise and roof it anew. Each comrade who for his Motherland has, for the moment, lost his future is a miniature of that shattered Temple. To restore him, and with him the future of our countries, that is the sacred work. 18 INTER-ALLIED CONFERENCE OF DISCHARGED DISABLED SOLDIERS AND SAILORS, London, May, 1918. SECTION I.-PENSIONS AND ALLOWANCES Pensions in the United Kingdom. BY LT.-COL. SIR A. GRIFFITH-BO sc A WEN, M.P. (Parliamentary Secretary to the Ministry of Pensions). The title Ministry of Pensions is, in a sense, a misnomer. It is too wide and also too narrow. It 'is too wide since we do not deal with all pensions. We have nothing to do with Old Age Pensions we have nothing to do with Service Pensions, i.e., pensions given for long service and good conduct in the Army or Navy we have nothing to do with the pensions of Civil Servants of the Crown. The pensions we deal with are solely the disablement pensions of men who have suffered injury or impairment of health in the war, and the pen- sions given to the widows and dependants of those who have fallen. We also grant allowances for the children both of dis- abled men and of war widows. The title is too narrow, because we deal with much else besides pensions. The whole future of the disabled man comes under our purview. We are responsible for providing him with further medical and surgical treatment after discharge from the Services where necessary ; for his re- education or training in a new trade where his disability unfits him to go back to his old occupation and for finding him employ- ment a duty which we share to some extent with the Ministry of Labour. We ought indeed to be described as the Ministry of the Discharged Disabled Man, or be known by some such title, if a convenient title of the kind could be found. Treatment, Training and Employment will be dealt with in other sections of this Conference. I am going to deal in this paper simply with the matter of pensions. Here I should say at once that the Ministry is of recent origin. It is a war product. Disablement and Widows' Pensions were dealt with by three separate departments at the commencement of the war. All 19 Navy pensions were granted by the Admiralty. Men's disable- ment pensions were dealt with by the Commissioners of the Royal Hospital at Chelsea, who were, in a sense, a branch of the War Office. The pensions for officers of the Army, and widows' and dependants' pensions were dealt with by the War Office itself. It was only on February 15th of last year that the Ministry of Pensions took over these various duties. At the commencement of the war the pensions granted were very small in amount and were generally considered to be quite inadequate. A private who had been totally disabled received from 10s. 6d. a week to 17s. 6d. a week, according to the length of his service. A partially disabled private received from 3s. 6d. to 10s. 6d. For the loss of a limb the maximum amount was generally given by the Chelsea Commissioners, viz., 10s. 6d. a week. Before the South African War the widows of those who had fallen received nothing at all from the State, though some provision was made in most cases out of the funds of the Royal Patriotic Fund Corporation. After the South African War widows' pensions were fixed at 5s. a week, but only in the case of the widows of men who had been married " on the strength." For children there was a flat rate of Is. 6d. a week. During the war a series of new warrants were brought out, both by the War Office and the Admiralty, which gradually improved the conditions. But these new warrants were unsatisfactory in many respects, and no carefully considered or co-ordinated scheme was in existence. Great dissatisfaction arose in the country at the manner in which the brave men broken in the war and the widows, children and dependants were being treated, with the result that Parliament decided to create a Pensions Ministry to deal specially with the question. The Eight Hon. G. N. Barnes, M.P., who is now a member of the War Cabinet, was appointed -to be the First Minister of Pensions, and he at once set to w r ork to bring out a new warrant for the Army and a new Order in Council for the Navy, granting pensions on a more liberal scale and codifying and co-ordinating the various warrants and enactments that had been in force up to date. The main features of Mr. Barnes' warrant are the following : 1. The scales of pensions were generally raised, 27s. 6d. being fixed as the amount payable to a totally disabled man, total dis- ablement being defined as : Loss of two or more limbs. Loss of an arm and an eye. Loss of a leg and an eye. Loss of both hands or of all fingers and thumbs. Loss of both feet. Loss of a hand and a foot. Total loss of sight. Total paralysis. Lunacy. 20 Wounds, injuries or disease resulting in disabled man being permanently bedridden. Wounds of or injuries to internal, thoracic or abdominal organs, involving total permanent disabling effects. Wounds of or injuries to head or brain involving total perma- nent disabling effects or Jacksonian epilepsy. Very severe facial disfigurement. Advanced cases of incurable disease. In the case of Non-Commissioned and Warrant Officers there are additions in accordance with rank. Partially disabled men are pensioned according to a descending scale corresponding with the degree of their disablement, the smallest pension given being 55. 6d. a week, which is the rate for a man disabled 20 per cent., while for minor disablements of less than 20 per cent, gratuities are awarded. It will be seen from these figures what a great advance has been made upon the practice prevailing before and at the beginning of the war. II. Children's allowances were raised to the following amounts in the case of the totally disabled man : 5s. for the first child, 4s. 2d. for the second, 3s. 4d. for the third, and 25. Qd. for each of the succeeding children. By the new amending warrant which has just been brought out by the present Pensions Minister, the Eight Hon. John Hodge, M.P., the children's allowances have been further in- creased to 6s. Sd. for the first child, 5s. for the second, 45. 2d. for each of the succeeding children. The amounts paid for children in respect of partially disabled men correspond, like the pensions, with the degree of disable- ment. III. To meet the case of men who were earning high wages before the war, and whose pecuniary sacrifice has, therefore, been great, another system was introduced, called the Alternative Pension. This is based on the man's ascertained pre-war earn- ings, his present earning capacity being taken into account. The effect of the provision is as follows : A totally disabled man who was earning 505. a week before the war can get in lieu of his ordi- nary disablement pension an alternative pension of 505. a week ; while if he were earning more than 505. a week he can get that amount plus half the amount beween 505. and his total earnings up to a limit of 1005. that is to say, a man who was earning 1005. a. week before the war can get 505. plus half the difference between 505. and 1005., or, in other words, he can get as much as 755. a week. IV. The pensions just described are payable to men whose dis- ablement has been the result of, or has been aggravated by r 21 military or naval service, and has not been the result of their own misconduct or serious negligence. Unfortunately, however, thousands of men were admitted into the Services who were unfit and ought not to have been so admitted, and have had to be dis- charged for disablements thafVere in no way due to service, and for such there is a system of gratuities or temporary allowances as a sort of compensation for the fact that they were taken away from their homes and passed into one of the Services. These gratuities may amount to as much as ^150, and they average probably something like 30. The amounts vary in accordance with the length of service, the degree of disablement, and one or two other considerations. V. Widows' pensions were also increased, and now they stand at half the amount that a man would receive if totally disabled, i.e., 13s. 9d. a week, with the addition of children's allowances on the same scale as those given for the children of totally dis- abled men. The pension is increased to 15s. a week when the widow reaches the age of 45. The system of Alternative Pensions also applies in the case of widows, and under the Barnes Warrant they were fixed at half what a totally disabled man would get, the highest possible amount being, therefore, 37s. 6d. ; but under Mr. Hodges' new warrant this has been increased to two-thirds of what the man could have got, or, in other words, the highest amount now is 50s. a week. To meet the case of widows whose husbands came by their death not as the result of military service, there is a terminable pension of 15s. a week for the period of the war and twelve months afterwards, corresponding to the gratuities given to men disabled in non-attributable cases. VI. Besides the widows of fallen men, there are also parents and other relations who may have been dependent upon them, and for these there is a system of dependants' pensions, based on pre-war enlistment, ranging from 15s. a week as a maximum to 3s. 6d. a week as a minimum. On the assumption that all deceased soldiers and sailors would, had they lived, have supported their parents if in pecuniary need and incapable, by reason of infirmity or age, of self-support, pensions up to 15s. a week are given to parents in such circum- stances. VII. Very liberal provision has been made to enable disabled men to accept treatment and training where it is deemed neces- sary. It was found that many men required one or the other, but the temptation to go back to work temporarily and in conse- quence to impair health, or to accept blind-alley occupation at good wages for the moment, was so great that many men were unwilling to accept either treatment or training. It was, there- fore, enacted that a man undergoing either, and thereby pre- vented from earning, should be paid an allowance for himself equal to the total disablement pension, i.e., 27s. 6d. a week, and 22 that in addition to this the wife, if the man was compelled to live away from home, should receive a weekly sum equal to a widow's pension, i.e., 13s. 9d. a week, and that the children's allowances should be paid. In addition to this, a bonus of 5s. a week, w^hich is paid at the completion of the course, is given to men who receive training. These provisions have been very effective in making possible and popularising this very necessary re-education of the men, which has made great strides since the warrant was issued. So much for the actual terms of the warrant. It will, however, be found in the experience of everybody that very nearly as much depends on the interpretation and administration of the warrant as on the terms of the warrant itself. When the Ministry of Pensions took over the work from the various naval and military authorities we came to the conclusion that the administration of the previous warrants had been to some extent illiberal and niggardly, very strict rules having been made as to what constituted naval or military duty, and pensions being refused in all cases which did not conform to these rules. We decided that a broader and more liberal spirit must be intro- duced, with results which I think have been on the whole satis- factory. To give one or two examples. A man who met with an accident was refused pension under the old system unless he was actually on duty at the time, i.e., on parade, or something of that sort. We have now decided that pensions shall be given in the case of all accidents occurring oversea, unless the man was himself seriously to blame ; and as regards accidents at home , we give pensions, provided that they occur when a man is at, or about, the place where he ought to be and is not blameworthy. In the case of men on leave, we give a pension if he comes by an accident on the Journey home or on the journey back, and similarly a man walking out from his camp or billet, and return- ing to his camp or billet, is pensioned. What happens to him while he is actually on leave, or out for the day, and not going out or returning, is a matter for him, and we are not responsible. The question of whether a disability was attributable or not, or aggravated or not, always presents great difficulties, and our principle is to give the benefit of any reasonable doubt to the man and not to the State ; but in view of the fact that mis- takes are bound to be made by Medical Boards, and also by Awarding Officers, an Appeals Tribunal has been set up to which a man may apply for hearing as to whether his disability was due to service or not, and the Minister, as a general rule, accepts the decisions of the Appeals Tribunal. Another difficulty which had arisen under the old warrant was that it w r as the custom of Medical Boards to ask a man, when they were reviewing a pension, what he was earning, and the pensions were reduced if a man were earning high wages. This system, which had very bad results, by preventing men from going to work until their pension had been settled, has been abolished, and the degree of disablement on which the pension 23 depends is assessed now in accordance with the man's physical- impairment or state of health and upon nothing else. The plan whereby men receive their pensions was up to quite lately the following. An Army Medical Board decided that a man was no longer fit for service and should be discharged, and the discharge followed three weeks after this Board. During that time he remained on Army pay, and the Local Committee were notified that he was going to be discharged, opportunity being thereby given for the Local Committee to get into touch with him. At the end of the three weeks his pension was deter- mined in accordance with the degree of his disability found by the invaliding Board. If delay occurred, which is bound to happen in a certain number of cases, owing to insufficient in- formation, &c. , the man received a temporary allowance until the pension was fixed, w T hich amounted to 145. a week. This sum was obviously inadequate, and it has now been raised to 27s. Qd. a week, with children's allowances. The three w r eeks' interval during which he remained on Army pay has been abolished, and he is discharged immediately after the Medical Board, receiving at the time coupons for his temporary allowance for four weeks. If his pension is not settled then, the temporary allowance con- tinues until it is. Pensions are of two kinds, permanent and temporary. A permanent pension is given in all cases where the disability has reached its final stage and where, therefore, no change for the better or for the worse is likely to take place, e.g., in amputation' cases or cases of blindness, and so forth. In other cases tempo- rary pensions are given, which are renewable from time to time on the finding of Medical Boards, and which vary according to the degree of disablement found on each occasion. It is em- phatically laid down in the warrant that no permanent pension once granted, unless, of course, granted in error, can be reduced, though it may be increased if the degree of disablement is in- creased. It is also laid down definitely that no man is to suffer' in his pension on account of any improvement in his earning capacity caused by his learning a new trade. Such in the main are the provisions made by the British Government for the gallant men who have fought for us and for the widows and dependants of those who have fallen. I do not claim that we have done all that is possible, but the figures I have quoted show what an immense advance has been made on our pre-war practice, and I think that I am entitled to say that we have made a large contribution both towards compensating them for their losses and also towards re-establishing them as' useful citizens in the future. In addition to these provisions, made by Mr. Barnes, for men serving in the ranks a new warrant, based on similar principles, was brought out by him for officers. Speaking generally, a second lieutenant's pension is about double that of a private, and" for the higher ranks additions are made, just as is done in the case 4 of warrant officers and non-commissioned officers. 24 In this paper I have dealt exclusively with pensions, and have said nothing about the work done by Local Committees in making advances to men pending the receipt of pensions or when waiting for treatment, &c., or in supplementing pensions in some cases. A paper will be read on the work of the Local Committees gener- ally, and I will only say, on behalf of the Ministry, that their assistance has been most valuable, and that without them, with their local knowledge and sympathetic touch, pension administra- tion would be well-nigh impossible. 25 LES PENSIONS EN FRANCE. PAE M. ALEXANDEE LEFAS, Depute d'llle-et-Vilaine. Les dispositions nouvelles edictees par le Gouvernement et par le Parlement francais ont trait (1) a 1' amelioration du regime des pensions de la Guerre et de la Marine. (2) a la re-education professionnelle des mutiles de la Guerre et aux soins ulterieurs que leur sante pent reclamer. I. Regime des Pensions. Deux projets de loi ont ete deposes par le Gouvernement. Le premier est relatif aux pensions des inyalides de la guerre, des veuves et des orphelins, et, en certains cas, des ascendants dont les descendants ont ete tues. Le second projet est relatif a la revision des pensions d'anciennete pour les sous-officiers et les officiers de carriere, retraites avant la guerre, et qui ont repris du service. Ce dernier projet est actuellement soumis a 1'examen de la Commission des Pensions, de la Chambre des Deputes. Le rapport de M. Le Brecq, depute, sera prochainement depose. Le premier projet a ete vote par la Chambre des Deputes, sur le rapport de M.M. Pierre Masse et Lugol, deputes. II est actuellement soumis a 1'examen de la Commission du Senat, qui ne 1'a pas encore vote. Le texte n'est done pas encore definitif. Mais voici les grandes lignes de la reforme, exposees dans le discours pronounce par le President de la Commission a la Chambre des Deputes.* (1) En ce qui concerne les invalides de la guerre, le projet de loi etablit en principe que les blessures ou les maladies et les aggravations de maladies survenues a un homme qui est sous les drapeaux, sont considerees comme survenues par le fait ou a 1'occasion du service militaire, si 1'Etat ne prouve pas le con- traire. Elles ouvrent droit a pension, si rinfirmite qui en resulte est definitive ; et a gratification renouvelable tous les deux ans, si rinfirmite est sujette a guerison ou a aggravation. Les gratifications sont concedees et servies comme les pensions, au lieu d'etre des secours gracieux du Ministre, comme elles 1'etaient jusqu'a present ; mais elles peuvent etre augmentees ou diminuees tous les deux ans, suivant 1'etat de 1'interesse. Le taux de la pension du simple soldat ou marin variera de cent a mille cinq cents francs, suivant son degre d 'invalidity. t * Of. discours de M. Alexandre Lefas, seance du 30 Novembre, 1917 Pour la discussion du projet, voir les seances de la Chambre des Deputes. f Jusqu'a present le maximum de la pensien du simple soldat n'etait que de 975 Francs. 26 Un decret a regie le mode d' evaluation de 1'invalidite, d'apres un ,bareme medical, poar chaque blessure ou maladie. Le projet de loi indique (articles 6 et 7) comment sera evalue le degre d'innrmite, sur les bases du meme bareme, pour les invalides atteints de plusieurs blessures ou maladies. Dans ce dernier >cas, la pension du simple soldat ou marin peut etre portee jusqu'a an maximum de mille huit cents francs, pour certains cas par- ticulierement graves. Pour les officiers, les taux de pension d'invalidite sont -restes a peu pres ce qu'ils etaient avant la guerre. Les taux des sous- officiers ont ete releves, puisque la pension du simple soldat est augmentee. Mais les relevements proportionnellement les plus eleves sont ceux qui ont ete faits en faveur des simples soldats ou marins (33 per cent, pour 1'mvalidite totale, et meme 45 per cent, quand 1'invalidite totale est accompagnee de certaines infirmites multiples) . Le projet de loi dispose egalement, qu'en outre de sa pension, 1'invalide recevra une majoration annuelle pour chaque enfant de moins de seize ans a sa charge. Cette majoration, proportion- nelle au taux de 1'invalidite, est de 10 francs par an pour une invalidite egale a 10 per cent., et de 150 francs pour une invalidite egale a 100 per cent. Les maj orations d' enfant sont les memes, quel que soit le grade de 1'invalide. Elles cessent apres le grade de chef de bataillon, conformement aux reglements fran^ais sur la solde, qui n'accordent d'indemnite pour les charges de famille que jusqu'a ce grade. (2) En ce qui concerne les veuves des militaires ou marins marts des suites de blessures ou de maladies survenues par le fait ou a 1' occasion du service, elles re9oivent une pension qui varie suivant le grade du defunt, et suivant que la mort est due a une blessure ou a la maladie. Le minimum propose par le projet de loi est de six cents francs pour les veuves de simples soldats ou marins. Si le militaire est mort sous les drapeaux ou dans 1'annee qui suit son retour dans ses foyers, la mort est presumee avoir ete causee par le service militaire, a moins que 1'Etat ne prouve le contraire. La veuve pensionnee qui a des enfants re9oit, en plus de sa pension, une majoration annuelle de 150 francs par enfant de moins de seize ans a sa charge. Les articles 12 et 14 du projet de loi reglent les droits des veuves et des enfants, en cas de remariage de la veuve, ou quand le militaire decede laisse des enfants de plusieurs lits. (3) En ce qui concerne les orphelins, ils heritent des droits que leur mere avait ou aurait eu : c'est-a-dire que la pension due a la veuve est servie a ses enfants, mais seulement jusqu'a ce que le dernier de ces orphelins ait atteint 1'age de 21 ans. Les enfants naturels reconnus jouissent des memes droits que les enfants legitimes. (Articles 15 et 16 du projet de loi.) 27 (4) En ce qui concerne les ascendants, dont le fils ou petit fils a ete tue, et ne laisse pas de veuve ni d'orphelin, le projet de loi admet que les ascendants les plus proches comme degre pourront reclamer une pension alimentaire au Tribunal, s'ils sont infirmes ou ages. Le taux de cette allocation ne varie pas suivant le grade. II a ete fixe par la Chambre a 200 francs pour un ascendant, a 400 francs pour deux ascendants, et par excep- tion a 600 francs pour la mere veuve ou la grand 'mere veuve. En outre, pour les peres ou meres qui ont perdu plusieurs enfants, 1' allocation est augmentee de 100 francs par enfant, a partir du second enfant decede sous les drapeaux ; et elle peut lour etre accordee par le Tribunal rneme si les enfants ont laisse des veuves ou des orphelins qui touchent une pension. Le projet de loi regie encore, d'une part, la procedure des reclamations et des proces en matiere de pension, et d'autre part, certaines situations speciales, celle des mobilises employes dans les usines ou bien aux travaux agricoles, celle des alienes, celle du personnel du Service de Sante militaire, celle des militaires disparus et de leurs ayants cause ; les questions de cumul ou d' option entre les di verses allocations et pensions qui peuvent etre dus par 1'Etat a des titres divers, &c. II a ete complete par divers projets, dispositions ou lois relatifs a la pension des marins du commerce, victimes d'evenements de guerre ; aux soins donnes a 1' education des enfants de mili- taires" morts ou invalides, lesquels enfants sont adoptes comme Pupilles de la Nation ; a la reforme de 1' institution ancienne dite ' Hotel des Invalides," &c. Notons qu'en vertu des lois militaires, le pension ou la gratifi- cation due a un invalide est calculee uniquement en fonction de son invalidite et de son grade, sans tenir compte du gain qu'il peut encore se procurer par son travail ; ce qui est un encourage- ment pour lui a reprendre le travail. De meme, pour les veuves et les orphelins, la pension est independante des ressources qu'ils peuvent se procurer par ailleurs, et notamment par leur travail. Get ensemble de dispositions sera complete par une loi sur les pensions des victimes civiles de la guerre, et par la loi sur la reparation de dommages materiels de la guerre. II. Autres Mesures Legislatives. (1) La loi du 2 Avril, 1918, consacre 1'institution d'un Office National des Mutiles et Eeformes de la Guerre ayant la person- nalite civile. Get Office constitue un organe de liaison entre les Administra- tions publiques et les Associations ou GEuvres privees qui s'occupent des militaires designes a 1'article 1. II a pour objet 28 de centraliser les informations concernant 1'action des dites ad- ministrations, associations ou oeuvres privecs, d'encourager et de faciliter la readaptation au travail des militaires susvises ; d'etudier les dispositions legislatives et reglementaires suscept- ibles d'etre prises en leur faveur et d'en suivre 1' application, et, d'une maniere generale, de leur assurer le patronage et 1'appui permanents qui leur sont dus par la reconnaissance de la nation. II est rattache au Ministere du Travail et de la Prevoyance Sociale. Dans les departements , des Comites departementaux et des Comites locaux doivent fonctionner en liaison avec 1' Office National. La meme loi institue une procedure pour les demandes formers par les mutiles qui desirent etre re-eduques. Elle donne 1' assurance que la pension ne sera point reduite du fait de la re-education et que la famille du militaire en re-education ne subira, de ce fait, aucun amoindrissement des sommes versees par 1'Etat. (2) Plusieurs propositions de loi se rapportent aux soins qui, dans 1'avenir, peuvent etre dus aux invalides de la Guerre. La question est complexe pour certaines maladies, telles que 1' aliena- tion mentale ou la tuberculose ; le probleme deborde le chapitre de la Guerre, et s'etend jusqu'au systeme general de prophylaxie adopte a 1'egard de ces maladies. Par ailleurs, il a ete propose que 1'Etat prit a sa charge les soins medicaux et pharmaceutiques necessites par la blessure ou par la maladie contracted au service. Mais on peut concevoir differentes faons de realiser ce programme : soit par 1'abonne- ment a des societes de secours mutuel, soit par 1'inscription sur la liste de 1' assistance medicale gratuite (qui jusqu'ici ne compre- nait dans les communes que les personnes privees de ressources), soit par 1'hospitalisation dans certains etablissements dependant de 1'Etat ou de 1' Hotel des Invalides. Ces di verses questions sont a 1' etude. (3) En ce qui concerne I'etablissement des re-eduques ou leur placement, une proposition de loi, votee par la Chambre sur le rapport de M. Bonnevay, et actuellement soumise au Senat, sur le rapport de M. Strauss, a pour but de faciliter aux pensionnes et a leurs veuves 1' acquisition et 1'amenagement de petites pro- prietes rurales et d'habitations a bon marche. Les societes de credit ,agricole et de credit immobilier seront autorisees a leur preter, a tres faible interet, un capital dont le remboursement annuel est garanti par une hypotheque sur le fonds achete, une assurance sur la vie de 1'emprunteur, et, subsidiairement , pour les paiements annuels, par une faible partie des arrerages de la pension. La Commission des Pensions de la Chambre des Deputes etudie actuellement, sur le rapport de M. Lefas, une autre combinaison qui permettrait au pensionne de transformer une partie de sa 29 pension en un capital, pouvant etre consacre a 1' acquisition d'un outillage professionnel ou d'une propriete rurale. En ce qui concerne le placement des invalides, un grand nombre d'emplois leur ont ete reserves dans des administrations publiques et dans les grandes entreprises ayant obtenu des con- cessions de 1'Etat. D'autres propositions ont ete faites au point de vue du place- ment dans les industries privees : mais cette question est plus delicate, et les difficultes de la bien resoudre sont telles, qu'il parait premature de 1'aborder avant que la necessite n'en soit demontree par les faits, apres la guerre. Jusqu'ici, le besoin de main d'oeuvre est tel, que les invalides n'ont pas de difficultes a se placer avantageusement ; et il semble bien que cet etat de choses subsistera meme apres la demobilisation. ANNEXE. Bareme des pensions, d'apres le texte qui & ete vote par la Chambre des Deputes. EXTEAIT DES BAEEMES DES PENSIONS. 1. Pensions d'Invalidite. Armees de Terre et de Mer. Grades. Adjutant-Chef Adjutant Aspirant Ser ent-Major Sergent Caporal Soldat Sous-Ojficiers et Soldats. 100% Officers. General de Division ... Vice-Amiral ... 12,600 General de Brigade ... Centre- Amiral . 9,600 Capitaine de Vaisseau t 7,200 Lieutenant-Colonel ... . Capitaine de Fre'gate . 6,000 Chef de Bataillon ... ... Capitaine de Corvette . 5,025 f 4eme echelon Lieutenant de Vaisseau , 4,905 Capitaine 3 Seme J 2eme echelon echelon 9) M 4,665 4,425 (ler e'chelon , 4,185 f4eme Echelon Enseigne de Vaisseau de lere classe. 4,185 Lieutenant... -{ 3eme echelon 55 55 ** 4,005 | 2eme echelon 3.825 1 ler echelon 55 '5 3,645 ( 2eme echelon Enseigne de Vaisseau de 3,585 Sous-Lieutenant ... i 2eme classe. ( ler echelon ,, 2,985 Aspirant de Marine 2,625 2,095 ,990 ,920 1,850 ,780 1,640 1,500 30 2. Pensions de Veuves ou d'Orphelins. de Mer. Armees de Terre et Grades. Taux excep- tionnel. Taux normal. Taux de rever- sion. Officers. General de Division ... Yice-Amiral 5,250 3,500 3,500 General de Brigade ... Contre-Amiral 4,000 2,667 2,667 Colonel ... ... ... Capitaine de Yaisseau 3,000 2,000 2,000 Lieutenant-Colonel ... Capitaine de Fregate 2,500 1,667 1,667 Chef de Bataillon Capitaine de Corvette 2,000 1,400 1,333 f4eme echelon Lieutenant de Yais- 1,950 1,350 1,300 seau. Capitaine { Seme echelon 1,850 1,300 1,233 | 2eme echelon 1,750 1,250 1,167 1^1 er Echelon 1,650 1,200 1,100 f 4eme echelon Enseigne de Yaisseau 1,650 1,200 1,100 de lere Classe. Lieutenant return to their pre-war occupations. Nor can those others be- 85 neglected who, although having already undergone a complete course of training, are compelled to go through a further period of training, the learning of a new trade or profession having become necessary as a result of accident or some other mis- fortune. There being every indication that the protection of disabled soldiers and sailors will become a permanent institution, and there being a forecast of a big emigration at the end of the w^ar, the systematizing of the questions regarding the international protection of disabled men is most necessary, and ought not to be put off any longer : every effort should be made towards the solution of the problem before the events cause it to become of too great an urgency and preoccupation. It is evident, meanwhile, that the whole problem touching upon the question of the international protection of disabled soldiers and sailors, contains two lesser problems that refer to details : (1) Will the State of origin and the national protective institutions be held to extend their protection of disabled men, on the latter electing to reside in foreign countries, and, if so, how could it be done in practice ; (2) would the countries of immigration be held to co-operate in this protection, and, if so, within what limits, and how could it be done in practice? The solution of the first problem is fairly simple, and, there- fore, does not entail any lengthy discourse, as it can only be based on the following conception : that, in so far as they can be practically carried out, the State of origin and the private national protective institutions will be held responsible for the fulfilment abroad of all obligations contracted by them towards disabled men prior to the latter 's emigration. The obligation of protection, once admitted, cannot be repudiated because the person entitled to said protection takes a step that is perfectly normal, and that he has a right to take, such as transferring his residence to a foreign country for legitimate reasons. This is important, especially with regard to pensions, subsidies and other financial aid ; it seems evident , therefore , that the burden of these aids should continue to be borne by the country of origin ; nor could it be admitted, or pretended, that this burden should be taken over by the State w T herein the disabled man has actually elected to reside. In this respect the only dispute that might arise would be regarding the modalities of said fulfilment, and on the subject of a few of these we shall speak further on. On the other hand, it is much less easy to define the attitude and the limits of tl%e co-operation in the protection of disabled men by the State wherein he has elected to actually reside. This task is all the more difficult by reason of the necessity of ex- amining, before anything else, the status of the various institu- tions and the texts of the laws enacted for the protection of dis- abled men that exist in each State. And not only this, but, as will be seen, there must be the further enquiry into whether or not they can be applied to disabled men in their quality of strangers. In the second place, the difficulty increases because 8G of the nearly total absence of adequate national and international legislation on emigration and on labour in foreign countries ; had these laws existed, they could have served as a basis for the adapting of regulations concerning the special emigration and the special labour in foreign countries of disabled soldiers and sailors. The duty of all Governments to carry out national or international assistance does not date only from the war, as has been so justly remarked. This is a duty that is inherent to social organisations, and it must be truthfully admitted that much has been done in this respect by the Germans. What is especially noteworthy is the practical and immediate use which that country has been enabled to make of all the State's benefits instituted since long before the war, particularly as regards the professional training of workmen who have been disabled by acci- dents that occurred w r hen they were at work. Whilst in other countries hardly' anything has been done in this respect, except in a few noteworthy cases, and as a result the entire system of protection for disabled soldiers and sailors has had to be initiated from the very beginning. Under these conditions, given the deplorable neglect, of which the majority of Governments have been guilty up to present, of all that has reference to the assistance to be given to foreigners, this Conference has been called together in order to discuss this grave problem, with a view of arriving at a satisfactory solution. However, whatever adequately practical regulations for this international protection may result from the perusal of this explanation and the debate that will follow, it were well to make the affirmation here, as a preamble to the study of this subject, that it is the duty of all the Allied Governments to co- operate most generously and with the greatest possible solidarity to the protection itself. This solidarity is dictated by practical necessity, for otherwise, in view T of the organisation of official representation and the authority, as a whole, of each Government abroad, the protection of disabled men outside their own country, if effected by means of the said organisation and within the limits of the said authority, would become de facto impossible of realisation as regards its most notable characteristics, and it would probably be reduced to a mere form of financial assistance that would be subject to all sorts of complications and encum- brances, that in any case would be inevitable. But, above all, this rightful solidarity would be in complete harmony with the nature of the present struggle of the Allies against the common enemy. In this crusade of the entire world in defence of the liberties and the nationality of peoples, the soldier's nationality has nearly lost all importance, having been shallowed up in the communion of the great cause. The different fighting armies are, in reality, but parts of one big army, and each soldier a soldier of the collective mass. The disabled soldiers and sailors of the different Allied countries are not, nor ought they be, strangers to each other. And by carrying round the world the signs of the common martyrdom, they become the sacred emblem of a solidarity that, with time, will be greater than that of arms. Side by side with the principle of the duty incumbent on each 87 Government, of protecting their own disabled soldiers and sailors, must be placed the principle of the same duty towards these men, that is incumbent on all the Allied people. Now the practical form to be given to the carrying out of this international duty by the Allied Nations can only be based on the following broad programme of measures to be adopted : (a) The direct providing for the elimination from the different legislations, and from the local public opinion, of all prejudiced regulations and of all hos- tility towards the disabled foreigner, inasmuch as he is a foreigner ; (6) the assistance to be given by the country of residence to the country of origin as regards the observance of the laws belonging to the latter ; (c) the equal treatment of the disabled foreigner with that given to the disabled native in all that is done in favour of the latter as far as being disabled, within the limits, however, of all practical possibilities, and with the exclusion of such measures as are already assured by the protective laws and institutions in- herent to the country of origin ; (d) special regulations to be drawn up in favour of the dis- abled foreigner as far as he is a foreigner. The unfavourable regulations which, given the actual condition of the legislation belonging to the Allied Nations and their Colonies , might strike the disabled man in his quality of foreigner , have reference in a few r cases, as is well known, to the liberty of access to the land of immigration, for instance, because of a state of indigency, practical impossibility to earn a living, illiteracy, infirmity, criminal precedents, transfer abroad as a result of propaganda by means of offer or promise of employment of any kind (the Contract Labour Act on Immigration, passed in the United States Congress, February 7th, 1917), or by means of steamer tickets paid for by a third party ; others , to the access , when allowed, or to the abandon of foreign territory after a certain period of residence (so-called taxes of immigration and re-emigration) ; others strike at the liberty of labour or of that t)f the exercise of professions (prohibition or more or less broad limitation as regards the carrying on of certain liberal professions, the exclusion or limitation to a very small quota in the com- petition of foreigners in certain labour activities, and more especial!) 7 with regard to those connected with public administra- tions, taxes on individual labour, that are levied either directly from the foreign labourer, or indirectly through the factory em- ploying him) ; and finally others, which in reality happen much more rarely, that have even regard to the possibility of enjoying the advantages of public instruction (admission to schools being conditional on the number of places vacant). And side by side with all these restrictions, the tendency in a few countries of increasing them both as to quality and quantity, the distrustful 88 attitude and struggles on the part of the local labour organisa- tions, and only too often the absolute lack of initiative and interest on the part of the authorities. Now, whatever may happen as regards the total abolition of all these elements unfavourable to the foreigner in their general relations towards emigration and foreign labour, it is essential that they should disappear in the presence of disabled soldiers and sailors. Kemember that by stopping even one of these men it would make it practically nearly impossible for the disabled men belonging to the State where such a regulation was kept in force, to emigrate. This would be the case with the restriction relative to physical unfitness, which could refer to nearly all the disabled men as such, especially if this restriction were applied to the limits at present allowed it by the text of the law. As an example of this, the above-mentioned Immigration Act of the United States may be quoted, wherein access to the territory of the Confederacy is forbidden even to anyone who, " at the time of the medical examination, the doctor entrusted with said ex- amination declares them to be mentally and physically defective, to such an extent that it would constitute for the man examined a hindrance to the possibility of his earning his living." And the results of such restrictions would be all the more iniquitous from the fact that, as has already been said, the majority of disabled men who will presumably feel obliged to leave their native land at the conclusion of the war will be made up of those who, on the outbreak of hostilities, were already established in the country where the said restriction is in force, and that are attracted back there because they wish to rejoin the families they left behind, and to try to gather up the interrupted thread of their pre-war occupations. To them the prohibition to re-immigrate will come as a bitter mockery of their sacrifice, as a cruel disillusion following the accomplishment of duty, and at the same time it will appear as a reward to the cowards who chose not to abandon their peace-time occupations ! It would seem that the necessity of avoiding these results is fully realised, for there has been a Bill presented in the American Congress which aims at facilitating the return to the United States of the citizens or subjects of the Allied States " wiio have become inadmissible on account of disabilities received during military service in the war "; it is to be hoped that this Bill will soon become law and be placed on the Statute Book. It would be expedient for the other States who possess the same kind of legislature to do likewise ; in the meanwhile , it would appear necessary to extend this same benefit to those disabled men who were not residing abroad prior to their military service in the present war, yet who may have no less urgent reasons for leaving their native land, as, for instance, the transfer of their own families, or the decease of all their relations in their native town or village concurring with the establishment abroad of a near relative. 89 Together with the doing away of this restriction, it would be also desirable if, as far as the disabled men are in question, the abolition of the other above-mentioned restrictions could be ob- tained : illiteracy, criminal precedents, indigency, the payment of the journey's ticket by a third party, the " labour contract " clause. The opportuneness of the suppression of the last two causes for prohibition of immigration is all the more easily apparent that there is little probability of their actually being verified; also, the danger deriving from them is in general a negligible quantity; as for the others, nothing appears to be in the way of their suppression. To begin with, the same considerations apply to illiteracy and to physical unfitness. The illiterate men that have become dis- abled in this war, and who, especially if residing abroad, went back to their native land to report to the military authorities, are not less deserving than the non-illiterate disabled men of the benefit of readmission to the country of their former residence. For reasons of justice and of political expediency, it would be fair to also readmit the illiterate men who, having gone back to their country in order to join the Army, were lucky enough not to become disabled. Even for these men such a treatment would be unjustifiably vexatious and sad which prevented them from returning to the land where they probably had left all their posses- sidns as well as their dear ones, on the termination of their services given in favour of their native country. Even at the risk of going beyond the strict limits that have been established as regards the scope of this paper and of the work of the Conference, I beg to be allowed to formulate the hope that a clause will be inserted in the laws belonging to those Allied States that eventually forbid immigration to illiterates, making an exception in favour of those who, having been residents of these same countries, had absented themselves to take part in the present conflict. Besides, this same Act of February 5th, 1917, on immigration into the United States appears to furnish another argument in favour of such an exception, inasmuch as it does not consider illiteracy as an absolute stumbling-block to admission into the States ; the efficacy of this cause for non-admission is mitigated by a series of exceptions which are evidently based on reasons of equity and of opportuneness, one of these being, notably, relative to those foreigners who had already been " legitimately admitted into the United States, and had resided there continuously for a fixed period of five years, and returned to the States within six months of the date of their departure." Now, would it be fair and just to treat with greater severity the foreigners who, having fulfilled all the other conditions, absented themselves from the United States not for personal reasons, but for the fulfilment of a duty, unable to state for how long a period they would have to remain absent, and, because of happenings independent of their will, w T ere obliged to stay away from the United States for a period of time exceeding six months? 90 Also with regard to criminal precedents, or at least for those referring to the period prior to that of the military duties that resulted in disablement, it ought, apparently, not to constitute an obstacle to immigration for disabled men. At all times, and to-day more than ever, when the armies are fighting for a common cause of so sacred a character, and against so vile an enemy, war has proved itself a moral regenerator, and a school for the awaken- ing of consciences. With regard to this, it ought to be remem- bered that there have been certain proposals made for some changes of a legislative character, in order to mitigate the punish- ments to which disabled men have been condemned as a result of their having committed crimes of a certain category, and having later behaved in such a manner as to indicate their repentance and reform. And identical measures ought to be taken with regard to the clause having reference to indigency , all the more so that , in view of the payments of pensions and of other financial subsidies that have been assured to the disabled men by their native Govern- ment and by the various protective and private institutions, their coming under the heading of real and proper indigency does not appear either possible or probable. And for this same reason there ought also to be the suppression of the obligation, established by the laws of certain States, as a condition of permanency in their respective territories, said obligation consisting in finding work within a more or less limited period of time, or the making of a deposit of a certain sum for each member of the family, whether or not capable of working. And finally, on the desirability of abolishing, with regard to disabled men, all forms of special taxation levied on the foreigner as such, it is not needful to dwell. And I only intend to hint at the further desirability that, at least as regards the disabled men returning to a foreign country, wherein they were established at the time of their recall to arms, and whence they absented them- selves exclusively for the purpose of fulfilling their military duties, certain facilities should be extended, as, for instance, immunity from custom duties with regard to luggage and tools. With these last considerations, that refer much more to the elimination of unfavourable regulations, which, if enforced, would attain the disabled men , than to special facilities extended to their further advantage, we have come within the scope of the other categories of measures to be taken, returning to the subject of international protection of disabled soldiers and sailors, at which we hinted further back, and about which it is time we should speak at greater length. And, first explaining that it is not possible to deal with each one in detail , or even to simply enumerate them in their totality a task evidently exceeding the limits of this report, and that would, besides, be nearly impossible, given the progressive character of a few of them as regards the assistance which the State wherein the disabled man elects to live, to the State of origin for the observance by the latter of their own laws and obligations towards : 91 the disabled man, one of the easiest measures to be put into effect in this respect would be, without any doubt, the payments of the disablement pensions to be made abroad. If, for the receipt of these payments, it should be indispensable that the disabled man should present himself each time at the nearest Consulate, it would be the cause of grave complications for 'those residing in districts where there is no Consular Office, nor one to be found in the near neighbourhood, and this would necessitate disbursements, the loss of valuable time, the exacting of power of attorneys, and other similar inconveniences. There- fore a way ought to be found for simplifying the matter, and of allowing the disabled man to cash his pension within the district of residence, if possible, and from those same local authorities that are entrusted with the satisfying of the pension claims due to the indigenous disabled men. It is evident, hpwever, that, given the lack of similarity between the administrative organisa- tions, and more especially as regards the pension bureaus of the different States, the final decisions of the authorities can be arrived at only after the exchange of views, and the drawing up of appropriate international agreements, fortunately of which important examples are not lacking, belonging to very similar subjects. I will cite, as an instance, the labour treaty drawn up between Italy and France, 15th April, 1904, that accords facilities with regard to the payment in France of pensions due to Italians and to Frenchmen at the Italian National Bank, and vice versa (Art. I B). Another measure to be taken, akin to the preceding one, and not less important, is the one connected with private national institutions, created or working in whatsoever manner abroad, with the object of protecting the national disabled men ; these institutions ought to find, as far as is possible, authoritative aid and support for the carrying out of their task amongst the authorities of the country wherein the disabled men have elected to reside ; and the co-operation between them and the public and private local protective institutions for the disabled men, ought to be* not only allowed, but encouraged. With regard to extending to the foreign disabled man the advantages enjoyed in each State by the indigenous disabled man, the first principle to be followed in this matter appears to be that of the application of the extension itself in the broadest and most unlimited manner. Especially it ought not to be possible to refuse to the foreign disabled man, on his arrival abroad, and whilst he is attending to all the formalities connected with the receipt of his pension, or with his re-employment, in view of the impossibility of his being provided for by his native authorities and private institutions, the donation of subsidies of the kind so-called " expectatives de pensions," with the proviso of its being refunded, if necessary. Nor ought he to be excluded from the benefit of professional training, should he not have been able to take advantage of it in his own country. And he ought to be able to enjoy, also, all the facilities relative to medical care in 92 case of sickness, to the renewal, repairing, choosing and adequate adaptation of prothesis apparatus ; to his re -employment and all that is more intimately connected with it ; to his receiving all necessary information ; to his introduction to commercial and industrial people ; to the extension in his favour of the obligation of all foremen or public administrations, for whom any w r ork is to be done, to employ a certain number of disabled men ; to aid him in the drawing up of his contracts of labour so as to protect him from any advantage being taken by foremen with regard to the amount of his salary or to the payment of the latter, and in general to the wording of said contracts ; the superintending , by those especially entrusted with this task, of his work. Nor ought he to be refused participation in the associations of mutual aid, instituted amongst local disabled men, nor his belonging to co-operative provision associations of any kind ; the possibility of sharing the benefits that will be eventually assured by appro- priate laws, with reference to the advancing of money for the acquisition of tools, to loans without interest being charged and other financial facilities ; the concession of cheap lodging and the providing of special machinery or power for work to be done at home ; finally , the sharing of all benefits deriving from social laws with regard to accidents at work, to premature disablement, and to infirmities in general, to old age and to strikes. It is to be hoped, as regards this last group of laws, that, at least with respect to the disabled men, there will be the abolition of the restrictive regulations which, in a few of them, aim at foreigners in general; for instance, where, in case of disaster, the permanency of the victim, or of his relatives, in the territory of the respective State is required, or that the relatives should be present there at the time of the disaster. It is also to be hoped that these abolitions will be included in the legislation of those countries where they are non-existant , and that inter- national agreements will be concluded so as to simplify, bring about quicker solutions, and eventually make free of expense, the winding up of all proceedings referring to liquidations within the country, and the necessary means for inquiry abroad. % The last category , which I have mentioned already . of measures to be taken with regard to disabled men abroad, includes all those that become necessary from the very fact that the disabled men are residing in a country which is not their own, and are, there- fore, of such a nature as to render their application to indigenous disabled men unnecessary. To cite an instance of this, there are the stipulations set forth in either national or international legislation for facilitating the return of disabled men to their own country, for cashing the amount of their savings when abroad, or allowing them to be represented by the local protective organisations, or, better still, by the Consuls and official agents of his native country, provided the consent of the interested parties has been obtained, in all such relations as they may have with the local administrative and judicial authorities ; this with a view of protecting them against the speculations of busybodies and intriguers to whom they might otherwise have to turn. 93 These are, as a whole, a few of the principal measures that ought to be taken for constituting the protection of disabled soldiers and sailors abroad. This report is, naturally, incomplete, and does not, as the writer fully realises, cover more than a small part of the question. Yet to have gone into it in a more detailed and minute manner before this Conference would have appeared premature, for by limiting ourselves to calling their attention to this most important problem, to describing a few of its general features, and some of the steps to be taken towards its solution, would seemingly be most correspondent with the terms of the constitution of this same Conference. This will, at any rate, serve as a pretext for further discussions and suggestions by those who interest them- selves as to the future and well-being of disabled soldiers and sailors, and perhaps a few of the suggestions contained in this report may be constituted into a point of departure, for the final decisions to be taken with regard to national and international legislation on the subject. Given its characteristics and the difficulties that will have to be superated with regard to it, the sooner the question of this legislation is taken up, the better. A special conference ought to be called together, composed of delegates from the Allied countries, and of special experts in all juridical matters; in the decisions arrived at by this body there must be taken into account the emigration to the different countries and the conditions of foreign labour in each one, of the various juridical arrangements that are enforced therein, especially as regards the social and administrative laws ; account must be taken of the suggestions made at various periods by experts and assemblies with reference to the best way of organising the care of disabled men abroad, of the aims and of the means placed at the disposal of the public and private institutions that have been created in each country for the providing of protection for disabled men and of the par- ticular exigencies of disabled men abroad. Having considered all these points, the above-mentioned Conference will decide as to the various international regulations in general that will super- intend the protection of disabled men, and will designate the special conventions that must be concluded between the different States, as also the rules to be inserted in the internal juridical arrangements of each one of the States. In conformity with the proposals already set forth in the pre- ceding Conference, having regard exclusively to the constitution of an International Bureau for the service of the protection for disabled men in the interior of each country, it is apparently intended to propose that the attributes of this Bureau should occupy a larger and more comprehensive sphere of action and that it should become a directing and co-operating central organisa- tion of all that is to be put into practice and proposed with respect to the protection of disabled soldiers and sailors, should overlook the observance of the national and international regula- iions already adopted, investigate and facilitate all necessary 94 reforms, especially superintending the care of disabled men abroad. It ought to be the duty of everyone to co-operate in this pro- tection, and, by so doing, in addition to the protective measures taken on behalf of the disabled men by the Authorities or by private individuals as regards their material welfare, surrounding them with an indestructible atmosphere of warm interest and affection which would help them to bear the sensation of the gravity of their accomplished sacrifice and to feel less alone and estranged in the midst of the busy life surrounding them. And it must also become the pre-occupation of all authorities and private individuals to do everything in their power to aid the disabled soldiers and sailors residing in foreign countries in order to make their lives happier in every respect. And for this reason it may become opportune to create a special international decoration to be given to all disabled men, as has already been done privately by a few of the Allied nations, which would command respect and esteem in every land. Having regard to the above, the following resolution is proposed : The delegates of the Inter- Allied Conference for the Assistance of Disabled Soldiers and Sailors, having recognised that the pro- tection of the disabled men constitutes a duty not only of the several countries of origin, but also of all the Allied nations, and that they have the obligation of the greatest solidarity and mutual assistance in carrying out this protection, Votes (1) That, with regard to the foreign disabled men, each Government should abrogate from the national legislation all decrees prohibiting the access of the respective terri- tories, or that in any way are unfavourable and place the foreigner in a position of inferiority with regard to the men of the country ; (2) That no obstacles shall be put in the way of the creation of foreign institutions for the protection of disabled soldiers and sailors ; that they shall be authorised to co- operate with the local public and private institutions of the same character, and that their work be facilitated ; (3) That to the foreign disabled men shall be extended to the utmost limit all the measures of protection adopted for the national disabled men ; (4) That, especially, there shall be extended to all foreign disabled men, and to their relatives, the benefits of social laws with regard to labour disasters, premature disablement and all infirmities in general , old age and strikes ; that similar laws shall be introduced into such juridical texts as are without them, and that all restrictions stated in them shall be abrogated in favour of the foreigners and their relatives ; (5) That there shall be international agreements and national laws for facilitating the return of the foreign dis- 95 abled men to the country whence they departed to go and join the Army in their native land ; for the collection of their disablement pensions, allowing them to accomplish it in the district wherein they reside and by means of the local author.! ties ; for the quick and gratuitous winding up of all legal formalities in foreign countries demanded by the liquidation of indemnities assured to them through social legislation ; for the easy arid safe transmission of their savings abroad ; for their being represented (provided they consent) by the consuls and national official agents ; for repatriation ; (6) That an appropriate Conference shall be called for deciding upon the text and form of said agreements as well as on the subject of the reforms to be indicated as worthy of introduction into the different national legislations : (7) That the International Bureau for the Protection of Disabled Soldiers and Sailors, apart from the complete collection of the documents relative to this work, shall be entrusted with the task of co-ordinating all the work of pro- tection done by each nation, and especialty to see to the protection of disabled men abroad and to the observance of the national and international regulations that have been adopted ; (8) That there shall be created a special international decoration for the disabled soldiers and sailors belonging to the Allied nations. 9G SECTION 2. WHAT HAS BEEN DONE FOR THE TRAINING OF OUR DISABLED SAILORS AND SOLDIERS. BY MAJOR EGBERT MITCHELL, C.B.E. One of the most tragic phenomena presented by this pro- digious age, and one which by its horror and magnitude moves public opinion most profoundly, is the harrowing spectacle of the immense numbers of sailors and soldiers which the methods of modern warfare have sent back to civil life mutilated and iii aimed. It is a problem of the highest importance which here presents itself, and we anxiously ask what is to become of all these glorious wounded for whom it will be very difficult, or even impossible, to gain a living by their customary employment. Pensions and their origin. In Great Britain, as in most foreign countries, the interests of disabled sailors and soldiers were for many centuries left to private charity. In feudal times the lord who brought his vassals to the King's army was expected to look after those who were wounded, and the widows and orphans of those who were killed in his service. The monasteries, too, were always there to supplement the charity of the negligent feudal lord, while after the decay of the feudal system, maimed soldiers and sailors looked almost entirely to the charitable institutions for care and sustenance. The dissolution of the monasteries left the maimed soldiers without any organisations prepared to look after their interests, and, in Elizabeth's time, when hundreds of soldiers lost health and limbs in Flanders and France, the duty was forced upon the State. Accordingly, in the last ten years of her reign, a series of statutes were passed making provision for the "maimed, hurt, or grievously sick soldiers," but as the obliga- tion to raise a rate for this purpose was laid on the counties there was a tendency for each county to evade the duty, and so the poor fellows were hurried from one county to another so that such payment might be avoided. The first real attempt to care for the sick and wounded in this country dates from the days of Charles II., when, in 1664, four special Commissioners were appointed ' ' to take care of such sick and prisoners of war as might be expected," whilst physicians, surgeons and marshals were appointed at all sea- ports. According to " Evelyn's Diary," the pensions in those days involved " the vast charge of no less than 1,000 weekly," as compared with the present day expenditure of nearly half a million pounds sterling. It was in the reign of Charles II.,, too, that the Royal Charter was issued which led to the founda- tion of Chelsea Hospital. Macaulay, in his 'History of England," tells us that, during the subsequent reign of William III., "grey-headed old pensioners crept about the arcades and alleys of Chelsea Hospital," and it is a significant 97 fact that up to the present time pensions have been allocated at Chelsea. A pension, according to Dr. Johnson's curious definition, was in England " generally understood to mean pay given to a State hireling for treason to his country." This would not have been true of the pension which Johnson himself subsequently received . nor of a considerable portion of those granted in his time ; it would not now be true of any. A modern pension is as much a payment for undoubted services as salary or wages, the differ- ence being that pensions are paid in respect of the past, salary or wages in respect of present, services. To-day, however, it is universally felt that no monetary payment will express the gratitude we owe to those who have offered their lives on behalf of the Mother Country and have been maimed in defence of our liberties. To these men, at least, we owe health (if health be possible for them), a place in the world, and opportunities by which they might be able to supplement their poor incomes thus providing them with the possibility of spending the remain- ing years of their Lives in a state of reasonable contentedness. The New Warrant of 1917. With these considerations in mind the Minister of Pensions has devised a scheme by which all partially disabled sailors and soldiers can either continue their previous employment or fit themselves, by studying under proper guidance, for full citizen- ship and useful occupation. Training is provided at the expense of the Ministry for all discharged disabled men whose disable- ment is due to, or aggravated by, naval or military service in the present war. The New Royal Warrant of 1917 introduced most interesting changes in the principle of minimum pensions to disabled sailors and soldiers. In the first place, every man who takes up train- ing is granted the sum of 27s. 6d. per week in lieu of pension, with any proportional increase according to rank. In the case of a married man allowances are made : To his children at the rate of 65. Sd. for the first child, 5s. for the second, and 4s. 2d. for each additional child. Where the man has to leave his home during the period of training, his wife receives a sum of 135. 9d. per week. Methods of Administration. For the execution of its training scheme the Ministry of Pensions utilises the Local War Pensions Committees, of which there are 350 scattered throughout the country. Affiliated with these committees are various special committees whose duty it is to deal with a'll applications for training from persons residing in a particular district. The local committee is thus responsible for all discharged men living in their area, and they make it their business to get in touch with every such man, whether or not he has obtained employment or occupation since his discharge, and see that the treatment or training which his condition requires is secured for him when he needs it. Many men are able, very readily, at the present time to obtain employment of one kind 16524 D 98 oi another, but such employment may, owing to their physical condition, be actually detrimental to their permanent health. Others may drift into occupations in which their employment rnay only be temporary, whereas if they had received training for a skilled occupation they would have the prospect of permanent employment. It is, therefore, vitally important in the man's interest and in that of the nation that any case which needs either treatment or training should be taken in hand at once. In most localities special schemes of instruction have been adopted to meet the particular requirements of the neighbour- hood, and these have been sanctioned by the Minister of Pensions. With the object of still further improving and extending facilities for training, the country has also been divided into twenty districts, each governed by a joint committee composed of representatives from all the Local War Pensions Committees within its area. Thus, for instance, the counties of Kent, Surrey and Sussex form one group, and to each of these groups a representative of the Ministry is assigned. This joint committee can then deal with all the cases of train- ing within the area which the localities are unable to provide for, and can arrange a systematic and concerted scheme of instruc- tion for the whole district. This arrangement has proved to be of great utility, and many districts have already established a most comprehensive list of training facilities within their areas Altogether, some forty-five different trades are being dealt with, and, in some cases, such as fancy leather work, an attempt is being made to foster trades which were largely in the hands of our enemies before the war. Thus, it will be seen that the system under which the training is administered has been care- fully devised and is capable of great elasticity, a quality neces- sary in view of the probable developments which will inevitably take place in the event of demobilisation. General Training Scheme. The scheme of training initiated by the Ministry of Pensions recognises the care of the disabled sailors and soldiers as a duty of the State and includes in its provisions : (1) The restoration to health of the disabled, where practicable. (2) The provision of training facilities. (3) The procuring of employment. The number of disabled sailors and soldiers capable of benefit- ting by a course of training is large, being estimated at about 80 per cent, of the total disabled; that is to say, the majority of injuries sustained are not of such a nature as to prevent the utilisation of these men, sooner or later, in civil life. The importance of starting training at the earliest possible date .was soon recognised, and all who have had practical experience agree that the disabled men degenerate with startling rapidity if they are left in idleness. Crippled men tend to mope and brood 99 over their misfortune, and if this natural depression is not dis- pelled, it soon develops into a chronic apathy and despondency. The ultimate object, therefore, of any scheme of training should be to restore the disabled man to his old position, and to make him feel himself a normal member of the community and to help him to forget the handicap under which he labours. Convalescents are, therefore, led to occupy themselves as soon as possible with the question of the future which is before them, and to this end the many weeks of inactivity in the hospital is the most suitable time. Especially is this the case in regard to the various limbless hospitals where the men have a good deal of time on their hands whilst waiting to be fitted for their artificial limbs. With the object of utilising such spare time, workshops were first established at the Queen Mary's Auxiliary Hospital at Eoehampton, where great success attended these classes even before the Government scheme was mooted. Indeed, it was in this rather humble beginning that the nucleus was formed for the national scheme of training as set forth in the Warrant of 1917. The chief facts which are usually taken into consideration when choosing a new calling for the disabled are : (1) The nature and degree of the disablement. (2) The personal inclinations of the disabled, who might have a strong preference for a particular trade rather than any other. (3) The callings chosen should, as far as possible, be simple and of such a nature that they can be quickly learnt. (4) The calling should give promise of a fair remuneration and the assurance of permanent employment to those whe undergo the necessary training. The practical value of a scheme being essentially judged by its results, it might be advantageous to consider those already achieved by the vocational training of the disabled in this country. Technical Schools. After obtaining their discharge from the hospital, the training of the men is usually continued at one of the many technical schools which are distributed throughout the country, where the hours of attendance need not exceed thirty per week. After a course of training extending from three to six months, the dis- abled man is then invariably able to enter the factory and to keep the regular hours of work, which may not have been possible at an earlier stage. The facilities in these institutions are rapidly increasing as the scheme widens its activities, and at the present time the Ministry has sanctioned training in no fewer than 345 technical institutions and agricultural colleges as well as in 513 workshops and factories. Meanwhile, the list is expanding week by week. Training is now undertaken in 45 different trades, several of which, before the war, were in the hands of the enemy. Thus the scheme is helping to promote new industries in thin country. 16524 100 The Trade Unions and Trade Societies. Every effort is made to ensure the placing of the disabled men in those branches of industry which seem to offer scope for em- ployment of a permanent nature. To this end the help of the various Trade Unions and other organisations of employers and employees has been enlisted, and they have cheerfully and readily arranged for such conditions of training and employment as will ensure for those trained a welcome into the ranks of organised labour. Such arrangements have been made in connection with no fewer than twenty-nine organised trades. These have been designated " Special Trades," and special advisory committees have been set up in each industrial centre where such instruction is given. The representatives of these associations, in consulta- tion with the officials of the Ministry of Labour and the Ministry of Pensions, have drawn up the conditions under which disabled men might be trained in each particular trade. These instruc- tions are printed, and include information concerning the length of training, the rates of pay, and other matters in regard to the relations between those already engaged in the trade and the new recruits from the disabled. Sixteen small booklets have been printed in connection with these special trades, which point out the most suitable openings for the disabled. These are circu- lated to every committee in the country, and it is hoped that most of the trades will be thus treated. In this manner the opposition to training which might other- wise have arisen among these various trades associations has been averted, and instead, their hearty support and co-operation is being received. Various Trades. Every effort is being made to find the most suitable openings in manufacturing and constructive work into which the disabled might be directed. Already courses of training are established in connection with certain branches of the engineering and build- ing trades, the manufacture of aircraft, wholesale and retail tailoring, the making of furniture and leather goods, and many other trades. In the present connection mention can only be made of a few of the openings into which the disabled have profitably been directed. (a) Boot and Shoe Making. In January, 1915, a scheme of training in this industry was brought before the Board of Management of the Cordwainers' Institute of London, and, with the assistance of the Trades' Advisory Committee, was duly considered, and the rules of working were drawn up. The classes were started in February, 1916, and have formed a model for the institution of similar classes in other parts of the country. The work offers advantages to those who are unable to stand continuously at their work. The period of train- ing is forty-six weeks, and the men are instructed not only in the making of hand-sewn boots and shoes, but also in measurement, anatomy of the foot, as well as in all branches of repairs. A short course of six months is arranged for those who only desire to learn boot repairing. The results in this branch of work have been eminently satisfactory, and after their period of training many of the students have received situations at good piece-work rates in West End establishments. Classes in boot and shoe making are now conducted at Cardiff, Dundee, Edinburgh, Manchester, Leeds, Bristol, Liverpool, Walsall, Leicester, Norwich, Barns- ley, Birmingham, Glasgow and other towns. In all, there are thirty-nine centres. (b) Retail Tailoring. One of the most suitable out- lets for many has been the retail tailoring trade. There seems no doubt that there will be a fair prospect of em- ployment for disabled men in this trade after the war. Even before the war employers failed to secure a sufficient supply of good British journeymen tailors, and there is a consensus of opinion among them that this difficulty was increasing. The old system of apprentice- ship was dying out, and the supply of British journey- men failed to meet the demand. The result was that the making up of garments, at all events in London and many of the large towns, was done to a very great extent by foreigners of various nationalities. The work of cutting and making up garments is a skilled form of employment and the wages paid are con- sequently good. A first-rate cutter or foreman tailor may be paid from 705. to ^10 per week, according to his ability. The average earnings of sewing tailors range from 30^. to 55s. per week. Naturally, a thorough training is necessary for this work, but the length of time varies with the learners' adaptability. A full-time day training course has for some time been in existence at the Regent Street Polytechnic, and a special twelve months' course of training for disabled sailors and soldiers has recently been established, with the concurrence of the associations of employers and workpeople concerned. Arrangements have also been made to start a course of a similar nature at the Merchant Venturers' Technical College, Bristol, and further training centres are also to be established in Glasgow, Leeds and Manchester, as an experiment, and if further demand arises training- centres will also be established in Aberdeen, Birming- ham, Cardiff, Edinburgh, Liverpool and Plymouth. 16524 ' D 3 102 (c) Leather Work. The, manufacture of leather goods is almost wholly concentrated in two districts London, where 60 per cent, of the trade is carried on, and Birmingham and Walsall, which account jointly for 30 per cent. Fancy leather goods and the light kinds of solid leather goods offer light work, but require dexterity and adaptability, and sometimes give scope for individual intelligence and artistic taste. The material is valuable and easily spoiled. This means that training is expensive, and a preliminary period of training in a technical school is strongly recommended. Such courses of training are already conducted at the Cord- wainers' College, London, and at the School of Art at Walsall. (d) Aeroplane Manufacture. Another comparatively new industry is the manufacture of aeroplanes, but during recent years very great progress has been made in its organisation. It is now widely distributed throughout the country, especially in and around the outskirts of large towns, and openings may, therefore, present themselves near the homes of disabled men. At the present time there is a great demand for suit- able men , and it is believed that the future developments of the industry will ensure a reasonable prospect of continuity of employment after the war. It has, there- fore, been arranged by the Trade Advisory Committee that disabled men may be admitted into the trade after passing through the necessary course of training. (e) Diamond Polishing. One of the most novel and successful schemes of training has been that of diamond polishing and cutting. In May, 1917, a well-known diamond importer, Mr. Bernard Oppenheimer, offered to teach discharged and disabled men this highly paid industry. The necessary machinery was rapidly erected, and in August, 1917, a start was made with about 20 men, who were trained by Mr. Oppenheimer 's instructors. The men undergo a course of training for six months. At the close of their training the men are drafted by Mr. Oppenheimer into his factory, where they start with a minimum wage of 2 per week, which is increased according to proficiency. Thus, a skilful polisher may earn as much as 4 or 5 per week at the work. Some critics may ask Is such a highly skilled trade suitable for men who have had no previous experience in mechanical work? A recent visit to the classes at Brighton elicited the fact that the men have come from almost every walk of life. I will cite two instances. One related to a man who, previous to the war, was a labourer in the London Docks. Enquiry of the in- 103 structor revealed the interesting information that he was one of the most promising students. A second man remarked that he had been an estate agent in Canada, and he naively said : " I would not leave these diamonds for all the tea there is in China '"clearly showing the keen interest he was taking in his work. It is hoped shortly to set up other training centres for diamond polishing at Acton Hall, Cheshire, and probably at Cambridge. It is interesting to note that not a single man who has entered for training in diamond cutting or polishing has discontinued of his own accord. (f) Engineering. At present the training classes in the various branches of engineering are not fully de- veloped, as the negotiations with the Trade Advisory Committee of the many branches of the trade are only just completed, and on the publication of the " Instruc- tions " they will be set up in as many centres as possible. The equipment and machinery needed presents some difficulties in the present state of affairs, but every effort is being made to instal the minimum requirements, and an arrangement will be entered into with the Technical Schools where such classes are established, so that the cost of special equipment will not fall on the local authorities. In connection with this branch of training it should be remembered that a very large number of disabled men have taken advantage of the terms offered by the Ministry of Munitions for training in munition making, and thus have already sejcured an acquaintance with modern machinery and a knowledge of the use of tools which will undoubtedly prove of great assistance should they eventually take up a more complete training for engineering work. (g) Dental Mechanics. Another industry which offers well-paid employment to a skilful man is the profession of dental mechanic. After lengthy negotiations, con- ditions of training and employment have now been settled, and a good many men are being trained either at Technical Schools or in several cases in the private laboratories of mechanical dentists and in the dental hospitals. Before a man can become a good dental mechanic, he has to acquire skill in certain technical processes. These processes include the handling of plaster of Paris as used in the making of fine casts, the melting and casting of metals, the accurate fitting of sheet metal to irregular surfaces, the use of the blow-pipe, wax modelling, the manufacture and polishing of vulcanite and the exact 16524 D 4 104 and artistic adaptation of porcelain teeth to the needs of the cases, no one of which is exactly like another. All this requires patience and application, and much practice under competent instruction ; but the work offers attraction in the variety of its technique, in the ingenuity and initiative for which it affords opportuni- ties, and in the certainty of a good and steady wage in the case of a man possessing aptitude and character. (h) Cinema Operating. One of the earliest schemes of training under the Ministry was that of cinema operating. Even before the full allowance, as set forth in the Warrant of 1917, was paid to the men, a start was made from the men who had left the Eoehampton limbless hospital. The classes are now thoroughly organised, and are held in the large film distributing centres of London, Newcastle, Cardiff, Southampton, Glasgow, &c. The course is an intensive one of three months, and the men are thoroughly taught not only the use of the projector, but also the working of motor generators, wiring, and many other technical operations concerned with the trade. That the training is thoroughly carried out is evi- denced by the fact that there has been no difficulty in placing every man w 7 ho has been trained in a good situa- tion. The leading cinema companies have been only too pleased to get properly trained men, and the wages range from 2 1000 4,746 Totaux generaux 9,992 17,186 5,725 Nota. Los ecoles pour lesquelles aucune indication n'a ete portee dans les Tableaux sont de creation recente, ou n'ont pa& repondu aux questionnaires qui leur ont ete envoyes. 120 Professions enseignecs. Une centaine de professions differentes sont enseignees dans ces ecoles. La plus demandee est celle de cordonnier (2,138 apprentis au 31 juin 1917) qui esduit les blesses, parce qu'elle leur permet souvent d'aller s'etablir dans leur pays d'origine et de s'occuper encore un peu de culture, comme beau- coup d'entre eux le faisaient avant la guerre. Cette tendance demon tre, que si beaucoup d'-anciens cultivateurs se detournent de 1'agriculture, c'est surtout parce qu'ils se rendent compte, non sans raison d'ailleurs dans la majorite des cas, que leurs in- iirmitees les empecheront de gagner un salaire suffisant, dans une profession deja peu lucrative au temps de la paix. Telle est la principale cause qui. eloigne 1'invalide des ecoles d' agriculture, vers lesquelles on fait cependant de grands efforts pour les diriger. La statistique nous apprend que 14.5 pour cent des eleves des ecoles se sont diriges vers les professions agricoles (pourcentage extremement bas, si Ton le compare a celui des cultivateurs blesses), 16.6 pour cent vers les professions liberates, administra- tives ou commerciales et 68.9 pour cent vers les industries de tous genres. Faisons observer que beaucoup d'invalides entrent dans les ecoles pour completer leur instruction primaire ou generale, afin de concourir pour des emplois administratifs ou suivre ensuite des cours commerciaux. En realite cette instruction ne peut etre considered comme 1'apprentissage d'une profession. Aussi ne la fai sons-nous pas entrer en ligne de compte dans les evaluations ci-dessus. Placement. Le placement se fait en general avec la plus grande facilite quand le mutile est vraiment apte a exeroer la pro- fession choisie. Aussi est-il difficile d'accorder une grande con- nance aux chiffres donnes par les statistiques officielles, qui admettent que seulement 54 pour cent des eleves passes par les ecoles prof essionnelles , seraient places dans la carriere qu'ils ont adoptee. De nombreuses causes d'erreurs rendent ce chiffre suspect. En effet, d'un cote beaucoup d'eleves sont portes comme places dans leur profession, qui 1'abandonnent ensuite, parce que cette profession ne convient pas reellement a leurs aptitudes. D'autres trouvent des situations differentes qui les attirent a tort ou a raison. Un grand nombre d'invalides restent trop peu de temps dans certaines ecoles, pour connaitre et pratiquer leur metier ; il n'est pas des lors tres etonnant que leur placement presente quelques difficultes. Le chiffre de 54 pour cent pour les places ne correspond eertainement pas a la realite et nous sommes convaincus que le placement effectif et durable, qui suit une reeducation rationnelle <>t complete, doit atteindre au moins 80 pour cent des reeduques. S'il en etait autrement, c'est que 1' organisation de Fenseigne- ment des ecoles serait en general defectueux et il importerait au'elles soient transformers et ameliorees. Nous avons de bonnes I 121 raisons de penser qu'il n'en est pas ainsi dans la majorite des ecoles ouvertes en France. Ajoutons encore quelques renseignements : Pour les 78 ecoles qui ont donne seules des renseignements suffisants au 30 juin 1917 : Le personnel administratif comprenait 278 personnes Le personnel enseignant 868 Au total ... ... 1 ,146 personnes Depenses. Depenses du personnel 708.427,62 Depenses de nourriture et d'entretien ... 2.125.425,07 Achat d'outillage 829.564,40 Achat de matieres premieres ... ... 836.509,49 Divers 722.681,22 Total 5.574.832,66 Recettes. Produits des liberalites, souscriptions,etc. 3.142.738,16 Remboursements sur allocations ... 285.066,65 Vente de produits fabriques 823.510,31 Subventions Etat 1.755.489,75 Departements 563.895,15 Communes 163.365,66 Divers 231.217,51 Total 6.965.283,19 II n'est pas sans interet de remarquer que la vente des produits manufactures donne une somme inferieure a celle des depenses pour 1'achat de matieres. Ce qui indique que, d'une maniere #enerale, les ecoles ne cherchent pas a realiser un benefice dans la vente des 'produits manufactures, mais que I'enseignement professionnelle reste, a juste titre, le souci dominant des administrateurs . Nous ne pouvons terminer ce rapide expose de la situation actuelle de la reeducation professionnelle des invalides de la guerre en France sans constater, avec satisfaction, que 1'idee de reeducation a fait de reels progres depuis 1'annee 1916. Aussi, en raison de cet afflux de candidats et des resultats cependant excellents, obtenus dans I'enseignement tel qu'il a ete pratique jusqu'ici, parait-il indispensable d'apporter diverses ameliorations dans les methodes employees. 122 II y a d'abord lieu de craindre que la multiplication indefinie des petites ecoles locales ne soit pas sans inconvenients tant an point de vue des depenses qu'au point de vue de 1'enseignement. Nous pensons qu'il vaudrait mieux developper et creer, s'il y a lieu, des ecoles regionales suffisantes pour recevoir les invalides de plusieurs departements, de maniere a rendre plus facile la direction generale et le controle technique et financier de ces etablissements. Nous croyons surtout, que le moment est venu d'ouvrir des ecoles ou des sections speciales dans les ecoles existantes, pour y admettre certaines categories d'invalides, susceptibles de recevoir une instruction professionnelled'un niveau plus elevee que celle qui est donnee actuellement. En effet, si Ton songe qu'a cote des mutiles auxquels leurs graves blessures, ou leurs connaissances restreintes, ou leur mediocre developpement intellectuel, ne per- mettent que 1'apprentissage des metiers les plus faciles et les plus c-ommuns, il en est d'autres que leur education, leur esprit eclaire, leurs infirmites plus legeres et leurs aspirations plus hautes, designent pour aborder avec succes un enseignement technique superieur. Tous ceux qui s'occupent de la reeducation des invalides sont unanimes a constater avec quelle rapidite les blesses acquierent, aussi bien une extraordinaire habilete manuelle, que des connaissances theoriques et scientifiques qu'on avait quelque crainte de leur voir assimiler avec peine. II y a chez tous une maturite d'esprit, resultat des epreuves qu'ils ont subies, une volonte d'apprendre, qui font que leur instruction professionnelle se poursuit dans un delai des plus courts et qui n'a rien de com- parable avec la duree des etudes dans les ecoles professionnelles ordinaires. II semble done qu'avec de pareils elements, on pour- rait facilement organiser des ecoles d'ordre agricole, commercial, industriel et administratif, dans lesquelles on preparerait une elite de jeunes gens, qui pourraient aspirer aux carrieres les plus brillantes et rendraient les plus signales services, dans les diverses branches de 1'activite economique d'un peuple. Nous sommes convaincus que dans un delai de deux ans , y compris une periode preparatoire de trois a six mois, on pourrait obtenir de merveilleux resultats chez un grand nombre d'invalides. Faut-il ajouter que la creation d' ecoles superieures speciales n'entrainerait nullement la suppression des ecoles ordinaires qui, repetons-le, rendent des services indiscutables ? Les unes seraient seulement le complement des autres et permettraient 1' utilisation integrale et rationnelle des forces de production con- siderables que representent nos valeureux invalides. II semble aussi tres interessant de creer des ecoles interalliees , dans lesquelles seraient admis des invalides desireux d'apprendre la langue et de s'initier aux methodes commerciales et industri- elles en usage dans les pays allies. On pourrait faire ainsi un echange d'eleves entre les blesses des differentes nations et cette collaboration sur le terrain economique, contribuerait a maintenir entre les peuples qui versent leur sang pour le droit et la liberte du monde, une collaboration aussi cordiale, aussi loyale et aussi fructueuse, que celle qui les a unis sur le champ de bataille. 123 II y a la de nouvelles et interessantes matieres a etudier et des problemes des plus passionnants a resoudre. Us sont dignes de retenir 1' attention de tous ceux qui se preoccupent de 1'avenir de nos invalides et de la reconstitution economique et sociale de nos pays. Telles sont les conclusions auxquelles nous amene 1'examen de la reeducation professionnelle des invalides de la guerre en France a la fin de juin 117. Cette activite ne s'est pas ralentie depuis lors, car le nombre des blesses augmente tous les jours et la France continue, avec la meme ferme volonte, a se preoccuper de 1'avenir de nos braves mutiles et estropies. 124 LA REEDUCATION DES MUTILES DE LA GUERRE. Par Dr. LE BRUN. Les questions relatives an traitement medical, a la readapta- tion, a la reeducation fonctionnelle et professionnelle des mutiles de la guerre, constituent des questions helas ! toujours d'une grande actualite et d'importance sans cesse croissante. Plus de trois annees de guerre leur ont fourni des reponses bien differ- entes, qu'il s'agit aujourd'hui de codifier quelque peu, grace aux legons de P experience, tres fecondes et ayant profondement modifie les attitudes de ceux qui ont eu a les soulever. Entre toutes ces questions, celle du travail de 1'invalide, connue sous le nom de reeducation professionnelle, a fait 1'objet de maintes discussions, de maints articles de journaux tant politiques que medicaux et surtout de nombreuses erreurs reposant sur 1'exclusivisme de telle ou telle a litre methode. A Porigine, la philantropie fut seule Pinstigatrice des premiers depots d'invalides ou Ton cherchait a la fois de guerir le blesse et de le consoler dans son infortune. Ce fut un elan magnifique de generosite et de devouraent. Ces oeuvres florissantes et belles, nees d'une pensee de charite, fussent restees florissantes et belles si 1'impitoyable guerre ne leur eut fourni constamment de nouveaux contingents. Ceux-ci furent causes des difficultes nnancieres, capitales pour leur existence. Ne pouvant faire toujours appel a la charite, au desinteresse- ment des fondateurs et des donateurs, on resolut d'occuper les mutiles a des travaux pouvant etre retribues. Telle fut en maints endroits Torigine de la reeducation profes- sionnelle. D'ailleurs pour s'autoriser d'une telle creation on prit pour pretexte de donner aux homines la distraction du travail, de leur procurer tout en les faisant beneficier d'un salaire 1'occasion de manifester leur reconnaissance car il etait penible d'avouer que Pon faisait travailler pour subsister. Quels sont nos griefs contre cette pretendue reeducation pro- fessionnelle, qui, batons nous de le dire, n'est pas universelle. 1. Congue ainsi, elle ne peut etre serieuse, puisqu'on n'est pas uniquement guide par le bien de rhomme mais en grande partie par Pinteret. . 2. De travail productif justement parce qu'il est une source de revenus s'est developpe de facon anormale au point de prendre plus d'importance que le traitement medical. 125 L'inevitable consequence fut d'ecarter de nombreux blesses de ces instituts. En effet, ceux qui s'y trouvaient virent leur sejour s'allonger indefiniment, le traiteineut n'etant pas suffisamment intense et suivi, consequence inevitable du desir des homines de s'eterniser dans des instituts ou s'ecoulaient, loin du danger, les jours faciles et renmnerateurs. On vit meme certains sujets retenus plus que de raison je n'ose dire apres guerison parce que tres habiles dans leur metier. En resume, le traitement fut diminue, les admissions furent restreintes et du fait de 1'attente prolongee, les entrants furent moins aptes a subir le traitement, leurs lesions etant plus anciennes, moins curables. De se qui precede, une question se pose, immediate : Pourquoi reunir dans un meme institut sous une direction unique, deux sections franchement differentes, souvent meme inoompatibles : la section medicale et la section professionnelle proprement dite. Si je pose la question de separation, j'en connais par avance les difficultes et les objections. Certes, 1'ceuvre accomplie a ce jour est bien belle, la reeducation professionnelle a fourni de superbes resultats mais j'affirme que sa mise en pratique a ete souvent precoce, parfois nuisible a la guerison du inutile, but primordial, et c'est pour cette raison, cette unique raison que je demande la separation. A 1'appui de ma these, j'apporte deux exemples suffisamment typiques : 1. Qui n'a vu dans des ateliers, cornme ceux des brossiers, de pauvres estropies de la main, s'evertuant malhabilement au travail, ne demandant au membre lese que le minimum d'exercice, tandis que les conseils du medecin eussent exige le contraire. D'autres fois ces mouvements forces se font dans les conditions les plus defectueuses au point.de vue des organes. 2. La guerison obtenue, au moins partiellement, on voit ces malheureux continuer durant la guerre ce metier sans avenir, appris a 1' Institut, uniquement parce qu'il rapporte actuellement de gros salaires. On sacrifie 1' avenir au present. La cause de ce double errement c'est la meconnaissance ou plutot 1'oubli de notre devoir vis a vis de 1'infortune qu'on nous envoie. Nous devons : 1. Le guerir en lui rendant 1'usage aussi normal que possible de ses membres et, quand cela ne se peut, un usage au moins rationnel, afin d'attenuer en lui le prejudice que lui a cause sa blessure. Cette guerison doit etre poussee tres loin, a sa limite: les interets de rhomme lui-meme et de la Patrie nous en font un devoir : c'est le devoir medical. 2. Le reeduquer, c'est a dire le preparer aux luttes de 1'avenir pour 1'apprendre a pouvoir se suffire a lui-meme, a tracer son sillon en ce monde : c'est le devoir social. 126 Or le devoir social malgre toute son importance suit le devoir medical ; en aucun cas il ne doit le preceder moins encore Fentraver. Le premier reclame evidemment le secours des pouvoirs ou de& philantropes, secours pecuniaire et moral; le second peut je ne dis pas qu'il doit esperer en ses propres moyens d'existence. Les objections a la separation sont nombreuses. Elles sont desformulees principalement par les gens de metier et parfois sous des formes assez convaincantes ; je n'en indiquerai qu'une, la plus importante : " Supprimer les metiers c'est habituer les hommes a 1'oisivete, en faire des desoeuvres ; ce n'est rien moins qu'immoral ! ' Le plaidoyer me parait quelque peu force et trop noir, sous une apparence de verite. Si je preconise la separation, je suis loin de reclamer la suppression du travail a 1'institut medical; au contraire, je demande que ce travail ne soit pas lui-meme sa fin, mais qu'il constitue un traitement et qu'il s'exerce dans certaines conditions. Voici ce que j'ecrivais a ce sujet au debut de 1917 et qui fit 1'objet d'un rapport presente a la Conference interallied ponr la reeducation professionelle en mai 1917 : "La reeducation fonctionnelle s'accomplit: " 1. A 1'institut de physio therapie; cliaque jour Pinvalide y k passe un temps determine pour y faire des exercices gradues, " sous la direction du medecin attache a ce service. C'est la, la " raison d'etre de 1'Institut des Invalides. " 2. A l } atelier; le metier peut et doit etre un moyen de con- ' tribuer a la reeducation fonctionnelle. Par le jeu de 1'outil, ' ' le inutile fait travailler des muscles plus ou moins leses ; il les >k soumet a une sorte de gymnastique qui transforme le travail " d'atelier en une mecanotherapie. " C'est pour ce motif que nous recommandonc vivement a nos ' * moniteurs de veiller sur leurs eleves pour que ceux-ci actionnent " toujours leurs muscles atrophies et leurs articulations semi- '* ankylosees. Nous leur demandons aussi de ne pas etre trop C{ exigeants dans la besogne a reclamer. Nous faisons un devoir tf a celui qui est charge de 1'enseignement de s'assurer par lui- able to secure and evaluate the facts pertaining 16524: E i 136 to each disabled soldier's experience, training, domicile, resources r &c. The Y.M.C.A. could render a splendid service by providing an adequate number of such capable advisors as well as by preparing the monographs. As soon as the disabled man has signed a regular educational enrolment card and filed it with the local Y.M.C.A. secretary, he should be provided with readable books bearing on the occupation for which he wishes to prepare. Just as soon as permitted by the doctor i he should begin performing simple operations related to his occupation if this is possible. Individual and class instruc- tion should be provided in Y.M.C.A. huts and other quarters while the disabled man is in convalescent camp or while awaiting transport, so as to lose no time and so as to combat the dangerous habit of idling. In this connection it is illuminating to note in the report of British delegates to last year's conference on this subject, that experience shows that of the disabled soldiers who commence their re-education before leaving the hospital only 5 per cent, fail to continue their training after medical dismissal; while, of those who do not commence their re-education in hospital, 80 per cent, never report for training. Again, let me urge the importance of so correlating the educational work for American disabled soldiers that studies commenced in France or England shall fit into the programme provided at home. It will be worth while to anticipate his return by sending reports in advance to the training centre concerned. Although I have no authority for indicating that such a course will be followed, the President of the United States might deem it wise to appoint a Disabled Soldiers Commission (perhaps more attractively named) to perform the following duties, in addition to others : 1. Unify and correlate the work of the several Governmental Departments and Bureaux which are interested jn dis- abled soldiers. The regulations governing disabled soldiers might well emanate from this Commission, even though it were deemed wise to leave its execu- tion to one department or bureau. The weight of military or other recognised authority should be behind these regulations. 2. Define the boundaries of service for the various co-opera- ting agencies or organisations. The Y.M.C.A. will, presumably, continue along the lines already autho- rised, especially overseas, but there may be other qualified organisations desirous of helping. 3. Correlate the training work begun overseas with training plans in America. 4. Designate the centres in the United States to be used for training disabled soldiers. In view of their avail- ability and special resources, a half hundred Y.M.C. As. 13T might well be included in the list of training centres to begin with. To secure a wide distribution, the following Association plants are suggested as typical : Boston, New York, Brooklyn, Troy, Syracuse, Rochester, Buffalo, Philadelphia, Pittsburg, Wheel- ing, Erie, Baltimore, Washington, Richmond, Atlanta, Cleveland, Columbus, Dayton, Cincinnati, Louisville, Nashville, Memphis, Birmingham, Detroit, Grand Rapids, Milwaukee, Chicago, Minne- apolis, St. Paul, St. Louis, Des Moines, New Orleans, Dallas, Ft. Worth, Kansas City, Houston, El Paso, Phoenix, Denver, Omaha, Fargo, Seattle, Portland, San Francisco, Sacramento, Los Angeles, San Diego. All training centres should, of course, be selected upon the basis of their ability to deliver results. Of course the blind and totally disabled can best be handled in special institutions rather than in Y.M.C.A. Schools, Y.M.C.As. and other institutions considered should be able to show some experience in handling adult students and should offer facilities for quickly merging the disabled soldiers into normal society ; they ought to have practice in occupational guidance and placement of men, and, finally, they should provide an uplifting atmosphere. It is taken for granted that the necessary dormitory, gymnasium and class room equipment is available in each centre selected. It is also taken for granted that this American Commission, like the British Pension Ministry, will not find it necessary to build special buildings in caring for disabled soldiers. 5. Supervise the work of all training centres to which Government aid is extended or to which soldiers are officially sent. 6. Promote the wise placement of disabled soldiers. The Y.M.C.A. should be asked to make their employment bureau service free to these men. The example of co-operation between the British Ministry of Labour and the Y.M.C.A. is worth studying on this point. Apparently the Government pays the bills and details Y.M.C.A. employment secretaries to do the work so as to insure the human touch and individual attention needed. The Disabled Soldiers Commission might wisely include the following : 1. Chairman, the United States Commissioner of Education. 2. Official Representatives of the War Department. 3. Official Representative of the Navy Department. 4. Official Representative of the Department of Agriculture. 5. Official Representative of the Department of Labour. 138 6. Chairman of the Advisory Educational Board for Dis- abled Soldiers. This Board should have representa- tives of the Association of College Presidents, of occupational, technical, agricultural and commercial schools as well as schools for the blind and maimed. 7. Official Representative of the Bureau of Pensions and Insurance. 8. A physician representing the American Bed Cross. 9. A Representative of the Y.M.C.A. War Work Council. 10. Executive Secretary, charged with carrying out the policies adopted by the Commission. At each training centre for disabled soldiers, a local advisory board should also be appointed on which a physician and educator, labour leader, employer and a disabled officer or soldier should have places. The executive officer of each local advisory board should be the head of the training centre. He should be appointed by the executive secretary of the National Disabled Soldiers Commission upon recommendation of the local board and be responsible to the national executive secretary. While I do not speak officially in placing the resources of the Y.M.C.As. of the United States at the disposal of the Govern- ment, for serving disabled soldiers, in a sense it is but a detail of" the offer already made and accepted. Here is the American Y.M.C.A. If our country can use it more fully, every Associationi will respond gladly. 139 HEPORT ON THE TECHNICAL TRAINING OF DISABLED SOLDIERS AND SAILORS IN ITALY DURING THE PERIOD DATING FROM THE OUTBREAK OF WAR 1915 UP TO THE END OF 1917. PRESENTED AT THE INTER- ALLIED CONFERENCE, LONDON, MAY, 1918, BY PROF. GIOVANNI CHEV ALLEY. The technical training for disabled soldiers and sailors in Italy is distinguished by three distinct features : (1) Propaganda with regard to technical training, and the preparation and persuading of disabled men to go through with it ; (2) Actual technical training (Technical Training Centres and Institutions) ; (3) Assistance given to disabled men on completion of technical training. I. The propaganda undertaken by the Italian Local Committees for the Assistance of Disabled Soldiers and Sailors has been made to cover a vast field, and has chiefly been done by means of the distribution of appropriate literature, of lectures and of the cine- matograph, &c. , so that the question of technical training for disabled men, with all its advantages, should be made clear not only to the men themselves, but also, and most especially, that the attention of all medical men, nurses, lady visitors to hospitals, and of all others who come in contact with the disabled men, be called to it. The moral influence which was brought to bear on the disabled men, whilst they were in second-grade hospitals, during the preparatory stages for technical training, was also very useful. That is to say, some sort of occupation suitable to their condition of the moment, and to their surroundings, is contrived for them, and it has the effect of mitigating the depressing influence of the idleness in hospital wards, of encouraging self-control in the men, and, in some cases, manual work has proved useful in aiding ihe action of mechanical therapeutics. The instituting of classes and work rooms in the hospital which is installed in the royal palace of the Quirinal, and is under the direct management of Her Majesty the Queen of Italy, has been a visible acknowledgement of the standard value of the moral element. 140 In the Castle oft Moncalieri, as well, (near Turin) , there has been instituted a hospital for disabled men, under the management of Her Imperial Highness, Princess Laetitia, Dowager Duchess of Aosta ; here the men are engaged in the manufacture of toys , for which special workshops have been installed : they also go through courses of elementary instruction. Nor, in this respect, must we fail to mention the actual training that has been accomplished by the Local Committee in Florence (Florentine Committee for Disabled Soldiers and Sailors), who have been the pioneers in their clever grafting of the Institution for technical training on to the second grade hospital for dis- abled men installed in the Villa Bondi. And finally, we have the second-grade hospitals that are in- stalled in the Eoyal Palace and in the Palace of San Vito, both of Turin, where, besides the elementary instruction, workshops have been opened for the manufacture of willow-work, basket- making, toys, bead work, and there is a school for drawing and engraving. The advantages shown by the preparatory technical training, as it is practised in the second grade hospitals, are generally acknowledged by us all at the present day indeed, the Disabled Men's Act has sanctioned them legally. It would be too long a task to enumerate, in detail, all the different articles that are manufactured by our disabled men toys, shoes, bead work, book- binding, cabinet making, surgical appliances, &c. It is hoped that this kind of preparation may extend its in- fluence to bringing back to the land the agricultural labourers, so- numerous in our country, by showing them the' practical possi- bility that exists in many cases of their being enabled to resume the work of which they were experts before becoming disabled. II. \ But that which stands out the most in all the work accom- plished by Italian Local Committees for the Assistance of Dis- abled Soldiers and Sailors, is what has been done with regard to technical training by the promotion of the institutions and schools for training for the disabled men. To this end the Italian people have most fully contributed with money and in many other ways. In view, however, of the enormous expenditure entailed by the adequate develop- ment of the institutions that have been called into existence by the awful demands made because of the war, the Government have granted the committees a subsidy for every disabled man kept in the various training institutions, amounting to It. lire 3.50 per diem for the indoor patients, and It. lire 2 per diem for the outdoor patients, for a stated period of not more than six months. In many cases , however , this period of time is much too short for a complete training, and, under those circumstances, the Italian Local Committees themselves defray the extra expense out of 141 their pockets, for as long as the disabled man is obliged to remain in the institution. For instance, in the Turin schools the aver- age stay is of about one year. The committees generally allow a small daily amount of pocket money to their pupils about It. lire 1 per diem ; part of this amount is put into a savings bank, and is handed to the disabled man when he finally leaves the institution. As a rule, better results are obtained from indoor pupils, but outdoor pupils are also accepted. The working hours range from seven to eight a day. The pupils are allowed to go out three times a week at the most. On completion of the training, the disabled man is put through an examination, and if this is successfully passed he obtains a certifi- cate. As regards elementary instruction, the examinations are given by a Commission especially appointed by the Educational Authorities, and therefore they receive legal sanction. The number of pupils in the ideal training school ought to be large. Without mentioning the many obvious reasons which would bear out this statement, it is plain that in small institu- tions there cannot be taught a sufficient number of trades to satisfy the bent or the physical powers of each individual disabled man. In Italy we have several technical training schools which very nearly fulfil this last requirement, as, for instance, those in Lombardy, Sicily, Rome, Emilia, Piedmont, &c. In these pro- vinces and districts all previous local organisations have been centralised into one big institution, thus obtaining most remark- able results. This, however, has not been possible everywhere, for in many places of no great importance the people have been induced, by a strong feeling of patriotism, to make it a point of honour, and as a token of their devotion to our country and to our soldiers, of founding and keeping up an institution of their very own, where, naturally, only a limited number of disabled men can be admitted, and a few trades taught. Even so, a sort of advantage is gained, for the disabled men are only too glad to be near their own people and friends, w r hilst the latter have better opportunities for taking an active interest in the men, and in giving them assistance when their training is completed. Later on the grouping together of the smaller institutions belonging to certain provinces was happily accom- plished, thus adding the possibility of the development of a better system of training. In the Venetian Province we have a good instance of this method of grouping the institutions together. The Union of the Venetian Committees has gathered into one single confederacy the several efforts that had been made by the cities of Venice, Verona, Vicenza, Padova, Udine, Treviso, Rovigo, and Belluno. Unhappily, the events of the war came to spoil the work that had been so well started. The Venetians, however, have not lost heart. Their troubles have linked them more closely 142 together, and, with the aid of our Government, of the League of Italian Committees for Disabled Soldiers and Sailors, and with the hacking of the entire nation, they have removed the once flourishing institutions of Venice, Padova, Verona and Udine to Florence. And there, as the proclamation made by the Union of the Venetian Committees has it, in the City of Flowers, these training schools, although so far away from their places of origin yet ever in spiritual communion with their native towns will continue to spread their beneficent influence, fraught with so deep a meaning in these troublous times, until the coming of that long hoped-for day when the unredeemed portions of Italian soil will at last be delivered from the yoke of the enemy. Our disabled men generally find in these institutions the train- ing as well as the workshops they require. Several of these institutions have also availed themselves of the facilities that alread} 7 existed in the Technical Schools belonging to the districts. Again, the disabled men can go through a course of training at the workshops that have been set up by philanthropic manufac- turers for this purpose. The trades that are generally taught in our Training Centres are : Shoemaking, tailoring, saddlery, carpentering, general mechanics, cabinet making, book binding, manufacture of wooden clogs, &c. ; furthermore, all trades indigenous to agricultural districts, as, for instance, basket making, cartwright and cooper trades, &c. In addition to these there is the commercial train- ing, which comprises book-keeping, typewriting, drawing, tele- graphy, &c. All disabled men who are learning a manual trade are also compelled to attend the public school classes during one or tw 7 o hours daily. As it has happened in other countries, the selection of trades that has been made for the disabled men in Italy has not always been a wise one; the result of much experience, however, has allowed us to lay down the following rules : (1) Whenever it is possible, the disabled men ought to be retained in the trade followed by them in pre-war days, or in one similar to it ; (2) The above rule ought to be applied especially to agricul- tural labourers, who constitute in Italy about 85 per cent, of the total number of disabled men. Through the efforts that have lately been made by the League of the Assistance Committees, and by individual committees as well, labourers have been induced to return to the land, disabled men having become convinced of the advantages accruing to them and their families by so doing. This is a step, however, to be taken only after the disabled men have learnt the use of labour appliances suitable to each particular case, and on their com- pleting a course wherein they have been taught the rudiments of modern agriculture ; in this way , and in spite of their physical disability, they may obtain from the land a much better yield 143 than they would have done had they persisted in following the ancient methods. (3.) In view of the very large number of disabled men who aim at obtaining small Government appointments, the necessity has been recognised of discountenancing their applications , and by so doing , sparing them many future disappointments ; it has been also recognised that it is infinitely preferable to give the disabled men a thorough training in appropriate trades and callings, which, besides being of a more profitable and inde- pendent nature, are also not quite so much sought after. (4) The authorities have also come to realise the necessity of discouraging the tendency w r hich has increased to- big proportions, of crowding into the cities. This has been, obtained by persuading the disabled men to return to their native towns or villages as much as possible. We will now make a brief sketch of the Training Institutions for Disabled Soldiers and Sailors to be found in Italy, and that are at present under the direct Authority of the National Institu- tion for Disabled Soldiers and Sailors. Starting in the farthest southern district of the kingdom, in Sicily there is the Disabled and War Blinded Soldiers and Sailors Committee, established in Palermo, which is deservedly con- sidered to be one of the best amongst the other most excellent Sicilian Institutions for Disabled Soldiers and Sailors that were called into existence by the committee. This institution was installed in the Villa Belmonte , and opened in November, 1915. It then had accommodation for 100 patients, but it has been greatly enlarged since then by the purchase of an important estate at San Lorenzo ai Colli, whereon buildings are being erected, forming an annexe for the original establish- ment. The institutions and its dependencies can accommodate 370 patients at the present date, and when all the buildings are completed there will be room for 450. From the date of opening up to the end of last March , 1 ,282 disabled men had received the hospitality of this institution. The Villa Belmonte, in which there are 170 beds, is used as a Preparatipn Ward. It is there that all the disabled men coming from the different hospitals in Sicily are collected, and after being provided with temporary or final appliances they are carefully nursed, in accordance to the requirements of each case, and go through the first stages of their technical training. Here are to be found schools and small workshops for shoe-making, basket- making, pottery, &c. Thence the disabled men are sent on to the Labour Ward r where there are regular class-rooms, big workshops for the manu- facture of surgical appliances, and a department for agricultural 144 technical training. Whilst in San Lorenzo, besides the tech- nical training, the disabled men receive a therapeutic treatment which is enormously beneficial to them. In this institution there are special courses for house painting, -cabinet makers, engravers, decoration of pottery, &c., besides the usual classes and courses found in other training centres. The disabled men are paid so much per hour in proportion to the' work they do. A few of them have obtained admission, for training, to workshops of the City of Palermo proper, where they go through a regular course of instruction. A considerable amount of importance has been acquired by the factory of San Lorenzo, where farming is taught in all its various branches : the making of butter and cheese, the care of fowls, the breeding of pigs and rabbits. Stables have been installed there, as well as beehives, and there are workshops for the repairing and fitting of agricultural implements. This farming branch, which is very cleverly managed, has already given remarkably good results, in spite of its having been initiated only a few months ago. Among the disabled men who have been received by this institution, there are quite a number of farm labourers. In the course of ten months this branch has had 125 pupils, of which 69 have been trained: there are, at present, 28 remaining, as the other 29 have, for various reasons, not persisted with the course. Taken all in all, the Sicilian Committee has done really admirable work. Further north of the peninsula we have, at Lecce, a School for Farming which accommodates 45 men, and was installed in the beautiful Villa Sans-Souci by the Provincial Committee for Disabled Soldiers and Sailors. Having been opened as late as last October, we cannot, for the present, emit any opinion as to the results it may give. In Naples there is a very good training centre that has been installed in the Hotel Haessler by the Neapolitan Committee for disabled men ; it now has accommodation for 140 men , but will shortly be enlarged in order to hold 250. Besides the public school classes, there ife a course for drawing and typing, and -several workshops as well. There is also an orthopedical esta- blishment, which can turn out about 100 artificial limbs per month. In order to start a course of farming, a special branch has been opened at Bellavista on an estate adjoining the Portici Agricultural High School. This school will co-operate with the 'Committee in this department. In Rome the Roman Institution for the Assistance to the Blinded and Disabled Soldiers and Sailors has been installed at the Villa Mirafiore, placed at the disposal of the Authorities by the members of the American Academy. This institution was opened in May, 1916, and can accommodate 200 men; besides its many classes and laboratories, it has several wards for 145 therapeutic treatment. The large workshop for the manufacture of artificial limbs that was fitted up by the British Red Cross and presented to Her Majesty the Queen of Italy, also belongs to this institution although it is actually situated in the Quirinal Gardens. A large allotment adjoining the grounds of the Villa Mirafiore is entirely cultivated by the disabled men. These same men have been authorised to attend a course for improvement rat the Perugia School for Farming, where the Committee for the Assistance of Technical Training for Disabled Soldiers and Sailors have, dating from September, 1917, instituted 38 scholar- ships to be given to the men from the Roman Centre. The disabled labourers belonging to the army corps of Bologna are equally admitted to this course. The Marchigiano Committee for the Assistance to Disabled Men of Ancona has established a farmers' colony at Porto Recanati, where 30 men are admitted. Here, there are special sections for the training connected with farming; and, in the Villa Almagia, in Ancona, this same Committee has instituted courses for both technical and commercial training. These, as well as many others that are connected with the sanatorium for nervous patients in* Ancona, and a workshop for the manufacture of surgical appliances, have barely been started; they are giving every indication of proving most successful. In Tuscany there are training centres for disabled soldiers and Bailors not only in Florence, but in Leghorn, Pescia, Pisa, &c. We have already mentioned the excellent results obtained by the Florentine Committee for the Assistance to Disabled Men, through their introduction to technical training in the second grade hospital installed at the Villa Bondi, where there is accom- modation for 110 residents. Besides this, there is the School for Farming, which constitutes a branch of the Villa Bondi Profes- sional Training School, and that has been working ever since December, 1917. The teaching there is both theoretical and practical, having special reference to farming methods in Tuscany. 'The disabled men can attend daily courses on the subjects of gardening, apple growing, grafting, clipping, beehives, &c. From the date of its initiation up to the present day, 50 disabled men have attended the lectures at the School for Farming. In January, 1917, a Training Centre was started by care of this same Florentine Committee in Via Ponte alle Mosse ; it has accommodation for 70 men, and is beautifully fitted up with first <.-lass laboratories and classes, and is under good management. As has already been said, the League of Venetian Committees has caused to be installed in Florence all the training centres which were previously working in Venice, Verona, Padova, &c. The Venetian Provincial Committee used to have in Venice an excellent^ organisation which was established in the British Hospital* with accommodation for 110 men, and with classes and workshops that already had given very good results. In Padova the Padova Provincial Committee had established a farming 146 colony capable of accommodating 150 men in the Villa Wollenborg, and there used to be another very good train- ing centre in Verona. And yet another was just going to be opened in Udine, whilst the several committees of Belluno, Rovigo, Treviso, and Vincenza were uniting their activities to those coming from different other districts in the Venetian Province with a view to assisting the disabled soldiers and sailors. The Austro-German invasion checked but did not stop this work, and it is now being resumed in Florence with renewed enthusiasm and earnestness. In Pescia the Italian Red Cross has established a Train- ing Centre in the Villa Calderai, with accommodation for 127 men, who can be trained in farm work by following the courses at the neighbouring Royal School for Farming. This institution aims at a closer co-operation between the Medical Board and the Royal School Board, in order to obtain perfect harmony as regards treatment and functional recovery and professional training. Ever since January, 1917, the training centre at San Zeno, Pisa , has been in working order ; it can take in 35 men , and is managed by the Committee for the Assistance, in Pisa, of Disabled Soldiers and Sailors. Another one is established in the Villa Corradini, Leghorn, having accommodation for 50 inmates, and managed by the Leghorn Association for Disabled Soldiers and Sailors. Ever since the month of May, 1916, the Italian Red Cross, with assistance received from other sources, had established the G. Romiti Institute in Spezia ; this institute takes in 130 disabled men and provides courses for the elementary training in tele- graphy, workshops of various kinds, and allotments for experi- mental gardening for flowers and kitchen produce. In Modena the Provincial Committee for Disabled Men has, since April, 1917, established the Autonomous Provincial Institute for Cripples. Connected with this, there are public school and manual labour classes ; especial attention is paid to the farming section. In Bologna there is a training centre that deserves the highest praise ; it was created by the Institution of Assistance to Disabled and Crippled Soldiers. It was in Bologna that the first hospital concentrating station was established, making it obligatory that all disabled men belonging to the local army corps should make a short stay at the training centre, with a view to their getting acquainted with the advantages of the system. The Bologna Training Centre has grown both in size and in importance and, to-day, can accommodate 150 pupils. The encouragement given to physical activities , such as . march- ing, calisthenics, bicycle riding, &c., calls for special notice; this is done with a view to the pupils attaining the highest physical efficiency consistent with disablement. Another good 147 feature of this institution is the great attention that is paid to the cultivation of the men's minds; to do this, they are taken to visit factories, museums, art galleries, and the many interest- ing monuments that abound in the Province of Emilia. In Genoa the Ligurian Local Committee has paid special atten- tion to the surgical treatment with reference to the general training. The technical training centre in the Villa Kaggio was opened in January, 1917, accommodates 73 men, and has several small workshops for the different trades ; these are being enlarged. The Lombard Committee has created in Milan a complex establishment for the assistance to disabled men which is most worthy of the great Lombard metropolis. The surgical treatment h in the care of the Pious Rickets Institution, whilst the Lombard Committee give their more special attention to tech- nical training and general assistance. This training centre con- tains, at present, three branches, viz., workshops, courses for commercial training (clerks, &c.), section for farming. The workshops branch is established in the Lady Finzi Ottolenghi Shelter at Goria, where, besides the living apartments and general offices, there are the educational laboratories for training, the wards, and, in appropriate huts, there are the classes where the various professional courses are followed. The pupils now in residence number 200 ; those that have been dis- missed after completion of training, 350. The branch for commercial training (clerks, &c.) which was formerly in the Marcelline Institute in Milan, has now been removed also to Goria, to the Gazzaniga huts. This course con- sists of the preparatory class, the clerkship class and the improve- ment class ; there is also an art school (for training drawing masters, indoor house painters, architect helpers, &c.). There are now 150 pupils there, whilst 300 have been dismissed after completion of training. The farming branch is situated in the Villa Pelitti, not far from the town of Precotto ; it has only recently been started , and can take in about 100 men. The auxiliary trades in relation to farming are also included in the courses at this branch, such as wicker work, manufacture of clogs, &c. There are also work- shops for blacksmiths' and carpenters' training, hothouses, stables, beehives, fruit gardens, experimental allotments for farming, &c. In even 7 section the teaching is both theoretical and practical ; the men each receive a small daily allowance for pocket money proportionate to their time of residence and proficiency in the course of learning. The Piedmontese Provincial Committee have their headquarters in Turin ; the different branches of their activities are spread all over the Province of Piedmont. The chief training centre is in Via Eossini, Turin ; quite small at first, it has since grown to generous proportions. It can now receive 190 pupils, and 148 when the new buildings which are going up are completed, that number can be increased to 300. It will then have very complete workshops, with every convenience, class rooms, and laboratories where surgical instruments will be manufactured for supplying the entire province. There is a handcraft's section and a section for commercial training for clerkships, &c. Just outside the city of Turin there is an annexe of the training centre, the Institution for Farming, of Bonafous, where disabled men are trained in farm work. This institution can take in up to 30 men, and the teaching is both theoretical and practical. Finally, in Casale, through the initiative of the Alexandria Sub-Committee, supported by the Piedmontese Committee, a small training centre has been started ; it is hoped that it will soon develop into a School for Farming suited to the importance of this agricultural district. Taken as a whole, the training centres now existing in Italy can accommodate up to 2,800 disabled soldiers and sailors. Thanks to the activities of the National Institution for Disabled Soldiers and Sailors, it is expected that many more of these institutions will be created in a very short time. III. We will now say a few words as to the after care that follows the technical training, and that devotes itself to sustaining and helping the disabled men on their returning to the life of civilians. This question is most important, and is closely con- nected with technical training, inasmuch that, without the after-care, all the advantages of the training would be lost. On leaving the training school, the disabled man nearly always has a small capital with which to get the necessities of life ; this is the result of those entries made during his training into the savings bank book by his Committee, and represent part of his earnings during the said training. To this amount have been added, from time to time, the rewards for training given by the Minister of the Interior or by the Committees themselves. The disabled man is also generally presented with the surgical appliances he may need, with tools or books required for his new trade. As a rule our disabled men find work to do with comparative ease on leaving the training centres, and nearly always obtain a much higher wage than they earned in peace time. Each Local Committee takes a special pride and interest in finding work for the discharged disabled men to do, and many have created Special Labour Exchanges. Nor are the men either forgotten or neglected once they have found work to do, each training centre taking special care and pride in watching over their old pupils, especially at the start. This is a subject on which Signer Aw. Martello will make his report with all the- earnestness called for by so weighty a problem. 149 So we will set this point aside and treat more particularly of the after care of disabled men on the completion of their training. In this respect it would be well to mention the activities of the Sicilian Institute for disabled men with regard to the after care of their old pupils who have obtained positions in the factories in Palermo. We refer to the Disabled Soldier's Home, which has proved a real boon to disabled men who, after leaving the training centre, have often found great difficulty in obtaining board and lodging. To this end the Sicilian Institute has rented suitable apartments, furnishing them and fitting them up for the occasion, and lets them out to their former pupils for a nominal rent. All the management of this Home is entirely left to its inmates with regard to catering and all other details. This undertaking, if well managed, ought to give the best of results and should soon find imitators. We thus have given a cursory glance to what has been accomplished in Italy with regard to technical training of dis- abled soldiers and sailors ; the work that has been done has been well done, and was chiefly. taken up spontaneously by the Local Committees. It will now be the task of the National Institution for State's Work to continue the task so well begun, to carry on this great humanitarian work in the same spirit in which it was begun. The wisdom and knowledge of the world which is characteristic of the eminent men who have been appointed to preside over and manage the Institution, assure us that the Italian legislation will be applied in such a way as to secure full efficiency for the Govern- ment's action. Thus, with a wisdom and knowledge worthy of our ancient Eoman fathers, shall we fulfil our pledge of gratitude towards our brave and beloved disabled soldiers and sailors. 15C TECHNICAL RE-EDUCATION IN ITALY, IN ITS RELATION TO THE LAW FOR THE ASSIST- ANCE AND PROTECTION OF THE DIS- ABLED. BY PROF. ETTORE LEVI, Member of the Executive Committee of the National Commission for the Assistance, &c. (Florence, Italy). The purpose of the present report is to present a succinct account of the Law for the Protection and Assistance of Men Dis- abled in the War, adopted by the Italian Parliament in March, 1917. For upon this law is based not only the organisation of Technical Re-education in Italy, but also the whole complex . work of the after-care and social assistance of every disabled man , whether he be incapacitated by wounds or through illness. The execution of this great undertaking has been entrusted by Parliament to a new organisation, known as the National Commission for the Protection and Assistance of the Disabled, composed of Members of Parliament, administrators, specialists, and disabled soldiers themselves, presided over by Prof. Durante, Senator of the Realm. The mission of the National Commission has been greatly facilitated by the work accomplished during the first two years of war, by municipal and regional committees, whose activities have been, since October, 1916, co-ordinated and directed by a ' Special Inspector, Prof. Enrico Burci, of Florence, attached to the Ministry of War, and appointed by the Prime Minister at that time, Sig. Boselli. The essential duties of the Special Inspector have been the re- organisation of the Military Institutes for the Reception of Disabled Men, and their co-ordination with those already estab- lished by the civil authorities. Only by such re-organisation and co-ordination could the uniform and continuous treatment, both material and moral, of the disabled be secured. The Representative of the Minister of War will describe, in another report , the details of the immense and beneficent organi- sation medical, military and civil by the achievements of which the National Commission has been enabled, since its in- auguration, to profit for the special ends of Technical Re- education. It must be alluded to here only from a general and schematic point of view~, but a more adequate report will be presented by Sig. Che valley. The amalgamation of the existing civil and military organisa- tions has been brought about of necessity, by the experience of the 151 first year of war. For this experience indubitably showed us that re-education, as a general measure, w T as doomed to failure, if it were not preceded by an adequate moral and physical prepara- tion of the disabled man from the initial stages of his incapacity, and followed by a wise and kindly supervision during the critical period of his return to normal surroundings. Ideally, this pre- re-education that is to say, the moral preparation of the patient should be initiated at the very moment when he first realises that he will remain hampered for life by his physical disabilities. In order to realise such an idea, we have attempted in Italy to concentrate without delay all the seriously disabled in two surgical First Eeceiving Centres, where they may live in an atmosphere favourable to their preparation for an active future. For this reason every patient, from whatever sector of our ex- tended front he may come, is immediately conveyed to Mantua for the Northern front, and Bari for the Eastern front, where he is ensured not only the most efficient medical and surgical treat- ment, but also the most intelligent and loving moral preparation. In order that such preparation, so obviously of the first import- ance, should be carried out in the most ideal way from the very start in the small field hospitals and in the hospital trains the National Commission has undertaken the publication and the listribution of a pamphlet of propaganda. This pamphlet, pub- lished in the simplest 'form, is designed to popularise the law bating to the disabled, explaining to the patient and to all who lay attend him doctors, nurses, chaplains, &c. what are the ights to which he is entitled , and all that these imply ; ledical and surgical attendance ; free provision of arti- icial limbs ; maintenance for six months in a School of Be- lucation ; the laws relating to pensions and legal medical attend- ince ; social relief and the securing of employment for discharged lisa bled men in public and private businesses. The pamphlet, ibundanfly illustrated, and distributed by the thousand through- mt the whole country, by means of the civil authorities, doctors, irish priests, &c., will also serve the purpose of explaining these [vantages to many discharged disabled soldiers who, during the irst period of insufficient organisation, did not profit by rights id privileges which had not been made adequately clear to them. From the first receiving hospitals in Mantua and Bari, the tients will be distributed, according to locality, among the rst concentration hospitals of Turin, Milan, Genoa, Bologna, lorence. Borne and Naples, thus being brought without delay into the neighbourhood of their families and of their normal environment. In these hospitals, chosen for their healthy and agreeable surroundings, the surgical treatment of the patient is completed, and, simultaneously, the moral prepara- tion, already initiated, is carried out by the personnel of the local School of Be-education. As soon as the patient is able to sit up in bed, he is encouraged to attempt light occupations bead- work, cardboard- work, toy-making, &c. Thus his passive entality is transformed into an active mentality, and he begins 152 to feel the hope of a renewed possibility of work and to appreciate its necessity. The wounds of the patient being nearly healed, he passes to the local concentration hospital of the second grade, where his physical and orthopaedic treatment is completed. The stumps of the mutilated limbs are then put into a condition favourable for the adaptation of artificial members, and crippled limbs are restored as far as possible to their functions. In this period the patient is no longer confined to bed, and his general re-education may be extended ; he is accordingly encouraged to attend the schools which exist throughout these dis- tricts. In such schools illiterates, unfortunately numerous in Italy, are taught to read and to write; or, having already mastered the rudiments of education , they may bring their know- ledge to some degree of perfection. The patients have also at their disposal small workshops, intended, for the most part, for the light manual work suitable to the great mass of our disabled, who come from agricultural districts : the auxiliary trades of agriculture, such as wicker-work and basketry, coopering, clog- making, &c. By these means, even those patients who per- sistently refuse to spend six months in the Schools of Re- education are enabled to return to their homes with some notion of the best way to exercise their normal occupations. During this period the patients are furnished with temporary artificial limbs. Then follows the third and last period of treatment. The physical treatment of the patient completed, after a month's leave he passes on to the School of Re-education already existing in each one of the above-mentioned cities. Re-education is, unfortunately, not compulsory in Italy; but the law has been framed with such foresight as to affect the greater number of those who have need of it, making compulsory for every indigent patient a sojourn of at least fifteen days in the Schools of Re-education. He is, accordingly, made to realise the possibilities open to him. and does not risk refusing such benefits owing to an incomplete appreciation of them. The return of those who may repent of their former refusal is thus made easy. Only in the School of Re-Education itself do the disabled receive their permanent artificial limbs. These are supplied by the special laboratory attached to each school under the direction of an orthopaedic surgeon. Many schools also furnish gratuitously the necessary implements for the exercise of the trades and handi- crafts taught there. This system has the object of centralising and retaining every patient for the longest possible time in the Schools of Re-education. These schools were established in Italy through local initiative, and for this reason neither their administration nor their pro- grammes have been perfected or co-ordinated. They are now, however, under the control of the National Commission, which 153 will reinforce and organise them according to a general and uniform design, as follows : 1. The great mass of disabled agricultural workers will be given some elementary scholastic knowledge (the campaign against illiteracy). 2. They will be taught at least one of the easier trades which may be followed in any part of the country, and are known therefore as subsidiary to agriculture. 3. The more informed and intelligent agricultural labourer will receive instead a general and technical instruction which shall advance him according to his former occu- pation, teaching him the more highly specialised methods of agriculture and of stock-breeding. Such a programme will tend to check the artificial move- ment toward the cities and the pernicious pursuit of Government employment. The first School of Agriculture at Palermo has already shown admirable results in this regard, and other Ke-education Centres are accordingly directing their steps to follow upon the same road. 4. Disabled men who prefer non-agricultural work will find in the same centres of re-education both primary and secondary schools and workshops where they may be trained in the trade most adapted to their condition, with special reference to local industries. Upon this point more ample details will be given in the report of Sig. Chevalley. We in Italy are convinced that the resident system is greatly superior to the non-resident, and we have, therefore, put the former into more extensive practice, yet without such rigid en- forcement as to prevent men availing themselves of every practical local training scheme carried out upon a different basis. We are equally convinced that the larger institutions present material advantages over the smaller. Up to the present time, however, the smaller institutions have perforce been more preva- lent with us, since, during the early days of private initiative in Italy, the local bodies, though zealous, were little controlled and lacking in means. The National Commission, now reviewing the entire situation with impartial judgment, intends to give the maximum of assistance to the more flourishing institutions, and inexorably to condemn the weaker and less successful. The work of supervision and control is carried out by continuous inspections , entrusted to committees chosen from among the members of the National Commission, and composed for the most part of a specialist in re-education, an administrator and a disabled officer or soldier. In this regard it is worthy of note that there exists in Italy a flourishing Association of Disabled Soldiers, numbering already some 20,000 members, and acting in strict accord with the mili- tary authorities and with the National Commission. Kepresenta- tives of this society are members of the Council of the National 154 Commission and of every local committee. They have also the right to control the methods of re-education prevailing in the various centres. The National Commission exercises its complex work of control through the medium of the local committees, which, during the first period of the war, spontaneously undertook the establish- ment of schools of re-education. The local distribution of these institutions is, however, unfortunate, being numerous in the north and scarce in the south. To obviate this grave inconveni- ence, the National Commission is undertaking, at its own ex- pense, to found a large institution at Bari, and another in Sardinia, and is intending also greatly to extend the already existing institution at Naples. But in thirty-three provinces of Italy there exist at present no Schools of Re-education, and it is not desirable that they should exist ; for, as we have said, the aim of the National Commission tends rather toward the perfect- ing of the larger local institutions. It is to be desired, however, that in these provinces the disabled who have rejected their first -opportunity for re-education should, if possible, be drawn back under its influence, and by every other means be helped and protected. To this end the National Commission has created, in the chief towns of these thirty-three provinces, official committees, com- posed in each case of seven members, one of whom is himself disabled. These committees exercise in the outlying districts the fundamental functions of the National Commission, and have also the duty of choosing the communal delegates, w T ho may be likened to the capillary vessels of an arterial sj 7 stem, extending their beneficent propaganda to every remote and obscure part of the country. In this work of propaganda, in the remoter dis- tricts, the delegates of the Society of Disabled Soldiers are invaluable coadjutors. The National Commission is actively engaged in the prepara- tion of a new and complete census of the disabled men who have .already returned to their homes. The Commission will thus be enabled to supply, with the least possible delay, what has been lacking in the past. For only by means of an exact report of the physical, re-educative and social circumstances of each individual is it possible to bring under fresh supervision those disabled men whose condition is still capable of improvement, to complete and perfect the application of artificial limbs, to attract to the Schools of Re-education those w r ho have not already profited by them, and to secure employment for those who have or have not been re-educated. The Commission is also organising a Special Committee for the Study of Prothesis, endowed with ample powers and an ex- tended programme. This committee will study, both from a practical and scientific standpoint, the subject of artificial limbs in general, and of those adapted for industrial purposes in particular. 155 Our experience justified us in the course we have followed r since, in the well-directed institutions, there are but few patients who refuse re-education. Unhappily, the contrary is sometimes the case. The percentage of those who reject re- education in imperfectly organised institutions, where the beneficent influence of example is lacking, has always been, and will always be, high. At present the percentage of disabled men who have been trained is steadily rising, w r hile the re-education of the crippled is not yet sufficiently extended, with the result that many of the latter become indifferent to every advantageous influence. But in every concentration hospital for cripples, and in the neurological centres, there exist both elementary schools and small laboratories to give an initial stimulus towards work. The National Commission expects shortly to establish for the cripples the same scheme of systematic re-education already secured for the disabled. For the treatment and re-education of the blind, the same general scheme will serve. From Mantua and Bari they are rapidly centralised in the ophthalmic first concentration hospitals of Milan, Rome, Florence, Naples and Catania, where, along with the necessary physical treatment, they receive the first moral preparation. Systematic re-education is earned on in the excellent Schools of Re-education in these same cities, which will be described in the report of Signor Mondolfo. The same general plan is followed for the permanently deaf-mute, who will be taught lip-reading in special institutes. The disabled of every grade receive free maintenance in the Schools of Re-education for a period of six months, which may be extended in the case of those who show themselves deserving. The financial requirements of the National Commission are determined year by year by the Ministry of the Interior, acting in collaboration with the Council of the National Commission. The finances of the Schools of Re-education, previously supported by private funds, will be taken over by the Commission, as is necessary or desirable. The Commission undertakes also to administer gifts or legacies made to the disabled. Lastly, the National Commission has also the task of extending its protection and assistance to all Service men incapacitated through illness. This is a work of immense proportions and of essentially medical character, which, however, must not be separated from re-education. For no patient, until he be restored to favourable physical condition, is capable either of re-education or of social usefulness. Special study is being given by the Commission to the grave problem of the tubercular cases, with the close co-operation of the military and civil sanitary authori- ties. It is intended that tubercular patients shall be taught, in special tuberculosis sanatoria, that regime of life which they must follow if they hope to be cured. While actively forwarding such anti-tubercular pre-education, the Commission expects to have among such patients a steadily increasing percentage who may become candidates for a future technical re-education, under 156 a special supervision which must never lose sight of the patho- logical origin of their disability. The financial and industrial future of all disabled men in Italy is facilitated by the fact that the foresight of the law has under- taken to insure them against industrial accidents, and will also advance to them, with the guarantee of their pensions, sufficient loans to make possible the building of farm-houses or the purchase of cultivable lands. The concession of such benefits is under the strict control of the National Commission, which will, however, give it the widest possible application, so that in time a large proportion of our disabled agricultural workers will become proprietors of small farms which they may cultiyate by their own labour. I have tried to review in a few words the scheme according to which, by virtue of the Italian Law, the National Commission is applying itself to the re-education, moral and physical, of our disabled men. But the Commission, not content with what has already been accomplished, aims at achieving an increasing efficiency, guided by the teaching of ever-changing experience. For this reason, the Commission has already initiated studies for the revision of the present law, which, though excellent in many points, has already shown certain deficiencies, notably in regard to the assistance. of the ultra-disabled* and of those incapacitated by illness. The Statutes which establish the duties and claims of the disabled must also be revised, according to the desires of the disabled themselves. With such a profound consciousness of her duties ; with an inexhaustible will towards good ; with a serene faith in what is to come, Italy has provided, and will provide, that the future of her noble sons is, and shall always be, worthy of their glorious past. * NOTE. See the report to the Inter- Allied Conference of the same author on the subject of the Assistance of the Ultra- Disabled (for example, blind, with double amputation of superior limbs, &c.). Those who may desire fuller information upon these subjects treated in the foregoing report may refer either personally to PROF. ETTOBE LEVI, Piazza Savonarola 11, Florence, Italy; or to OPERA NAZIONALE PER LA PROTEZIONE ED ASSISTENZA DEGLI INVALIDI DI GUERRA, Palazzo Taverna, Via Monte Giordano, Rome, Italy. 157 VOCATIONAL TRAINING AND VOCATIONAL RE-EDUCATION IN CANADA. By Major E. T. MACKEEN. Vocational training of the returned invalided Canadian soldiers was first beg-uii in a small way, early in 1916, in various con- valescent homes and hospitals throughout the country. The results were so satisfactory that arrangements were perfected for an extension of the work to all our hospitals, and serious con- sideration was given to the problem of vocational re-education and the importance of rehabilitating invalided men generally to take up again the responsibilities of civilian life and industrial activity. All invalided men when returned to Canada are under the control of the Militia Department. Those requiring further treatment are maintained in convalescent military hospitals until such time as all that can be medically done for them is accom- plished. During the time that they are in these military hospitals, the men have the opportunity of engaging in bedside occupational work or in taking up the more serious undertaking of vocational training. A special staff of vocational officers attached to the invalided soldiers' Commission co-operate with the Military Hospital Authorities in the performance of these duties. As soon as all that can be done medically for a convalescent man is accomplished the man is discharged from the Service. He is granted a pension, when justified, and is automatically transferred to the Department of Soldiers' Civil Re-establish- ment. The functions and powers of this Department are briefly ^as follows: (a) The providing of hospitals, convalescent homes and sanatoria, whether permanent or temporary, for the care or treatment of invalid officers, non-commissioned officers, men or other members of the Canadian Expeditionary Force who have been honourably dis- charged therefrom, and the administration, control and erection of all such hospitals, convalescent homes and sanatoria. <(&) The vocational, educational and other requisite training for civil occupation of all persons who have served in and who have been honourably discharged from the Canadian Expeditionary Force. {c} The provision of employment and all such assistance therein as may be requisite or available for the persons aforesaid and generally for their rehabilitation in civil life and activities. 158 (V7) All matters relating to pensions for the persons aforesaid, in co-operation with the Board of Pensions Commis- sions. The Department of Soldiers' Civil He-establishment is pre- sided over by a Minister who is assisted by a Parliamentary Secretary and a Deputy Minister. There is a Sub-Department which devotes itself particularly to vocational training and vocational re-education. This is known as the Invalided Soldiers' Commission. This Commission is presided over by a Director assisted by an Officer i/c Discipline, an Officer i/c Medical Service and a Vocational Administrator. The personnel of the Vocational Branch in order of their responsibility is as follows : Vocational Administrator. Vocational Secretary . Provincial Vocational Officers. District Vocational Officers. Principals of Vocational and Re-educational Classes. Instructors. The first two-mentioned officials make their Headquarters at Ottawa and are responsible for the general administration of vocational work throughout the country. Each Provincial Vocational Officer has complete control in his respective Province and District Vocational Officers are allocated to each centre in the Province where the hospitals are located and training work is carried on. In each Province, for the assistance of the Voca- tional Officer, there is established a Provincial Advisory Com- mittee on Training, the functions of which are briefly as follows : (a) To prepare, with the assistance of the Vocational Officer, schemes of instruction in general subjects and ele- mentary vocational training in, or in connection with, the convalescent homes or hospitals of the Province. These schemes are submitted for the approval of the Invalided Soldiers' Commission, which may then sanction the expenditure involved in any scheme, or sugg'est modifications, or otherwise, of the scheme. (b) To organise and carry out such schemes as may be approved by the Invalided Soldiers' Commission. (c) To maintain a regular inspection, preferably through the Vocational Officer, of all instruction being car- ried on under schemes approved by the Invalided Soldiers' Commission. (d) To make a survey of the facilities at present, and from time to time, available for vocational training in : (1) Public educational institutions. (2) Private educational institutions. (3) Private workshops, farms, &c. (e) To assist the Employment Commission by providing definite information as to the training received by men who desire assistance in obtaining employment. 159 (/) To appoint or approve local Sub-Committees on training* in connection with local employment Committees in centres where it may appear to be necessary to have such a committee. (g) Generally, to advise and assist in the training of re- turned soldiers in every possible way. The duties of a District Vocational Officer are briefly as follows : (a) To act in co-operation with the Advisory Committee on Training, of the Province. (6) To make personal surveys, when necessary, of all cases where the man indicates his desire to be helped to obtain employment and to transmit suggestions on each case to the Provincial Employment Committee or its local Sub-Committee. (c) To act as a member of the local " Disabled Soldiers' Training Board " and to transmit its recommenda- tions to the Invalided Soldiers' Commission. ,(d) To arrange, through the Advisory Committee on Train- ing, or otherwise, for the placing in educational institutions, private workshops, farms, &c. of all men who have been passed for training by the Commission, and to maintain a regular inspection of all such men and report upon each case at stated intervals to the Commission. '(e) To arrange for regular or occasional meetings of the local Disabled Soldiers' Training Board, as the circum- stances may require. (/) Such other duties as may be assigned him by the Corn- mission from time to time. Each District Vocational Officer is further assisted in his work iby a Disabled Soldiers' Training Board consisting of : (a) A member of the Provincial Committee. (6) A District Vocational Officer. (c) A specially selected medical officer. The duties of the Board are as follows : (a) To consider all cases which, in the light of the medical reports, appear to be subjects for special training and to report upon each, with suitable recommendations, to the Invalided Soldiers' Commission. (6) To consider, from time to time, reports of the progress of men undergoing training and to make recom- mendations as to change of treatment, or of training or its discontinuance. In addition to this in large centres where re-educational work is carried on there exists a Technical Advisory Committee which consists of the best men available in their respective industrial professions or occupations. These men make it their special 1GO work to counsel and advise the principals of the schools and the instructors in the performance of their duties. The purpose of this is to provide the very best intensive instruction in the par- ticular professions or occupations represented by the members of the Committee. Bedside occupational work is carried on in the Military Con- valescent Hospitals with the co-operation of the medical officers in those institutions with a view to engaging the men's minds as far as possible in practical, instructive and interesting occu- pations. They are thus enabled to fill in many hours of use- fulness, which would otherwise be spent in unprofitable pursuits, or in brooding over their condition. This work has the further advantage in many cases, of compelling corrective physical effort for the hands or feet or limbs, which would not be available were it not for the interest which the work inspires in the men. It has also been found possible to introduce in this work, subjects which frequently direct the men into useful professions and occupations which they will follow up during their convalescent vocational training and ultimately in re-educational courses. Men in the convalescent stage in the military convalescent hospitals, when unable to carry on vocational work, attend classes in a great variety of subjects. These classes are under the most competent instructors which we can secure; as far as possible the classes are held in the hospital or adjacent buildings. Classes are provided in wookworking, machine shop work, 'typesetting, mechanical draughting, architectural draughting, art metal work, motor mechanics, farm tractor machinery, poultry farming, hog raising, glass gardening, gardening, shoe repairing, boot- making, stenography and commercial work, sign painting, illus- trating and a variety of other occupations. It has been found in many cases, that men learn enough during the convalescent stage to take on greater responsibilities upon their return to civil life, and also to engage in entirely new trades and occupations. In these classes are found many men who never before enjoyed the opportunity of going to school, and for the first time they are enabled to learn reading, writing and the simple rules of arith- metic. It not infrequently happens that men here reveal latent ability and talent which would never have otherwise been un- covered. Instances have frequently arisen where men have been able to graduate from one of the lower trades to an occupation which will command vastly greater remuneration and a higher social standing than that enjoyed before the war. The stimulant to the mental faculties and the consequent raising of the standard of intelligence of the labouring man as the result of the work .done in these classes is most apparent, and the medical officers are generous in their admiration of the remarkable aid which this work is to the general rapid convalescence of the men. While bedside occupational work and vocational training during convalescence has accomplished much for our men, the more serious phase of the vocational work is that of vocational re- education. 161 In June, 1916, the Government of Canada passed an Order in Council granting re-education courses to the members of the Canadian Expeditionary Force and also to the Reservists of the Forces of Great Britain and His Majesty's Allies in this war. Such Reservists must have been bond fide residents of Canada at the outbreak of the war and must be unable to return to their previous occupations by reason of their disability incurred on service. These re-educational courses are started after the man is discharged from the Militia, and for this purpose he is taken under the control of the Invalided Soldiers' Commission. A scale of pay allowances for men undergoing a re-educational course was adopted, which is extremely generous, as will be seen from the following citations : (a) A single man living in the institution secures free board and washing and is allowed 1 14s. per month. Where the total amount received by way of pension, and this allowance is less than 3 85. per month, an additional allowance is granted, so that the minimum amount receivable shall bje 3 85. per month in addition to free board and washing. (b) A single man living out receives 1 14s. per month, plus 4s. per day subsistence allowance. Where the total amount received by way of pension and these allow- ances is less than 9 14s. per month an additional allowance is granted so that the minimum amount receivable is 9 14s. per month. (c) Married men living in receive free board and washing and 1 14s. per month, with the following addi- tions : (1) For wife having no children 7 7s. per month, less pension of husband; (2) if with one child under maximum age of 17 years, for a girl, and 16 years for a boy, 8 7s. per month, less pension of husband and allowance for children under the Pension Regulation ; (3) if with six children under the maximum ages, 12 per month, less pension of husband, and allowance for children under the Pension Regulations. Other provisions are made for the case of a widowed mother dependent entirely on the support of an unmarried son and for the parents of a man who are both old and incapable of work and totally or partially dependent on the son. Re-education courses are granted for periods extending from three to twelve months and at present embrace 120 trades and occupations. The procedure in granting a re-education course is- as follows : All convalescent men are interviewed by a special interviewing officer attached to the staff of the District Yocational Officer as soon as the man is available upon his return to Canada. His industrial, educational and person history is secured at this in- terview and recorded on a special form. This report is available when the man is discharged and considered a case for re-education 162 under the terms of the Order in Council providing for same. The man is brought at the proper time before a Disabled Soldiers' Training Board. His case is given very careful consideration, and he is directed by the Board in the selection of an occupation, profession or trade suited to his disability and one in which it is felt his mental equipment, after proper instruction, will enable him to obtain success, and a higher rate of remuneration than he hitherto enjoyed. The Disabled Soldiers' Training Board, after enabling the man to make his choice and approving it, forward their recommendation to Headquarters at-Ottawa, where the case is again thoroughly gone into by a special Board, and the recom- mendation is either confirmed or disapproved. If the recom- mendation is approved and the course is granted, the man imme- diately starts his course and is placed on pay and allowances with the Invalided Soldiers' Commission. The re-educational work is centred as far as possible in the larger industrial cities in each province. The men are given free transportation to these cities and every provision made for their comfort in entering upon their course upon arrival. The Provisional Governments and Uni- versities in Canada have co-operated most generously with the Invalided Soldiers' Commission by placing at their disposal every facility for organising and carrying on instructional work in their institutions under the immediate control of the Provincial Vocational Officer. The instructional staffs are selected by him and are paid by the Invalided Soldiers' Commission. As far as possible the instructional staff is chosen from the returned officers, non-commissioned officers and men, and only such civilians are employed when absolutely necessary, as are not under the terms of the Canadian Military Service Act. It is the policy of the Invalided Soldiers' Commission to utilise as far as possible the facilities available in all large manufacturing institutions in the centre where the work is being carried on, for the purpose of imparting a large part of the training to the men. In this way the men have an opportunity of adapting themselves gradually and unconsciously to the environment of industrial activity. By the time their course of training is completed the final assumption of work in an industrial concern is natural and free from the abruptness which would follow were the training entirely con- fined to a technical school or university. Where training can be given in industrial shops, the scheme followed is to do all the preliminary work for the first half of the course, in the classes in the technical schools or universities, and the remaining half of the work to be completed in the factories or industrial establish- ments. Another advantage of this scheme is, that in the great majority of cases the problem of finding employment for these men is solved, because the men are automatically absorbed, if efficient, into the plant where they have received their training. Some idea of the growth and present extent of the work carried on in Canada can be gained from the following statistics : Feb., 1917. Feb., 1918. Number of instructors ... ... 38 492 Number of men taking vocational training during convalescence 787 3,500 163 Feb., 1917. Feb., 1918. Number of men taking bedside occupational work ... ... 500 Number of men taking re-educa- . tional courses ... ... ... 81 1,600 Number of different trades and oc- cupations in which men are trained ... 25 120 The proportion of men undergoing vocational training and re- educational courses, to the number of men 011 the strength of the military hospitals in Canada, can be gained from the following figures : Feb., 1917. Feb., 1918. Number of men on the strength of the Military Convalescent Hospitals in Canada 3,599 11,415 To date approximately 425 men have completed their re- educational courses and have been returned successfully to civilian life and industrial activity. Great emphasis, in our re-educational work, is placed upon the importance of giving individual instruction, and it will be apparent by studying tKe figures of the number of instructors engaged in the work, that success has been achieved in this direction. The policy of plac- ing men in industrial plants for the whole or part of their train- ing, as circumstances permit, is justified, and has worked out wonderfully well, and great credit accrues to the patriotic impulse which enabled Canadian manufacturers to undertake gratuitously, and without any payment to the men, their training under actual industrial conditions by their foremen and work- men. While men are undergoing their re-educational course, while in classes or in the factories, they are under the constant supervision of inspecting officers and medical officers of the Com- mission so that, as far as possible, conditions which would militate against their health and success, are eliminated. These officers also study the home conditions of these men with a view to making their lot while undergoing this course as happy and free from worry as possible. This social welfare work is most important, and is even followed up after the man has completed his course and secured employment. The finding of employment of all men returned to Canada and discharged is vested in Provincial Employment Associations r who, to date, have carried out their work with conspicuous success. Close touch with these Employment Associations is maintained by Vocational Officers, who assist thgm in every way possible. They particularly devote their energies to finding suit- able employment for those men who have taken vocational train- ing dining convalescence or re-educational courses. For this purpose and for the purpose of determining the best industrial establishments in which men can be trained, each re-educational centre has a specially selected officer designated, an industrial surveyor who devotes his entire time to making a logical and 164 complete survey of the facilities in these establishments for training and employing men. It is impossible in the brief time allotted to me to give more than a brief outline of our work in Canada, but I hope that I have conveyed to you the impression that Canada is straining every effort to solve satisfactorily the problem of returning men to civil life and industrial activity with the utmost thoroughness and expediency. We feel that every country is a pioneer in this hitherto unknown problem, and in common with other countries we welcome this great opportunity of conferring with one another with a view to evolving the very best methods and means of accomplishing our high purpose the discharge of our country ' full obligation to her valiant men who voluntarily sacrificed personal interests and comforts and that of their dependants to such an enormous extent in order to assist in defending the world against the menace of Prussian Militarism. 166 THE TRAINING OF THE DISABLED SOUTH AFRICAN SOLDIER AND ITS LESSON. BY LIEUT. -COLONEL E. N. THORNTON, O.B.E., S.A.M.C. Different Problems from those of Other Countries. Just as the part played by South Africa in the present World War is different from that of any of the other Dominions or Allied Countries, -so the problems which arose in connection with her disabled soldiers are exceptional. The decisions arrived at and the system adopted are giving such satisfactory results that it seems to be worth while to place them on record. Different Campaigns. On the outbreak of war South Africa was faced with rebellion in a section of its white population, and when this was quelled she undertook to deal with German South - \\Vst Africa. At the conclusion of the latter campaign, which was undertaken by her troops alone, she sent a small Ex- peditionary Force to Europe, and shortly afterwards a larger force to German East Africa to co-operate there with Imperial and Allied troops in the reduction of that country. She has been operating in the Union, in German South- West Africa, in German East Africa, in Egypt and in Europe. Casualties. Happily our forces did not suffer very heavy casualties during the rebellion and the German South-West African Campaign, but with the despatch of troops to Europe and German East Africa it became evident quite early that special steps would have to be taken to cope properly with disablement problems. In German East Africa it was not anticipated that casualties other than from disease would be particularly heavy, whereas it was expected that casualties from wounds in Expeditionary Force in Europe would be at least as heavy in proportion to the numbers engaged as those of other countries. No Limb Factory , and Insufficient Means for Technical Educa- tion in South Africa. The outbreak of war found South Africa without any facilities whatever for the manufacture of modern artificial limbs, and with insufficient means, except at two or three of the larger towns, for the technical education of the civil population. It was considered unlikely that a factory for artificial limb- making could be opened in South Africa during the course of the war, for expert limbmakers were more urgently required in Europe, and the cases actually occurring in South Africa were relatively few r in number. It was also clearly impossible to send patients back to South Africa until more or less recovered from their injuries, so that all these various issues pointed to the advisa- bility of establishing in the United Kingdom all the machinery necessary for the proper treatment of disabled soldiers. 16524 F 3 166 Erection of Hospital in London. The Committee of the South African Hospital and Comforts Fund specially erected a hospital in Richmond Park, and it was arranged that all permanently dis- abled men should be admitted to that hospital. This, arrange- ment enables the permanently disabled men of the European Expeditionary Force to be brought at an early stage of their ill- ness to the notice of the South African Authorities. Cases who have lost limbs in Africa are given the opportunity of being brought to England for the purpose of being fitted with artificial limbs, and, if they so desire, of undergoing Vocational Training. Vocational School at the Hospital. The Vocational Training School is established in connection with the hospital and in the same grounds. It consists of buildings erected jointly by the Committee of the South African Hospital and Comforts Fund and the Committee of the Governor General's Fund the latter being responsible for the cost of equipment, salaries of staff and run- ning expenses generally. Some large houses also in the vicinity have been taken and converted into hostels for the accommodation of out-students. Vocational Staff. The Vocational Training Staff consists of nine instructors under an Educational Organiser. Training is given in the workshops to enable the men to become expert work- men in a large number of trades.* The arrangements are noticeable in that highly skilled pro- fessional instructors are employed. As a result not only is work being turned out up to an expert standard, but the men realise that an extraordinary opportunity is being afforded them. The workshops are registered by the City Guilds, and the various classes are inspected periodically by experts. Procedure on Admission. When a patient is admitted to the hospital, whether from the European Expeditionary Force or from Africa , he is at once put into one or other of three categories , namely : (1) Likely to become fit for further military service ; (2) Doubtful whether will be fit for further military service ; (3) Unlikely to be fit for further military service. If in Category 1 or Category 2, the patient is given curative treatment only, but if in Category 3 steps are taken at the earliest * The callings taught are those of Metal Turners and Fitters, Tool Makers, Brass Finishers, Coppersmiths, Tinsmiths, Engine Drivers and Attendants, Acetylene Welders, Electrical Fitters for Power, Light, Tele- phones and Bells, Cinematograph Operators, Electrical Testers, Meter Readers, Dynamo and Switchboard Attendants, Sub-station and Accumu- lator Attendants, Motor Car Drivers and Repairers, Carpenters and Joiners, Cabinet Makers, Boot Makers and Boot Repairers, Clerks, Store- keepers, and Timekeepers, Bookkeepers and Accountants and Salesmen, while some students are sufficiently advanced to take positions as Secretaries and Managers. 167 possible moment to go into his case, with a view of ascertaining whether he will require Vocational Training, and if so to interest him sufficiently so that when convalescent he will be keen to take it up. Close relations are established between the Vocational staff and the staff of the Hospital proper, and every influence is used by doctors, sisters and lady visitors to get permanently dis- abled men interested in the classes as soon as possible. As a matter of fact , it is found that patients generally can be interested in work at a very early stage of convalescence, and often long before they are well enough to get out of bed. Hope for the Disabled from, Early Days. The members of this Conference are well acquainted with the waves of depression which come over a limbless or otherwise permanently disabled man in the early days of his illness depression w T hich retards his iccovery and maybe permanently distorts his mental outlook. The fact that work is going on around him which offers hope for his future ; that he himself is brought from the earliest days into t! linking what his work can be, and that then, at an early date, ho can commence to take up such work himself, goes far to ward off these attacks of depression. Under our scheme the men start earlier than in any other institution in the United Kingdom, as this hospital is the onlv primary hospital which has Vocational Training Classes estab- lished in connection with it. No Compulsio.i Ewc'rcin* It mast be stated that no com- pulsion of any sort :., adopted. The Vocational staff have access to the permanently disabled patients in the wards for the purpose of discussing their future and of seeing whether they can interest the men in the work. Such patients are advised by their doctor or Ward Sister to attend the classes. There the matter ends. If they do not go, they are not penalised in any way. If they go, they can discontinue at any time, and it is remarkable that so few do discontinue their attendance when once they have made a start. Decision as to a Patient's Future Career. Three factors are taken into consideration in deciding as to a patient's future career. Firstly, and most important, the man's own inclination. Secondly, his physical disability and his suitability for the calling from a medical point of view; and thirdly, his suitability from an educational standpoint. These are settled early at a joint conference of the patient, the doctor and the Educational Organiser, and generally without any great difficulty. Class Work Done Under Medical Supervision. The class work is done under the strictest medical supervision. Patients are started gradually ; at first they work, it may be, for a few minutes, then longer, according to their inclination and their medical fit- ness until they are able to work throughout ordinary class hours. Some of them commence typewriting in bed. It amuses them to write their letters home by typewriter. What at first is recrea- tion leads the way to work in earnest. This gradual return to work opens up a vista of future usefulness. 16521 F ! 168 Facilities for Recreation. While no compulsion is exercised in regard to students attending classes whilst still patients in hospital, they do not lose their out-door recreation. Indeed, if sufficiently well they actually gain hours to themselves. Thus these patients attend their classes mainly in the mornings, and instead of having to wait by their bedsides until the Medical Officers have left the wards on completion of their rounds, they have their dressings done first before all other patients, and are allowed to go to the classes. A minimum of twelve hours' attendance per w T eek earns two late passes per week, and extra indulgences in the way of early passes on Saturdays and Sundays. Frequent excursions, outings, &c., are arranged, and every man attending the classes has the opportunity of going out accord- ing to his fitness. Every Saturday afternoon disabled men who wish, and are well enough to go, attend football matches, while on Wednesday afternoons they have the opportunity of visiting factories or other places of some educational interest if they are FO inclined: Needs of Agriculturists. Although the bulk of the disabled men are townsmen, the needs of students desiring an Agricultural Training are not overlooked. In practice, if a disabled man desires to take up farm work, he first puts in his time learning to make himself a handyman in the different shops connected with the hospital, and he is instructed in farm book-keeping. On leaving the hospital he takes up further training, either at an Agricultural School in England or in South Africa. Successful Students. A number of the students have already passed examinations of the London Chamber of Commerce and the National Union of Teachers, first-class certificates being ob- tained in quite a considerable proportion of cases. Arrangements have similarly been made for the examination of men in the workshops by the various London Guilds, and it is hoped that the majority of men will be certified as competent workmen not alone by the Vocational Training School, but also by a competent Authority outside. Students not Retained in Hospital. No man is allowed to be kept as a hospital patient a day longer than is necessary for his medical treatment, but he is discharged from hospital at the earliest possible date, and is kept as an out-student, where he can, if necessary, still receive medical treatment as an out- patient. On Discharge from Hospital Patients Remain Union Soldiers. On discharge from hospital the men are not discharged from the Army, but are kept on as Union soldiers in hostels close to the hospital, and continue their studies at the hospital workshops. The men wear uniform, and are subject to military discipline. The training as out-students remains voluntary, in so far that no one need undergo it contrary to his wishes, nor continue it longer than he chooses. So long as he elects to continue it, how- ever, he is obliged to submit to military discipline. 169 Inducements to Remain on Discharge from Hospital. The greater number of students who have attended as hospital patients continue as out-students on discharge from hospital. The in- ducements in the case of limbless men are threefold. Firstly, the incentive of becoming proficient at their trade. Secondly, the desire to have shrinkage of their stumps more or less complete before their return to South Africa; and lastly, the oft'er to each student, on completion of his course, of a second artificial limb as a joint gift from the South African Hospital and Comforts Fund and Red Cross, South Africa, as well as, in leg cases, a peg leg from the Government. The majority of students can learn sufficient at Richmond to ensure a good livelihood on return to South Africa, but wherever possible they are placed in factories or workshops in England for a few weeks prior to em- barkation, so as to get practical experience under normal working conditions. During their training as out-students the men receive their pay as soldiers and are subsisted in the hostels, while their wives or relatives continue to receive the usual soldiers' separation or dependents' allowances. The men, when trained, a,re sent back to South Africa, with a few exceptions who have found good posts in England. Very few of the men under train- ing have been failures, and I believe the fact that it has been possible to keep them under military discipline, and not as civilians, has been responsible in no small measure for the success which has been achieved with the men w T ho have been discharged from hospital. Arrangements for Reinstatement in Civil Life. A word should be added as to the arrangements for re-instatement of the men in civil life on return to South Africa. The problem has been placed by the Union Government in the hands of the Central Committee of the Governor-General's Fund, and the whole Union has been divided into areas with a local committee in charge of each area, on whom the responsibility rests for finding employ- ment for returned soldiers. Progress Reports. On a man's admission to the workshops a full report is prepared as to his previous employment, physical disability, and the trade for which he is to be re-educated. This is sent to the Union Government, with copies for the Central Committee of the Governor-General's Fund and for the Local Committee of the area in which the man desires to live on return to South Africa. Copies of Progress Reports on each case are sent in from time to time to these Committees, so that they have complete information well in advance, and should have little difficulty in finding suitable work for him on his return. Indeed, a considerable number of the students have been notified already prior to their return that suitable work has been found for them which they will be able to take up at once on their discharge from the Army on return to their homes. The scheme has the blessing and sympathy of the Imperial Authorities. It is worked with the full knowledge and approval of the High Commissioner for the Union of South Africa on 170 behalf of the Union Government and of the Committee of the Governor-General's Fund. The High Commissioner exercises supervision in close concert with the South African Hospital and Comforts Fund in London. The interest thus taken in the work is shared by the whole of the South African community in London, and has contributed largely to the remarkable results obtained. Every man, however crippled, who passes through the training is treated as a valuable asset to the Union, to which ultimately he returns. Each Country has Two Objects in View. Such is the South African scheme of Vocational Training. It is designed to meet a small problem compared with that of the Allied Countries and other Dominions, for South Africa has one of the smallest white populations of any of the nations represented at the Conference a little over a million and a quarter. I take it, however, that each country has two objects in view : Firstly, to put permanently disabled men into the best possible physical condition, and secondly, to train them to be self-supporting members of the community. There seems to have been a tendency in most countries to regard the latter as impossible until the former has been accomplished, or nearly accomplished, by which time many men are unwilling to take up training. The Objects can be Achieved Together. Our scheme aims at attempting to achieve the two objects together. Under it ap- proximately 90 per cent, of those disabled men for whom Vocational Training is appropriate are induced, in their own interest and quite voluntarily, to take advantage of the oppor- tunities afforded them. Such a satisfactory result is due to the facilities for early training, which enable patients to become interested in work in the early days of their illness and before they have become thoroughly hospitalised. Conclusion. The importance of impressing upon members the desirability I might almost say the necessity of commencing training sufficiently early has led me to bring the South African scheme to the notice of the Conference. 171 Y A-T-IL LIEU DE REEDUQUER LES MUTILES DANS DES ECOLES SPECIALES? PAR M. ALLEMAN. I/ elan d'enthousiasme qui porta, des la premiere annee de la guerre, des esprits utopistes a realiser hativement la restauratioii professionnelle des mutiles s'est heurte a d'ameres deceptions : on avait reve de restituer, en quelques mois, a 1'activite economique, anemiee par les besoiiis de la guerre, des elements qui avaient perdu leur valeur productive, et d'autre part d j assurer 1'existenoe par le travail, aux epaves de la terrible tourmente. Or 1' experience a prouve que la formation professionnelle baclee rapidement lie donne aucun resultat pratique, que les mutiles sortant d'une courte periode de reeducation, vegetent pendant quelque temps dans la nouvelle profession, pour se jeter ensuite sur un " petit poste " ou sur une specialite des industries de guerre qui peut les faire bien vivre pendant Pepoque actuelle, mais les mettra sur le pave des que reviendront des conditions normales. Pas plus avec des mutiles, qu'avec de jeunes appreiitis moins pourraiton croire, puisque leurs aptitudes physiques soiit reduites on ne fait des miracles. L'apprentissage d'une pro- fession exige uii minimum de temps, sans lequel il doit necessairement raster incomplet; et cela est un grave ecueil dans le probleme de la reeducation des invalides. Ainsi se pose la question : Coiivieiit-il de soumettre les mutiles a une formation professionnelle nor male et de les reeduquer clans les ecoles professionnelles qui, en temps de paix, preparent les jeunes gens a la pratique des metiers? Les avantages de ce systeme paraissent a premiere vue considerables. Pas plus pour 1'apprentissage pratique que pour les etudes scientifiques, on ne s'improvise professeur. L'instructeur ne doit pas seulement posseder a fond tous les details du metier, il ne doit pas seulement connaitre toute la technique de la profession, il faut aussi qu'il sache enseigner. Or Tenseignement demande des aptitudes particulieres, une tournure d } esprit speciale, un enchainement methodique des idees, qui ne se developpent ou ne s'acquierent sans une preparation pedagogique serieuse. Le bon instructeur sait a quel moment il doit appeler 1' atten- tion de ses apprentis sur tel detail, il connait les defauts inherents aux debuts et la maniere de les corriger; il evalue 1' importance des notions techniques a joindre a la pratique. De plus il sait conduire les eleves; il connait la psychologic de ses hommeb et distribue avec discernement le blame, ou 1'eloge; il conqr.iert aisement la connance de ses apprentis qui est un sur garaiit du 172 succes et son autorite s'etablit sans discussion, comnie resultante de ses qualites professionnelles. La valeur de I'instructeur fait la valeur de ses eleves. Dans ces conditions il apparait de toute utilite de mettre a la disposition des mutiles 1' experience de 1'enseignemeiit acquise par les maitres qui, dans les organisations du temps normal, sont charges de la formation professionnelle de la jeuiiesse. Ce qui lie s' improvise pas non plus on n'en a que trop souvent fait 1' experience c'est 1'organisation d'une ecole. On a beau etre anime d'ardente syinpathie pour les mutiles et leur sacrifier sans oompter son temps et son bien, on n'en possede pas pour cela les qualites et les connaissanoes necessaires pour installer des locaux, fixer les distributions du temps, arreter des pro- grammes d'eiiseignement, etablir des reglements, choisir et guider le personnel, orienter les invalides vers une profession, creer tous les details qui constituent par l^eur ensemble les elements indispensables au foiictionnement complet d'un institut d' education professionnelle. Tous ces desiderata sont realises dans les ecoles pratiques des metiers mieux qu'ils ne pourraient Fetre dans les etablissements ephemeres nes de la guerre et destines a disparaitre peu apres sa fin. On installe facilement un atelier de cordoimerie, d'ebenisterie r mais qu'il s'agisse de creer un apprentissage qui dernande un outillage mecanique varie, des appareils de demonstration, des collections d'echantillons, des moyens d' intuition qu'il faut des annees pour rassembler ou constituer, que de difficultes, que de depenses ! Faute de pouvoir reunir aisement tout ce materiel qui caracterise P organisation scolaire complete, on se contente des rudiments indispensables et Ton obtient un " a peu pres " doiit le rendement repond aux moyens. Mais si 1' utilisation des competences du personnel, de 1'organisation et de I'outillage pedagogique de nos ecoles pro- fessionnelles semblent de prime abord plaider pour la reeducation des mutiles dans ces institutions, il n'en est plus de. menie lorsqu'on envisage tons les inconvenients qui resulteraient de semblable mesure. Les ecoles pratiques des metiers prenneiit les jeunes gens a la fin de leurs etudes primaires et visent non seulement leur forma- tion professionnelle, mais aussi leur education, c'est-a-dire la culture de leur intelligence, de leur volonte, de leurs sentiments. De la des developpements de programmes, que la tendance necessairement utilitaire de la reeducation des mutiles fait proscrire et que la qualite d'homme de 1'iiivalide a reeduquer rend superflus. Tout en poursuivant une restauration professionnelle complete, Pecole de mutiles doit veiller a reduire sa duree au strict minimum et, par consequent, elle est forcee d'elaguer les pro- grammes, les rnatieres et les parties de branches qui lie trouveroiit pas directernent leur application dans la pratique du metier. 173 De plus la simultaneity de 1'enseignement dans les ecoles pro fessionnelles impose une duree uniforme pour la preparation de tous les eleves, quelle que soit leur intelligence et leur applica- tion ; la hate que Ton doit avoir de rendre aux mutiles des moyen& d' existence ne permet pas de perdre leur temps a attendre les progres de camarades plus lents ou moins doues. Ces deux considerations sufEraient, a mon avis, a elles seules pour condamner la reeducation des mutiles dans les ecoles professionnelles. II en est une autre cependant, d'ordre moral, qui est d'importance capitale. L'esprit taquin de jeunes garcons qui, esperons-le, garderont toujours le respect de leurs allies, glorieusement estropies, mais n'en sont pas moins enclins a des plaisanteries qui pourraient heurter la sensibilite des invalides, constitue un obstacle serieux a 1'ouverture des ecoles profes- sionnelles aux mutiles. De plus ceux-ci, handicapes par leurs infirmites, moins vifs d'esprit peut-etre que leurs jeunes cama- rades valides seraient exposes a se decourager de se voir depasser. Si Ton juge, a juste titre, que la place de 1'invalide reeduque n'est pas a 1'usine, a cote d'ouvriers solides et intacts, a plus forte raison ne faut-il pas admettre que le nmtile en reeducation soit le voisin de jeunes gens qui poursuivent normalement leur etudes et leur apprentissage. Enfin 1'ou tillage d'une ecole de metiers est uniforme pour tous les eleves; peut-il en etre ainsi pour des mutiles? ISon, car c'est une preoccupation grave des specialistes de la reeducation pro- fessionnelle des mutiles de doter ceux-ci des oiitils les mieux appropries a 1'etat de leurs membres. Serait-il, du reste pratiquement possible d'ouvrfi Les ecoles professionnelles aux invalides? Ceux-ci doivent commencer leur reeducation des qu'ils sortent de 1'hopital, du centre d'appareil- lage ou de Tinstitut de reeducation fonctionnelle et nc peuvent pas attendre 1'ouverture d'une nouvelle annee scolaire pour se mettre au travail. Je sais que le sejour dans ces centres liospitaliers pourrait servir de preparation a Tecole profeseion- nelle, mais entres a des dates differentes, les mutiles en sortiraient avec une preparation bien inegale; les uns y auraient perdu du temps, les autres ne seraient pas aptes a recevoir Tenseignement qui leur serait destine. Je crois avoir etabli suffisamment que 1'admission les mutiles dans les ecoles professionnelles serait tres difficile d'abord et hautement prejudiciable a la bonne marche de la reeducation. Dans quelle mesure pourrait-oii toutefois tirer profit de ces. institutions ? En leur empruntant une partie du personnel experimente et en y soumettant les autres elements charges de 1'enseignement a une preparation pedagogique serieuse ; en s'inspirant de leur organisation et de leurs programmes, qui seraient adaptes au but particulier a atteindre. 174 ,.; m ? r des specialites exigeant un outillage mecanique varie ou difficile a reunir, 1'admission. des invalides aux ecoles ordinaires semble seule s'imposer, mais encore faut-il que ces apprentis y constituent une section absolument independante, avec ses regle- ments et ses programmes speciaux, avec sa methode propre. Le sacrifice peut paraitre considerable, d'organiser et d'outiller . un grand nombre d'instituts de reeducation professionnelle, alors que Ton possede. deja des ecoles de metiers; mais la nation doit tout a ceux qui out tout sacrifie pour elle et la preuve est faite que chez les Allies on ne lesine pas pour assurer aux victimes de cette horrible guerre les moyens d'existence dans les meilleures con- ditions possibles. Methode d'apprentissage. Faut-il adopter pour la reeducation des rnutiles 1'une des inethodes en vigueur pour- 1'enseigneinent professionnel de la jeunesse et qui consistent a faire pratiquer les gestes ouvriers pour les gestes eux-memes et non dans le but de produire un objet utilisable ou vendable? Ces methodes, pedagogique ou du sloyd, se sont iinposees dans les ecoles professionnelles ordinaires en raison du but educatif qu'elles poursuivent. Le sloyd notamment, par Initiative qu'il laisse aux eleves, en ce sens que les grandes lignes seules de theme a realiser sont indiquees et que chacun orne ou decore a sa facon Fobjet qu'il fabrique, presente de tres serieux avantages; mais il ne me parait applicable que la ou Ton dispose d'une tres longue periode pour achever Tapprentissage. A la conference interallied de Paris en mai 1917, j'ai eu 1'honneur de proner la methode productive, qui consiste a suivre le precede applique pour Tapprenti a Tatelier, sauf a graduer methodiqueraent les differentes operations. Une annee de plus d'experience n'a fait que confirmer mon opinion a ce sujet. II importe que des le premier jour, le mutile en reeducation ait I'impression qu'il travaille et non seulement qu'il apprend ou qu'il s'amuse. L'ambiance doit etre celle d'un atelier bien plus que d'une ecole, parco qu'elle correspond mieux a 1'esprit des eleves arrives a 1'age ou ils sont, et parce qu'on ne familiarisera jamais trop vite les hommes avec le milieu dans lequel ils devront vivre plus tard. De plus, j'estime que 1'interet des apprentis est bien plus vive- ment stimule si 1' objet de leur travail est un produit reel de leur Industrie et non une miniature ou un modele d'etagere. Comment veut-on inculquer aux eleves le cote commercial de leur profession si le produit de leur travail ne correspond pas a ce qu'ils auront a livrer plus tard? Ou est la preoccupation du choix de la matiere premiere et de 1' utilisation econoinique des dechets? Ou est 1'occasion d'apprendre a evaluer un prix de revient? Qu'est-ce qui peut porter les apprentis a comprendre qu'ils ont interet a travailler vite autant que bien? 1T5 Je crains que les hommes habitues a fignoler les travaux pres- crits par les methodes educatives n'aient une cruelle deception le jour ou ils travailleront pour leur compte ou pour celui d'un patron, en constatant que leur rendement est insuffisant en quantite. A ces arguments puises dans 1'iiiteret du inutile lui-meme s'ajoute le point de vue economique de la question. II est bien eiitendu que nul sacrifice ii'est trop grand, consenti pour la reeducation des invalides. Mais en ces temps d' utilisation parcirnonieuse de toute matiere et de rarete de main d'oeuvre, ne vaut-il pas mieux transformer en objets utilisables dans la vie de la communaute les matieres premieres consacrees a 1'apprentissage des mutiles? II y a profit pour la masse et reduction considerable des frais de la reeducation. Toutes ces raisons me paraissent peremptoires pour s'arreter dans la reeducation professionnelle des mutiles a la methode productive. Plans d'apprentissage. Le procede preconise plus haut de la methode productive d'apprentissage n'est pas sans presenter certains ecueils. Lorsqu'on applique une des methodes educatives, telles qu'elles- sont en usage dans les ecoles professionnelles ordinaires, on n'hesite pas a graduer les operations a enseigner aux eleves,. etant donne que leur ordre a fait Tobjet d'etudes sy sterna tiques. II n'en est pas de meme si les hommes apprennent le metier dans un atelier proprement dit, vivant des cornrnandes telles qu'elles se presentent, au jour le jour. C'est precisement cette situation qui cause a Tadolescent, dont la formation professionnelle est confiee a un patron quelconque, un retard si grand dans la poursuite de son apprentissage : sans souci de I'interet de son eleve, le maitre lui confie le travail qu'il execute le mieux et le plus rapidement, parce que son profit personnel en depend. II est incontestable que, par ce procede, Tapprenti zele atteint des le debut la perfection dans des operations de detail; mais toutes ces operations devant revenir frequemment dans le cycle complet de 1'apprentissage, il aurait trouve 1'occasion de s'y perfectionner dans la suite, tout en appreiiant du nouveau, si Ton s'etait contente d'une precision et d'une dexterite relatives dans rexecution d'un element du travail. De plus il peut se presenter que les commandes regues a 1'atelier n'offrent pas 1'occasion d'etudier tous les travaux qu'un artisan accompli peut etre appele a effectuer ou que du moins, 1'apprenti n'y est pas initie. De la des lacunes dans la forma- tion, qui, plus tard, seront peut-etre comblees au detriment du client ou de 1'employeur, mais qu'il importe d'eviter dans la reeducation des mutiles. 176 Deux choses sont necessaires a cet effet : (1) faire un choix judicieux des commandes; (2) etablir des plans d'apprentissage complets et detailles. Le chef consciencieux d'un atelier de reeducation ne recher- chera et n'acceptera que les commandes qui interessent directe- nient ses apprentis. II condamnera generaleinent les travaux en serie, sauf lorsqu'il a un nombre tres grand d'apprentis qui tous, dans ces travaux, peuvent s'initier a un detail de la profession a un degre quelconque de leur preparation. II designera en outre pour 1' execution de telle commande riiomme ou le groupe d'hommes arrives au point ou ce travail leur fera faire fin nouveau pas dans la preparation profession- nelle. Le choix des commandes et la distribution des travaux doivent etre 1'objet des principales preoccupations du chef d'atelier.. La recherche de 1'ordre methodique dans lequel se suivent les diverges operations du metier conduit a Petablissement d'un plan . d' etudes. Je me permets de signaler ici la solution de cette question importante qui est adoptee a 1'Institut de reeducation de Port- Villez. L'apprentissage complet de chaque profession comprend quatre degres et chaque degre comporte Tetude d'une serie determinee d' operations. Pour chacune de ces operations, une duree moyenne d'apprentissage est etablie, qui n'est tout^fois nullement immuable, et s'abrege ou se prolonge d'apres F intelligence, le zele, 1'aptitude de chaque individu. A la fin de chaque mois, les chefs d'atelier etablissent des / " notes d'apprentissage/' ou ils consignent, outre des observa- tions personnelles, pour tout eleve le point exact ou il en est arrive. L' etude de ces notes et leur comparaison avec le plan normal permet a Ja direction de se rendre un compte exact des progres realises par chacun, de rechercher la cause des retards, de con- stater event uellement des erreurs d' orientation professionnelle et d'y remedier. Ces notes d'apprentissage et le classement per degres des eleves constituent de plus un vif stimulant pour ceux-ci, qui apprecient bien mieux les progres qu'ils out realises par une cote d' apprecia- tion en chiffres de leur degre d'avancement que par le rendemeiit effectif de leurs efforts. Ils savent que pour passer de tel degre au suivant, il leur reste telles operations a apprendre et ils s'y appliquent avec d'autant plus de zele que le but est assez proche et nettement marque. Un autre stimulant se joint a celui de 1'aniour-propre, c'est le taux du salaire qui monte d'un degre a 1'autre: au Ir, 6 ernes; Theure; au 2e, 8 ernes; au 3e, 11 ernes; au 4e 15 ernes. Quoique 177 1'appat du gain immediat ne doive pas etre 1'objectif essentiel de leurs efforts, les mutiles apprecient beaucoup les progres qui se traduisent par une augmentation de leurs allocations. Enfin I'etablissenient du plan d'apprentissage doit necessaire- ment envisager les subdivisions de la profession, qui constituent dans certains cas des specialites, auxquelles des mutiles pen vent s'arreter, si leurs aptitudes ne leur tolerent pas de tendre a une formation complete ou si les conditions du travail de la region ou ils habiteiit permittent 1'exercice lucratif d'un " sousmetier." Dans ces cas, les notes d'apprentissage fournissent coiicurremnient avec la fiche individuelle dm mutile ou sont brievement con- signees les caracteristiques economiques du milieu ou vit 1'in- valide, des indications precises pour conseiller la specialisation dans une partie de la profession, ineme sans avoir termine 1'apprentissage complet. A. Titre d'exeniple, voici le plan d'apprentissage de la Vannerie. Osier. preparation de 1'osier, fonds roiids de toutes dimensions. fonds rectangulaires de toutes dimens. fonds ovales de toutes dimensions. ligatures de bords. fonds speciaux (berceloniiettes, fauteuils). montage et tressage des paniers ronds et ovales. montage et tressage des paniers rec- tangulaires fermes. bords ordinaires et arises. bords tresses et bords de fantaisie. montage et fabrication de differents paniers a jour. montage et fabrication de differents modeles de fauteuils. pieds de berceaux. Note. L'apprenti qui se destine a travailler dans un atelier pent se contenter des deux premiers degres ; celui qui veut xs'etablir comme petit patron doit avoir termine le quatrieme degre. Yoici maintenant les notes d'apprentissage de cet atelier pour le mois de fevrier. Ir degre, 5 mois, 1 mois 1 mois 1 mois i mois 1 J mois 2e degre, 4 mois, 1 mois 1 mois 1 mois 1 mois 3e degre, 4 mois 4e degre, 4 mois 1 mois A. 3e degre, 2 niois B. 2e degre, 3e mois C. 2e degre, 2e mois D. 2e degre, Ir mois E. Ir degre, 5e mois F. 2e degre, 2e niois G. 2e degre, 4 mois H. 2e degre, 3 mois 2 operation (3/2/2). a ete maintenu a ce point pour insuffisance. T. peut etre place ; compte travailler pour un patron, progres tres rapides ; a fait en un mois les operations de deux. 3e degre, 2 mois : 2 operation. J. 2e degre, 4mois K. 2e degre, 3e mois L. 3e degre, 2e mois M. 2e degre, Irmois N. 3e degre, Ir mois 0. Ir degre, 2e mois 178 stationnaire par suite de 1'etat de son bras, bonne volonte, progres lente. le operation. Avancement rapide. stationnaire, souvent malade. le operation, blesse a Tepaule, avance lentement. est a 1' atelier depuis 4 mois ne fait pas de progres. etc. On se rend aisement compte de 1'interet capital que presentent ces notes d'apprentissage, qui obligent d'une part le chef d'atelier a constater periodiquement les progres realises par ses eleves et permettent d'antre part a ceux-ci, et a la direction de Fecole de verifier le degre d'avancement dans rapprentissage. Ces notes sont consignees sur les fiches individuelles des hommes, oil un simple coup d'o3il fait suivre la marche de la reeducation depuis ses debuts. Ceci n'est pas de la vaine paperasserie ; c'est un travail extremement productif que je me permets de signaler a F atten- tion de tous les dirigeants d'instituts de reeducation. Conclusions. 1. II n'y a pas lieu d'introduire les mu tiles dans les ecoles professionnelles ordinaires, sauf dans des cas particuliers, et dans des conditions speciales. 2. La methode productive doit etre preferee aux methodes dites educatives. 3. II est du plus grand interet d'etablir pour cnaque profession un plan d'apprentissage et d'exiger periodiquement des chefs d' atelier des notes cotant le degre d'avancement de tous les eleves. 179 THE HANDICRAFTS IN RE-EDUCATION. According to the adage disease and remedy are found together. jS"ever can this have been more true than now. Problems and difficulties abound. So do solutions. The streams of wounded and disabled men are met by counter streams of sympathy and the universal desire to help. We have labour scarcity, but a new army of workers waiting to be trained. The shortage of food and raw material reveals new possibilities of cultivation. Our deserted villages have new populations of returning men waiting to be settled in them and bring new life in place of desolation. Against depleted industries we can set the thousands of workers returning with new ideals and new ardour from the trenches. The countryside, long melancholy with poor cottages, decaying industries, and arrested life, may be rejuvenated by the new armies of new craftsmen trained by those who have made British handicraft world famous, however neglected at home. The assistance of British artists and craftsmen is essential to the success of any scheme of re-education, official or private. The defect of all schemes of training at present published lies in the failure of their promoters to employ, or even consult as teachers or advisers, men who have been remaking our national reputation during the last half century. France has not made this mistake, the Central Empires have not made it; nor has Switzerland. France is making use of all her artists both in training and in preparation for a new industrial era, for an industry in which considerations of quality and fitness hold first place. For the last 20 years the Central Empires for their own profit have farmed the ideas and inventive genius of French and British craftsmen. Switzerland, in concert with the alertest brains in France, has within the last few months begun a campaign for the revival of industrial and decorative arts in all her cantons. In all the schemes outlined for France and Germany the re- education of the wounded and disabled men and their re-absorp- tion into productive life is felt to be of paramount importance, and both ideas are linked up with the idea of industrial reform. In this country much has been said for years past about the needs 180 of industry and- the importance of handicraft, but now the increasing numbers of men in want of training makes of each a burning question. Industry cannot be renewed without a new spirit; as the promoters of reform in France have said " henceforth the spirit of artistry must inform all that we do." The craftsman differs from the ordinary workman only by the intensity of his concern for the quality of his work. Concern is the child of interest. Interest begets that love of the work which alone produces quality. Quality is the only thing which pays, and pays all the time. We call ourselves a commercial nation. Let us learn in time to train our workers to care for that which profits, for fitness and quality in material and workmanship. All the rest will be added to us. The wounds of war and industry may^ alike be healed by the right training of our disabled men. But to those of us who urge that the revival of handicraft is an essential factor in the revival of industry and that industrial revival demands first invention, handiness and adaptability, all of which are produced or cultivated by craft practice, it may be said that the world-trend is not towards individual crafts, but to large scale production, to repetition work, to automatic machinery. This may be true, but it is no less true that the more mechanical a man's livelihood, the less demand that work makes on his higher faculties, the more imperative his need of opportunities for the exercise of those creative faculties with which the meanest of us is endowed. But there is another aspect of the problem. Munition work has shown that increased output is the result of short shifts, and it is easy to see that this discovery may be widely applied. Short hours mean increased leisure. Leisure cannot bring happiness unless made useful and productive. Higher pay should mean a higher standard of life. With every rise in standard the luxuries of the lower become the necessities of the higher. Moreover, " those who work for princes must live like princes." This means better houses, better furniture, better education, higher amusements. All these are the province of the arts and handicrafts. Craft makes for culture in every sense but the Prussian. It is the antidote to Prussiaiiism. In addition to all this is the further consideration that even under the best conditions agricultural life, gardening, fruit farming, dairy work, all have their slack seasons. To make life fully productive these slack seasons should be employed in some form of craft by which the worker could supplement his earnings from the land. Agricultural life is enriched by these supple- mentary activities, a fact confirmed by the experience of France, Scandinavia, Denmark, Switzerland. Thus, the re-education of the disabled, the revival of agriculture, of industry, higher education and the raising of the standard of life all depend 011 181 the right use of the handicrafts and 011 the full use of the energies of our craftsmen at the present juncture. The basis of training, of healthy agriculture, prosperous industry and commerce is provided by the handicrafts. As a step towards this the creators of the various handicraft enterprises which have come into being in the past 25 years should be asked to direct training in their own workshops or in work centres set up in every district. The existing educational institutions and machinery should be used to the fullest extent. Each should become a centre of actual production and directed by men and women who are both skilled workers and designers. Men should be set at once to production ; work is its own teacher. In such productive work the men, the teachers and the whole educational system would benefit greatly. The ordinary scholars of existing institutions could share in the work and instruction. Each enterprise would be a continual demonstra- tion of the educational value of handiwork. Where technical and craft schools are used as instruction centres facilities could be given for research in the crafts, trades and processes taught there. In this way education, creative activity and National life would be knit together more effectually. In all cases local Advisory Committees should be formed, somewhat on the model of the Consultative Committees estab- lished by the London County Council, and attached to each training centre. These Committees, formed of masters, artists and craftsmen, workmen's delegates and educationalists would advise on methods of training and production. They should be attached and should report to a central organising committee composed largely of craftsmen, designers and technical experts, workmen's delegates, manufacturers, the whole committee being responsible to the Ministry of Pensions in the first place and afterwards to the Ministries of Labour and Eeconstruction. Schemes of housing, urban reconstruction, town and village planning should aim at the provision of craft and industrial colonies or settlements, and craft or industrial villages, and in so doing should give to those familiar with the crafts some opportunity of advising on the arrangements of such village^. The new housing schemes should not only give employment to large numbers of discharged men in the various crafts and arts connected with building, but should provide for the re- establishment of old industries. Under the direction of competent artists and craftsmen the arts of the smith and founder, terra-cotta worker, modeller, plasterer, carver, metal-worker, potter, glass-worker, chair and furniture-makers and other crafts could be revived and settled in the new villages about to be created. Neither artistic gifts nor desire have been lacking, but only opportunity. Can we not use the opportunity now that it ha& come? 182 The multiplicity of the new building schemes and their com- plexity will mean the creation of fresh transport organisations. They will require the construction of new roads, and, perhaps, the utilisation and repair of our inland waterways also. In these activities men who have no bent for industry or handi- craft can find useful employment; by aiming directly at con- structive work the minor questions will fall into their proper places. All the forms of craft activity indicated are essential to the full life of any Nation. They are invaluable as training and preparation for any form of industry, and even if the whole world is given over to automatic machinery, the crafts will be needed as a field for experiment, a relief from monotony and as an enrichment of life. We may be asked how all these workshops, training centres, industrial villages are to be paid for. These enterprises are social investments, and public credit should be used to finance them. Doubtless municipal aid could be given in many cases. These enterprises should in time create new social assets ; the principle of co-operative trading might be extended. The work- shop centres, industrial villages, agricultural reforms we need could in a very brief space become realities if the co-operative plan were generally accepted. What the Trades Union attitude to the new army of workers will be is of great importance, but there is every reason to expect their sympathetic help, for every man who acquires a new craft should be a member of a corresponding Union. It may well be that the Unions themselves may be transformed into something corresponding to Guilds of Mastery with all that word implies. They would then become once more schools and nurseries of government and centres of political, commercial and social order. 183 LA REEDUCATION AGRICOLE DES INVALIDES DE GUERRE EN ITALIE. PAE LE DOCTEUK MARIO GUSMITTA. Le probleme du renvoi a la campagne des invalides agricoles apparait. chez toutes les nations, d'un grand interet economique ; if a pour notre pays une importance presque vitale. L'ltalie, tout le monde le sait, est un pays essentiellement agricole. Le fait que sur 286,610.37 de km, 2 de superficie totale elle possede une surface agraire et forestiere de 263,975.54 de km. 2 , c'est-a-dire le 92 pour cent, et plus, de toute son extension, suffirait a le demon trer. Neanmoins, de tout ce grand territoire dedie a 1' agriculture, notre nation ne retire pas, en proportion, un ren dement suffisant. Parmi les causes, certainement hombreuses, de ce phenomene, quelques-unes dependent des conditions naturelles et des milieux, corame la sterilite de quelques regions, les conditions climate- riques, le paludisme, &c., &c., d'autres sont en rapport avec les conditions demographiques de notre population rurale. Parmi ces dernieres causes, 1'insuffisance de la main d'ceuvre agricole vient au premier rang. Une telle constatation pourrait sembler paradoxale a qui sait que 1' Italic fait partie des pays les plus riches en hommes : la densite de population est en moyenne de 126 habitants au km. 2 et, parmi eux,.plus du tiers sont agriculteurs. Pourtant, disons tout de suite qu'il s'agit de rarete relative et non absolue ; et cette rarete vient, d'une part des conditions speciales de notre agriculture qui, a cause de 1'inegale division de la propriete et de rinsumsant emploi des animaux et des machines, demande un plus grand nombre de bras qui serait d'ailleur inutile, d'autre part de la desertion trop facile et trop grande des champs par les populations agricoles qui emigrent a la ville ou a 1'etranger. Des deux phenomenes, le premier (abandon de la campagne pour la ville), commun a toutes les nations, ou 1'industrie est plus developpee que 1' agriculture, est relativement peu considerable chez nous, tandis que le second, particulier a notre pays, atteint en temps ordinaires des proportions colossales determinant chaque annee 1'exode d' environ un demi-million d' hommes, en grande partie agriculteurs, qui vont chercher un rendement plus remune- ratif de leur propre travail. Etant donnees ces conditions, particulieres a 1'Italie, d'une continuelle et impressionnante diminution de la main d'oeuvre agricole, et parce que, egalement en temps normal, il faut avoir 184 recours pour les travaux des champs a des bras rnoins actifs comme ceux des femmes et des enfants, il n'est pas possible et il ne convient pas, pour nous Italiens de renoncer aux dizaines de milliers d'invalides que la guerre actuelle met hors des lignes des combattants. D'autant plus que ces elements, une fois rendus a la terre, lui resteront fortement attaches, ne pouvant evidemment emigrer a cause de leurs conditions physiques et de leur adaptation au milieu. Mais nous ne voulons pas traiter les questions de la reeduca- tion agricole des invalides seulement au point de vue economique national, mais, et par-dessus tout, au point de vue de 1'interet prive du travailleur. Nous negligeons meme 1'avantage de pouvoir immediatement, et avec un moindre effort, tirer parti de 1'experience deja acquise dans le travail habituel precedent. L'important est de considerer si, dans les memes conditions, le rendement utile, et par suite le profit, de 1'invalide est plus grand si celui-ci reste dans 1' agriculture ou s'il se dedie aux metiers industriels ou aux emplois. Et la reponse se devine si Ton tient compte de la grande liberte d' action du paysan en comparaison de celle de 1'ouyrier, des plus petites difficnltes techniques et manuelles, de la 'moins grande responsabilite pro- fessionnelle, de plus faciles utilisations dans une infinite de travaux complementaires des grandes cultures, enfin du plus sur et du plus stable placement de la main d'ceuvre en union avec les autres membres de la propre famille. Si done les idees ci-dessus sont les idees generates de caractere economique (et je neglige ici de parler de celles de caractere moral et social, bien faciles a imaginer) desormais conmues de tous, sur lesquelles est fondee 1'orientation professionnelle des mutiles agriculteurs, la lenteur et les difftcultes a travers lesquelles s'est developpee en Italie, 1'oeuvre d 'assistance dans la reeduca- tion agricole, pourront sembler etranges et pen explicables. Et, a mon avis, la raison principale qui en Italie a mis un obstacle au developpement rapide et efificace des institutions dediees a 1'enseignement agricole de nos militaires invalides c'est d'avoir manque de direction fondamentale , d'espirit organisateiir de la reeducation agricole. Sur les principes fondamentaux, nous avons tous ete d' accord et des le debut, de sorte que Ton ne mit jamais en doute dans un pays agricole comme le notre : 1'importance de cet enseigne- ment professionelle ; la necessite de ne pas enlever aux champs les bras meme les moins valides ; le peril de 1'exode a la ville des mutiles agriculteurs reeduques dans les arts et dans les metiers industriels. Mais si tels principes sont restes, en Italie, a peu pres a 1'etat de conceptions theoriques c'est parce qu'ils out manque les directions d' action et par consequent les organes qui sur de 185 telles directions auraient du pourvoir a 1' application pratique de ces principes memes. II sembla dans les premiers temps, et aujourd'hui encore beau- coup le pensent, que la reeducation agricole signifiat un simple entrainement des pay sans aux travaux des champs, et Ton discuta pour savoir s'il n'etait pas le cas de renvoyer les invalides dans leurs families, a peine gueris completement et munis, en cas de besom, d'appareils orthopediques ou de protheses, considerant qu'une activite mouvelle dans 1'exercice du metier primitif serait sortie spontanement de 1'exercice naturel. D'autres, et ils furent nombreux, declarerent que Ton devait se borner dans les ecoles de reeducation a apprendre aux mutiles 1'emploi des instruments de travail qui letir convenaient ; et enfin la majorite estima que la plus complete integrite de la reeducation devait consister a donner a 1'invalide une instruction elementaire tres simple et quelque enseignement professionnel comple- mentaire. En partant de telles conceptions, il etalt evident que pour faire la reeducation agricole, un petit espace de terrain ou on pourrait envoy er les mutiles au travail devait suffire ; et toute intervention organisatrice de la part de 1'Etat ou de personnalites preposees a 1' assistance des invalides devenait ainsi inutile. C'est ainsi, en effet, que surgirent de nombreuses sections d' agriculture annexees a nos Instituts de reeducation profes- sionnelle. Maintenant, on ne peut certainement concevoir de cette maniere la reeducation des travailleurs de la terre comme du reste toute autre reeducation de metier. J'ai cru bon, il y a quelque temps, de fixer ces idees en une formule : Faire la reeducation a 1' agriculture veut dire prendre un agriculteur invalide et moyennant la restauration et 1' exaltation, dans les limites du possible, de ses activites physiques, morales, intel- lectuelles et prof essionnelles , le rendre progressivement apte a exercer son metier integralernent ou dans la forme et dans la mesure qui mi sera permise par 1'infirmite qu'il conserve. Nous devons lui donner, en connaissance et en experience, ce qu'il a perdu en force et en activite. Le probleme de la reeducation professionnelle est done vaste et complexe, et par consequent vastes et complexes doivent 6tre les organes qui sont appeles a donner une solution pratique a ce probleme. Dans les premiers temps, 1'Etat surpris par les graves et imperieuses necessites de 1'organisation militaire du pays, n'eiit pas le moyen de s'occuper de ces questions, on dirait, d'ordre social. Nous devons toutefois rendre temoignage a la verite : 1'Etat reconnut, des le debut, toute r importance de cette pre- occupation, et il voulut donner une aide morale et materielle constante aux initiatives privees qui naquirent aussitot parmi nous. Seulement plus tard, alors que 1'activite de personnalites et de particuliers etalt devenue plus vaste et plus intense, et la 186 necessite d'une organisation deveiiant par suite pressante et inevitable, 1'Etat se trouva contraint a intervenir. Ainsi furent prises des dispositions et emises des instructions qui aboutirent a la nouvelle Loi sur 1' Assistance aux Invalides de Guerre du 25 mars 1917. En ce qui concerne la reeducation agricole, nous n'avons eu durant toute cette periode qu'une seule tentative d' action dirigee par 1'Etat. En aoiit 1916 a la suite d'un Decret en faveur des Invalides, le Ministre de 1' Agriculture et du Commerce de cette epoque crut bon de reunir une Commission pour 1 s etude des moyens pratiques et rapides suivant lesquels pourrait s'accomplir, apres des Instituts agraires, la reeducation professionnelle des mutiles agriculteurs. Le but du Ministre etait de voir s'il etait possible de mobiliser nos ecoles Nationales d' agriculture pour les destiner a la reeducation des invalides de la guerre. La Commission nommee par le Ministere de 1' agriculture, elle fut dissoute apres deux reunions sans prendre ni decisions, ni mesures d'aucune sorte, et pourtant 1'unique resultat de cette activite de 1'Etat, si vite epuisee, fut r institution de 1'Ecole de reeducation agricole des mutiles a Perouse. L'Oeuvre NatJonale qui s'est substitute a 1'Etat dans la pro- tection des Invalides par les dispositions de la Loi du 25 mars 1917 n'a pas apporte une contribution plus grande a 1'Oeuvre des Invalides agriculteurs, bien que la brievete de son fonctionnc- ment, puisse, il est vrai, justifier jusqu'a present son silence. Ainsi parmi les associations nationales, seule la plus grande institution privee, c'est-a-dire la Federation des Comites d' assis- tance aux invalides de la guerre, a demontre I'intere't qu'elle prenait au probleme de la reeducation agricole dans la seule forme qui lui etait permise en n'encourageant 1' execution par les moyens rnateriels dont elle dispose. Effpctivement, dans une reunion du Conseil ler juillet 1917 elle nommait une commission chargee de faire des propositions concretes au sujet de la creation de Sections agricoles speciales pres des maisons de reeducation ; ou d'encourager celles deja organisees, de maniere que la plus grande partie des sommes offertes fut destinee a favoriser le developpement de la reeducation agricole . La Commission proposa une somme de 400,000 frs. a repartir entre les sections agraires institutes, ou en cours d' institution, ou a celles qui devraient etre organisees dans 6 mois. Le resultat de cette belle initiative de la Federation ne fut pourtant pas conforme aux propositions de la dite Commission, parce que le Conseil federal qui examina ensuite la question ordonna de distribuer la somme disponible divisee en parts de 50,000 frs. a tous les Comites Federes indistinctement, non avec 187 I' obligation inais avec la vive et pressante priere de les destiner an developpement de la reeducation agricole. De cette fagon, le stimulant d' indications imperieuses venait a manquer certaine- ment ; toutefois 1'oeuvre de la Federation meme parce que seule jusqu'a present en Italie qui eut prouve d'une maniere tangible qu'elle voulait se preoccuper du probleme d' assistance aux invalides agriculteurs a certainement servi d'efficace encourage- ment au developpement actuel de la reeducation rurale. Ainsi 1'oeuvre primitive de travail agricole de nos pay sans niutiles, non soutenue/ ni assistee par aucune institution de 1'Etat, non organisee et disciplined par aucune association nationale, seulement aidee par quelque concours matereil bien modeste en comparaison de 1'immensite des besoins cette ooeuvre est nee et s'est developpee dans plusieurs centres de notre pays par la seule initiative de quelques personnes competentes et de bonne volonte et par les seuls efforts d' associations locales. II n'y done pas a nous etonner si nos Ecoles et nos Sections d' agriculture pour les militaires mutiles se ressentent des qualites et des defauts de cette improvisation locale. Les defauts sont certainement graves et tiennent surtout comme nous 1'avons deja dit precedemment a 1' absence d'une conception fondamental, d'une direction initiale dans 1' organisa- tion de ces Instituts de reeducation agricole. Les qualites car il y a aussi des qualites consistent en une plus grande elasticite de f onctionnement , en une plus grande adaption aux diverses exigences regionales^ en une meilleure utilisation des elements et des moyens locaux, en un choix plus important des divers types d' organisation professionnelle. Et en eifet, nos Ecoles agricoles de reeducation, de la plus modeste a la plus importante, presentent une physionomie speciale, une marque particuliere qui les differencie 1'une de 1'autre. Creees, presque toutes pres des Instituts principaux de reeduca- tion professionnelle, dans plusieurs centres essentiellement indus- triels ou artistiques ou de culture intellectuelle , elles ont con- serve leur caractere de simple succursale pour renseignement agricole, gardant des proportions et une organisation modestes. Dans d'autres centres plus en contact avec le milieu rural elles ont assume un developpement plus ample et plus complexe ; dans d'autres enfin, ou dominaient les Institutions de culture agricole, elles sont nees autonomes et bien caracterisees. Nous pouvons par suite, grouper approximativement nos insti- tutions d'enseignement rural en trois categories : Une premiere categorie constitute par les ecoles d' agriculture annexees aux ecoles principales de reeducation (en font partie les Sections de Florence, Genes, Livourne, Modene, Pise, Eome). Une deuxieme categorie represented par les Sections agricoles faisant partie des Instituts Professionals complexes, qui par leur 188 developpement ont atteint une organisation superieure et presque autonome. Telles sont les ecoles de Milan, Palerme, Pescia. Une troisieme enfin formee par les Ecoles de reeducation agricole exclusive, representee par les Institute d'Ancone, d<- Lecce, de Perouse. de Voghera, de Turin. Examinons separement les institutions de chaque groupe particulier. Lie Comite de Florence, qui possede une ecole excellente et florissante de reeducation professionnelle avec les Sections de Villa Bondi et du Ponte alle Mosse, avait, des le debut du fonctionnement de ses Instituts, employe a 1'entrainement agricole le jardin de la Villa Bondi. On y enseignait le jardinage et quelques notions elementaires d' horticulture. Durant ces derniers mois ayant eu comme concession une petite propriety pres de Fiesole, elle y a institue une veritable Section agricole, mettant a la tete un expert en agriculture, et donnant I'enseignement technico-pratique dans les differentes branches des travaux de la campagne. Cette Section se trouve encore dans sa periode d' organisation, et du reste, etant donne la predominance des autres institutions de reeducation dans cette ville. elle n'a pas assume un developpement considerable. L' Ecole agricole annexe de la Maison de Reeducation profes- sionnelle du Comite de Genes, situee a Villa Eaggio. constitne une Section de cette Maison meme. La Direction Technique est confiee au chef jardinier de la ville de Genes, assiste d'un personnel competent. On y donne, sous une forme theorico - pratique, I'enseignernent d'agriculture generale, culture des champs, horticulture et d'une maniere particuliere la floriculture avec une attention speciale aux reffes des vignes americaines. Actuellement, on est en train de faire des installations pour 1'elevage des animaux de basse-cour. Jusqu'a present la section dispose d'un demi-hectare de terrain augmentable en cas de plus grand besoin. L' Ecole agricole n'a pas un nombre determine de places, mais elle est de plus en plus frequentee par ceux qui, etant agriculteurs , suivent les autres enseignements professionncls. Elle compte aujourd'hui 43 eleves. L' Ecole d'agriculture de Villa Corradini a Livourne constitue egalement une dependance de la Maison de reeducation instituee par 1-' Association Livournaise pour 1' assistance aux mutiles de guerre. Elle est dirigee par le chef -jardinier de la ville de Livourne, Mr. Paoletti. On y donne un enseignement pratique sur 1' agri- culture en general, c'est-a-dire, culture des champs, horticulture, jardinage et elevage des animaux de basse-cour. 189 L'Ecole dispose d' environ dix mille metres carres de tres bon terrain situe autour de 1'Institut. Depuis le jour de 1'ouverture de 1'enseignement jusqu'au- jourd'hui, elle a ete frequentee par dix invalides et actuellement elle compte trois eleves. L'Ecole d' agriculture de Modene a ete creee dans le but de completer les soins physiques et orthopediques par 1'exercice technique et methodique de la profession habituelle adapte aux effets d'une bonne reeducation professionnelle : elle constitue done une ecole de travail manuel pour 1'entrainement des invalides agriculteurs. L'Ecole meme est une section de 1'Institut de reeducation professionnelle des mutiles et estropies de guerre, cree dans cette ville parTceuvre d'lm Comite provincial autonome. L'Ecole a lieu dans une surface de terrain mis en pre de 25,300 m. 2 , situe dans la Villa San Faustino pres de 1'Institut et concede gratuitement par la Ville ; on y a construit un pavilion en bois pour 1'abri des ouvriers et du materiel de travail. Pour cette Ecole, 1'on n'a pas etabli un veritable programme, mais le Prof esseur C . Brighetti , qui la dirige , applique les blesses , avec 1'aide d'un personnel expert, au defrichement graduel de ce vieux pre et a la culture des plantes potageres et d'autres produits adaptes au climat et au terrain. Depuis cinq mois environ une cinquantaine d' estropies de guerre travaillent quelques heures par jour exergant ces membres offensees avec un visible profit. On se propose ensuite de com- pleter 1'enseignement pratique par des cours frequents d'instruc- tion agricole. La ville de Pise, bien qu'elle ait une modeste Maison de Reeducation, institute par le Comite local pour 1'assistance des mutiles de guerre, possede une Ecole agricole annexe de 1'Institut de San Remo. L'enseignement de 1' agriculture a ete assume par la Direction de 1'Institut public agraire de Pise avec un programme approprie et precis et avec le concours du Prof. Avanzi charge des cours d'agriculture pratique. Le Cours est theorico-pratique et se fait en partie dans 1' Ecole -qui dispose de plus d'un demi-hectare de terrain, transforme en potager, pre et jardin ; en partie, pres de 1' Ecole publique agraire nominee ci-dessus. La Maison de Eeeducation de Pise possede aussi une etable modele , un poulailler et une garenne ; en outre elle a un atelier pour le travail des sabots, de la vennerie, des chaises, etc. Le Comite de Rome pour 1'assistance aux mutiles de guerre, en instituant a la Villa Mirafiori une vaste et belle Maison de Reeducation (actuellement completee par la pre-reeducation a 1'hopital de Concentration installee au Quirinal) n'a pas eu 1'intention d'y etablir une veritable Ecole pour 1'instruction 190 agricole, mais elle a voulu constituer une Section de travaux champetres pour 1'entrainement de ses agriculteurs invalides. Pour cela un vaste terrain, compris dans 1' enceinte de la villa, a ete employe aux diverges cultures horticoles et champetres, sous la direction d'un expert qui pourvoit egalement a 1' instruc- tion theorico-pratique des sciences agricoles. La Section d' agriculture est completee par des ateliers pour 1'enseignement des divers metiers plus communs de la campagne, et de nombreux travailleurs des champs, estropies et mutiles, ont fait ainsi dans cette Section de Borne leur entrainement physique et professionnel. Parmi les institutions agricoles d' assistance aux invalides de guerre, de la seconde categoric comme du reste duns toutes les autres formes d'assistance professionnelle Milan vient au premier rang, grace a la prodigieuse activite de son Comite, a la competence des membres dirigeants et a la richesse des moyens dont elle dispose. L' organisation de cette nouvelle Section est assez recente, car la creation n'en fut commencee que vers la fin de juillet 1917. A cette epoque, ayant acquis la Villa Pelitti a Precotto et execute les travaux les plus necessaires, elle y transporta 1' atelier pour la /fabrication des sabots, des paniers et des balais et y forma le premier centre des laboratoires qui commencerent a se destiner a 1' agriculture. Elle dedia 1'Etablissement a " Cesare Battisti " afin que lui soit consacree 1'importante somme que le personnel des chemins de fer italiens avaient recueillie, par souscription nationale, pour honorer la memoire du martyr glorieux. .La Villa Pelitti, grand edifice a trois etages et une autre con- struction independante a deux etages, contiennent les dortoirs et tous les autres services annexes, de m^me que les installations didactiques et techniques pour 1'enseignement agricole. On y a en outre adjoint : Une etable pouvant contenir cinq vaches pour fournir du lait et le travail de ce lait se fait dans une petite fromagerie voisine ; Une ecurie pour les animaux de trait employes pour les machines et les charrues ; Une porcherie avec des pores destines a la reproduction ; Deux garennes avec des animaux de races diverses ; Un vaste poulailler avec des groupes de volailles de race italienne doree ; Un rucher pourvu de ruches de diff erents types ; Une magnanerie avec des appareils pour 1'eleva ie suivant le systeme de Lombardie et du Frioul ; Des hangars pour abriter les machines agricoles ; 191 Une serre chaude pour la multiplication des plantes de jardin et une serre temperee avec des carreaux de verre pour la semence precoce et pour le roulage ; Un atelier de forgeron et de menuisier pour la reparation des appareils et machines, de meme que pour la construction de materiel- agricole. Le terrain du jardin a ete utilise pour la culture horticole et contient egalement une pepiniere d'arbres a fruit et de plantes ornementales. Les champs de cereales et les prairies, de meme que les essais des machines agricoles, se font dans des terrains peu distants de la Section. Pourfant le nombre tou jours croissant des eleves et la necessite de donner constamment une organisation plus rationnelle et plus complete aux diverses Sections, ont contraint le Comite a louer un autre terrain vaste et contigu aux autres avec des maisons bourgeoises et des maisons rustiques qui permettront la construc- tion de nouvelles Sections pour les industries secondaires, c'est-a- dire la fabrication des barriques pour le vin. Dans cette Ecole on impartit 1'enseignement theorico-pratique comme base d 1' instruction professionnelle et Ton ne neglige pas 1' Ecole element aire. Ainsi les eleves passent plusieurs heures de la journee dans les ecoles et T autre partie du jour aux travaux agricoles diriges et surveilles directement par un personnel expert. C'est durant ces exercices qu'ils s'habituent et se familiarisent avec les appareils orthopediques et les protheses de travail, et qu'ils apprennent a en apprecier 1'utilite. La Section agricole est dirigee par un professeur d' agriculture qui est a la fois instituteur et directeur. II est assist e par un veterinaire, par un maitre d'ecole, par des chefs de travaux qui sont proposes aux Sections speciales. L' Ecole agricole de Precotto (Milan) contient une centaine de places, mais ce nombre augments toujours a cause (Tu developpe- ment constant de 1'etablissement. Et etant donne les installa- tions vastes et completes de cette Ecole, 1'organisation technique qui en est serieuse et rationnelle, le fonctionnement qui s'en montre pratique et parfait, Ton ne peut douter qu'elle prendra place, parmi les premieres Ecoles, non seulement d'ltalie, mais encore de 1'etranger. Mais la Section agricole de 1'Institut Sicilien pour les Mu tiles de Palermo egale 1'ecole de Milan pour sa preparation et son organisation : elle la surpasse meme pour son fonctionnement qui est moins recent, et qui lui a permis de profiter de 1' experience acquise. A Villa Helg, a San Lorenzo in Colli, pres de Palerme ou se trouvent les ateliers remarquables de I'lnstitnt de reeducation. 192 un vaste terrain presque inculte fut transforms miraculeusement en un champ d' experiences ou toutes les plus communes cultures horticoles et rurales out trouve et trouvent encore une application profitable. A ce terrain on en a recemment adjoint un autre d' environ 10 hectares qui se trouve en plein travail et dans lequel on cultivera les primeurs pour 1' exportation. II contiendra egale- ment un verger On y fera la culture intensive du froment, des legumes et des tubercules comestibles, tous produits si nece's- saires dans le moment que nous traversons. A cote des diverses cultures auxquelles les invalides s'exercent, ou des differentes operations agricoles proprement dites qu'ils reapprennent , c'est-a-dire de la preparation du terrain a la recolte des produits, a cote de cela done, se sont installes divers types de petites industries locales, adaptees aux besoins de la region sicilienne. II y a ainsi, en developpement continuel, un vaste rucher pourvu de ruches des types rnodernes les plus varies (Sartori, Dadaut, Blatt, Tonelli, Morale, etc.). Une installation pour 1'elevage des poulets, vraiment admirable,, coiistruite suivant les avis les plus rationnels, contient plus de deux cents poulets. La Section compte egalement une dependance speciale pour 1'elevage du lapin qui produit les meilleurs echantillons dos races les plus perfectionnees. II y a outre uri atelier pour la fabrication des paniers ou travaillent, comme ouvriers fixes, un grand nombres de mutiles loges et d'autres viennent s'y exercer petit a petit pendant quelques heures par jour pour apprendre un metier secondaire. A part cela, les invalides qui ont prouve leur aptitude parti- culiere, ou dont 1'etat physique le perrnet, suivent un' cours pratique de montage et demontage des machines et des moteurs agricoles a 1'Institut Public Zootechnique de Palerme, et apprennept egalement a conduire ces machines. Enfin sont installes, -et en plein fonctionnement , une fromagerie, une por- cherie , une etable , un laboratoire pour la fabrication des conserves alimentaires et un petit atelier pour la reparation des machines agricoles. La Direction technique de cet etablissement est confiee a un licencie es sciences agricoles, qui a deja occupe d'importantes places dans 1'enseignement et dans la propagande agricole : le Docteur Angelo Aliotta. II est assiste d'un aide-comptable qui a fait des etudes officielles de viticulture et d'oenologie et par un veterinaire qui a la charge de consultant zootechnique , enfin par les differents chefs des ateliers et des sections agricoles. L'enseignement que Ton donne dans cette ecole de Palerme est presque exclusivement pratique. Ceci pourrait nous paraitre un defaut si nous ne considerions que etant donne le niveau, encore primitif, de culture de cette region insulaire de notre pays c'est deja un resultat merveilleux que celui que Ton 193 obtient, par line methode tangible et probante, en detachant 1 'esprit de ces travaillcurs des usages arrieres et des~ habitudes irrationnelles qui rendent steriles leurs methodes de culture. Ainsi cet Institut, qui a deja reiidu a la terre environ 200 invalides et qui entre actuellement dans line periode de developpe- ment plus actif, apporte une contribution de premier ordre a la reeducation rurale de notre pays, L'Etablissement de Peseta organise par les soins de la Croix- Rouge Italienne offre le type d'un Institat complet pour 1' assist- ance aux mutiles, avec ses installations medicales et d'entraine- ment, avec son atelier orthopedique et de protheses, avec ses laboratoires prof essionnels, destines exclusivement a la reeducation agricole. Cree durant les premiers temps de la guerre, quand encore aucune disposition legislative ne reglait 1'accueil des invalides dans ces etablissements, 1'hopital de Pescia anrait du, selon 1' intention des membres dirigeants, pourvoir un traitement complet des mutiles durant tout le temps de leur assistance, depuis le premier moment de la lesion soufferte, jusqu'au plus eloigne du retablissement physique et professionnel. Dans ce but, et dans 1' installation et dans 1' organisation de 1'Institut on avait pourvu, d'une maniere modeste mais efficace aux quatres periodes principales de leur traitement, c'est-a-dire : chirurgique, physiotherapique , d'entrainement fonctionnel, orthopedique et de protheses, de reeducation professionnelle. Les organisateurs de 1'Hopital avaient en effet pense que, dans la pratique, ces diverses periodes ne sont pas separables, mais qu'elles s'alternent, qu'elles se substituent et se superposent 1'une a 1'autre pendant le cours du traitement, suivant les con- ditions particulieres de chaquc individu. Mais, vu que la loi se montra non conforme a de tels pro jets et divisa nettement les diverses periodes de traitement des mutiles, I'hopital de Pescia crea la Maison de Reeducation pro- i(sionnelle generique, conservant toutefois intactes ses instal- lations sanitaires et ses moyens techniques. L'Institut avait pourtant toujours eu 1'intention, des le debut de son activite, de se specialiser dans la Reeducation agricole, guide dans cela, non seulement par 1'idee fondamentale de rendre a la campagne le plus grand nombre possible d'invalides de guerre auparavant agriculteurs , mais aussi par le milieu essentiellement agricole de la region et par 1'heureux avantage de 1' existence dans cette meme ville, d'une des plus florissantes ecoles pratiques d' agriculture de tout le Royaume. A cet effet. d'accord avec cette ecole I'lnstitut de Pescia, tout a fait le premier parmi les autres Instituts semblables, eut une Section pour I'enseignement de T agriculture et des metiers analogues. Mais il ne suffisait pas aux organisateurs de conserver une seule section professionnelle pour 1' instruction rurale, ils voulurent proceder a la specialisation exclusive et complete de lfi-,24 G 194 1'Etablissement dans la reeducation agricole, et, precisement dans ees dernieres semaines, grace a 1'abondance des moyens mis a sa disposition par la Croix-Rouge Italienne, 1'organisation a te completee et 1'ecole a commence a fonctionner. L'Etablissement de Pescia, qui dispose actuellement de 170 places possede outre les installations techniques dont nous avons parle, les terrains necessaries a 1'enseignement pratique des travaux des champs. Une spacieuse propriete faite de plaines t de collines presente les types les plus communs de culture : culture des cerealesf de la vigne, des oliviers. Un jardin vaste et tres bien travaille est utilise pour la production des cultures horticoles qui sont une specialite de la Region . Un tres grand champ situe pres de 1'Institut permet 1'emploi des machines agricoles qui sont fournies par 1'ecole d' agriculture de la ville. Enfin le jardin, riche et spacieux de la Villa Calderai, ou se trouve la direction et 1'hopital pour les mutiles, sert a 1'eiiseigne- ment pratique de la floriculture. Dans un grand edifice a trois etages, construit a cet effet par la generosite du proprietaire de la Villa, Mr. Calderai, se trouvent les dortoirs, les E coles et les laboratoires pour les industries agricoles. Une autre petite construction abrite la Direction de 1'entreprise agricole, les reserves de graines et les instruments de travail. Enfin viennent les etables pour les vaches> la laiterie, les porcheries, la garenne, le poulailler, le rucher, tous d' installation recente. L' organisation de 1'etablissement est faite de maniere a pour- voir a 1'enseignement theorique et pratique de 1' agriculture en general, des industries agricoles et des petits metiers de la cam- pagne. It y ainsi di verses sections d'enseignement : cultures herbacees, cultures des arbres fruitiers (fructiculture) , horticul- ture, jardinage, elevage des animaux ; puis cenologie, huilerie, laiterie, et enfin cordonnerie, fabrication des sabots, travail des sieges et des meubles de la campagne, travail de la paille et de 1' osier, construction des futs et des barriques pour le vin, repara- tion et construction des chariots et des charrues necessaires aux travaux agricoles. La Direction de 1'Ecole est confiee a un professeur de sciences agricoles, assiste en ce qui concerne la surveillance et 1'enseigne- ment pratique des diverses metiers par d'autres chefs-experts et chefs de metiers. Cependant tout le fonctionnement de 1'Institut est soumis a la Direction de 1'Ecole Publique d' Agriculture de Pescia, qui met a la disposition de TEtablissement des professeurs pour les sections et tout son riche materiel de travail. L'enseignement theorique, a part 1'ecole elementaire obliga- toire qui constitue la base de 1 'instruction pour tous les invalides recueillis consiste en conferences populaires, trois fois par semaine, faites par le directeur de 1'Ecole et les divers professeurs de 1'Institut Public d' Agriculture, et illustrees de demonstrations 195 pratiques par des experiences, des modeles, des tableaux et des plans. Pour les plus cultives et les plus intelligents , on a constitue un cours d' economic agricole comptabilite et technique rurale qui destine les eleves aux emplois d'administrateur, d' agent de campagne, de surveillant agriculteur. Comme on le voit, d'apres tout ce que nous avons decrit, 1'ecole de Pescia comme les deux precedentes pourvoit completement et d'une maniere rationnelle a la reeducation agricole des invalides de guerre en Italie. Parmi les Instituts du troisieme groupe, c'est-a-dire ,ceux qui sont independants ou annexes a des Ecoles d' agriculture, pre- existantes, la plus grande partie en a ete creee depuis peu et par suite n'a pas encore atteint tout son developpement. II faut cependant excepter Turin et Perouse. Le Comite piemontais pour 1' assistance des mutiles s'est des le debut occupe de la reeducation de ses agriculteurs invalides, en les faisant entrer dans une ecole professionnelle de protection qui existait deja au Chateau de Lucento pres de Turin : 1'Institut Bonafous. Get Etablissement est une Colonie Agricole qui abrite pour 1'apprentissage des travaux des champs, les jeunes gens depourvus d'appui moral et materiel sumsant. II dispose d'une propriete d'environ 70 hectares avec des jardins, des potagers, des vergers et des pepinieres. II possede des pres irrigues et des champs ou se fait une bonne education agricole. Un Institut Zootechnique du Gouvernement contenant une pepiniere forestiere, en fait partie. Parmi les diverses cultures qu'on y pratique, tres im- portante est celle du tabac qui est perfection nee dans les soins de la plante elle-meme jusqu'a la mise en tonneau. On y eleve des boeufs pour la boucherie, des vaches pour le lait, des pores et des lapins. Dans cet Institut se trouvent aussi des ateliers de charron, de menuisier, de forgeron, de marechal-f errant. L 'Etablissement possede de nombreuses machines modernes pour la culture agricole. Les invalides, sous la direction des professeurs et du personnel technique attache a 1'ecole, assistent et prennent part aux divers travaux que Ton accomplit dans la grande culture comme dans les cultures particulieres et dans 1'elevage du betail. Les invalides sont exerces egalement a la construction de& corbeilles, a la fabrication des sabots, a la reparation des machines agricoles et des chariots. L'enseignement est essentiellement theorico-pratique. Les legons theoriques sont des explications des travaux accomplis dans la journee, des constatations et des observations que petit a petit les professeurs et les eleves sont amenes a faire. 16524 G 2 196 Cette ecole fonctionne comme nous Taverns deja dit, depuis plus d'un an, mais elle a ete et est encore pen frequentee. Durant I'annee derniere quatre eleves se sont inscrits et actuellement il y en a seulement six. L 'Ecole de reeducation pour les mutiles de guerre agriculteurs a Perouse fondee a la fin de 1916 sur 1'initiative d'un Comite Provincial et grace a 1' attention particuliere du Senateur Faina, est situee dans les locaux de la Fondation pour 1' instruction agricole. Elle a ete organ isee par les soins de cette Fondation meme et de 1'Institut Public Superieur Agricole de Perouse. Un Comite local est charge de la surveillance de 1'Etablisse- ment et le fonctionnement est confie a un personnel technique sous la direction du prof. Vivenza de 1'lnstitut superieur d' agri- culture. 11 y a ega lenient un personnel medical pour 1' assistance sanitaire et la direction des applications orthopediques qui se font dans cet Institut en un petit atelier de protheses etabli pour 1 montage des appareils. L' instruction qui dure un trimestre au minimum et un semestre au maximum comprend : 1'Instruction elementaire, 1'Instruction complementaire, 1'Instruction professionnelle. L'enseignemerit complementaire comprend les notions elemen- taires de sciences physiques, chimiques et naturelles, les plus u tiles aux agriculteurs, appliquees suivant la methode experi- mentale. L'enseigriement professionnel se fait par des conferences illustrees et des exercices pratiques dont le materiel necessairfi est au besoin fourni par 1' Institut agricole superieur, par 1'Etablissement ambulant d' agriculture et par la Fondation pour 1' Instruction agricole et les terrains annexes. Les cours theorico-pratiques , qui sont faits sous cette forme, traitent des sujets suivants : Cultures des champs, elevage du betail, horticulture et fructiculture, viticulture et oenotechnique . culture des oliviers et huilerie, culture du murier et elevage des vers a soie, organisation des terrains. Les invalides sont egalement exerces a 1'emploi des machines agricoles (y compris 1' aptitude a conduire les chaudieres a vapeur et les moteurs a explosion pour les travaux des champs) et a la pratique des petites industries rurales et forestieres. L 'Ecole qui fonctionne, comme nous 1'avons dit, depuis la fin de 1916 et qui dispose de 50 places a, pour de nombreuses raisons, fonctionne jusqu'a present incompletement et par inter- valles. Tout a present, elle semble vouloir reprendre 1'activite qu'elle peut fournir. La fondation de 1'oeuvre d'assistance pour la reeducation agricole professionnelle des invalides de guerre de Voghera date, de tres peu de temps ; cette ecole fut en eff'et creee a la fin de juillet 1917 et n'a commence a fonctionner que le 20 aout de cette meme annee. Elle fut instituee par 1' Institut agricole 197 catholique de Voghera par ses propres moyens et avec le concours cle Societes publiques et privees. Elle fonctionne comme -asso- ciation independante suivant les reglements etablis nar nn Statut diiment approuve. L'Institut de Reeducation a son centre pros de 1'Ecole Publique d' Agriculture superieure " C. Gallini," qui, avec le consentement du Ministere de 1' agriculture, a mis a la disposition de 1'Institut 'les terrains, les installations agricoles et le materiel d' etude et de travail. La Direction de 1'Ecole et 1'enseignement sont confies au personnel technique de 1'Ecole de 1'Etat. On y a adjoint une Direction Sanitaire pour 1'assistance medicale et orthopedique des invalides. L'enseignement agricole qu'on y donne est theoricopratique. L'enseignement theorique se fait au moyen de lecons element- aires. L'enseignement pratique a lieu dans la propriete de 1'ecole et dans les installations annexes. Les mutiles etant tenu coinpte de leurs aptitudes speciales apprennent tous les travaux de culture de la propriete, c'est-a- dire : agriculture generate (culture des champs, f ructiculture , viticulture, jardinage, culture du murier) ; industries speciales (elevage du betail et des betes a lait, elevage des vers a soie) ; enfin service et manutention des machines agricoles. L'Etablissement est en train d' installer un vaste jardin de rapport et elle donnera des cours temporaires pour le travail du lait. Outre ces divers enseignements agricoles il y a aussi des cours d' instruction elementaire. L'Ecole a eu jusqu'a present une vingtaine d'eleves et actuelle- ment elle en a 9. II s'agit, comme on le voit, d'une premiere periode d'experi- mentation qui, nous 1'esperons, sera suivie d'une neriode de plus complet et de plus fecond developpement. Au sujet des deux dernieres ecoles pour la reeducation agricole des mutiles dont nous avons annonce 1'ouverture, nous n'avons que peu d' informations. Celle de Lecce Institute dans la Villa " Sans Souci " par les soins du Comite Provincial d' Assistance Civile, semble avoir deja commence a fonctionner avec 13 eleves. D'apres le peu que nous savons, c'est un Institut fonde sur le type de ceux de Voghera et de Perouse deja decrits et qui depend d'une Institution Pro- fessionnelle Agricole pre-existante dans cette ville. L'Ecole d'Ancone organisee par les soins du Comite Regional Marchigiano pour les soldats mutiles n'a pas encore fonctionne jusqu'a present. 16524 G 3 198 L'Institut est situe a Porto-Kecanati dans une propriete d' environ 40 hectares en grande partie faite de plaines et de demi-plaines et le reste de collines. II y aura une direction technique constitute par un Directeur agriculteur-mecanicien, un chef de travail, un chef d'atelier pour I'emploi des machines agricoles, enfin des professeurs experts qui seront fournis par les sections ambulantes d'agriculture d'Ancone et de Macerata. Les cours professionnels de caractere theoricopratique com- prendront 1' agriculture en general, horticulture et fructiculturc ; elevage des animaux ; travaux secondaires d'agriculture; con- servation des fruits et fabrication des conserves. De plus Ton donnera et c'est une tres bonne idee un developpement particulier a 1' etude des machines agricoles. L'ecole peut contenir actuellement 30 invalides et Ton veut porter ce nombre a 50, le plus tot possible. Au sujet de cette description sommaire que nous venons de faire, des Sections et des E coles professionnelles agricoles pour mutiles, nous pouvons nous permettre de faire quelques remarques. Parmi les trois categories dans lesquelles j'ai era pouvoir grouper ces divers Instituts de Keeducation, la deuxieme apparait comme bien superieure aux deux autres. Est-ce la un simple hasard, ou cette superiorite ne correspond- elle pas a une meilleure conception initiale ou a une plus logique et plus rationnelle direction dans 1'organisation de ces ecoles? C'est du moins ce que je pense. Les Sections agricoles institutes pres des maisons principales de reeducation et qui constituent une simple section profession- is elle, comme celles du premier groupe, sont peut-etre les moins aptes a donner un resultat satisfaisant. Dans ces Instituts (et j'eus deja 1'occasion de le dire) la section agricole reste presque toujours la plus negligee parmi tous les autres enseignements. L 'incompetence des membres dirigeants, 1'insufnsance des moyens techniques et pratiques d' instruction, la faible activite des travaux agricoles, la ou les ecoles de metier bien organisees et plus frequentees promettent une plus grande nouveaute et une plus grande variete de travail avec la perspective de trouver plus tard un emploi remunerateur (tout le monde connait la tendance qu'ont les pay sans a deserter la terre pour 1' atelier) portent presque fatalement les professeurs et les eleves a se mefier et a defter d'un tel genre d'enseignement. Tant il est vrai que, ordinairement, ceux qui se dedient a 1' agriculture sont seulement les invalides qui, ou par suite de leurs qualites intellectuelles, ou par suite de leur affaiblissement organique ou de leur non- chalance habituelle, sont incapables d'exercer un autre metier quelqu'il soit. 199 Pour cette raison ces sections agricoles ont peu de valeur et peuvent servir tout au plus, si elles sont bien surveillees et bien disciplines, comme moyen excellent d'entrainement, de re- education fonctionnel et de preparation aux ecoles de reeducation proprement dites. Plus importants, sans aucun doute, sont les Instituts du troisieme groupe, c'est-a-dire ceux independants qui ont ete crees dans un but essentiellement agricole et qui, pour le plus grand nombre, sont confies a une Ecole d'instruction agricole du gouvernement. Car, en effet, dans ces etablissements la partie professionnelle correspond a toutes les exigences d'un enseigne- ment efficace, grace a la competence des membres dirigeants et a la richesse des moyens. Mais, je 1'ai deja dit precedemment, reeduquer a 1' agriculture ne veut pas dire enseigner 1' agriculture. II ne faut pas oublier que nous avons a faire a des infirmes, a des affaiblis physiquement, a des individus deformes, moralement et physiquement anormaux et que, par suite, le probleme de leur reeducation professionnelle est en meme temps medical et educateur. Dans les discussions longues et animees qui eurent lieu a Paris -a la Conference interallied pour les invalides de guerre, au mois de Mai de 1'an passe, on a plnsieurs fois affirme (et on 1'a approuve dans les conclusions) que la Direction de ces Maisons de Eeeducation doit etre avant tout medicale, tout en conservant, bien entendu, le concours des experts competents. De plus, que les ecoles de travail doivent etre situees pres d'hopitaux ou d' Instituts medicaux afin que les soins chirurgicaux et physio- therapiques aient lieu en meme temps que 1'enseignement professionnel. La Direction Sanitaire de 1'Ecole a, independamment des soins eventuels medicaux et chirurgicaux, un devoir tres important a accomplir, en ce qui concerne 1' application au travail de ces eleves invalides. L'examen minutieux de I'impuissance qui les a atteints, le siege et la reduction des diver ses activites mo trices, 1' application des soins physiques et mecaniques aptes a augmenter, a retablir et a coordonner les diverses puissances de travail (entrainement et reeducation organique) sont en effet de la competence exclusive de la Commission sanitaire. De meme d'ailleurs que 1' utilisa- tion des appareils orthopediques et de protheses capables de corriger et de remplacer les parties atrophiees ou absentes (soins prothetiques et orthopediques) ; 1' etude des moyens mecaniques plus efficaces pour rendre 1'invalide apte a 1'exercice des differents travaux (protheses de travail) ; 1' etude et la designation des genres de travaux que permet 1'affaiblissement organique de 1'individu (orientation professionnelle) ; et enfin la surveillance des effets produits par le travail (considere comme agent physique) sur 1'organisme en general et sur la partie malade en particulier. L'oeuvre des maitres professionnels commence et s'explique seulement apres tous ces soins. 16524 Gr 4 200 Et c'est precisement 1 'absence complete d' organisation tech- nico-sanitaire des ecoles autonomes d' agriculture qui ; con- trastant avec les principes fondamentaux d'une reeducation rationnelle rend sterile 1' action de ces instituts, en entrave le fonctionnement et, par cela meme, en diminue 1'utilite. Au contraire les instituts que j'ai classes dans le deuxieme groupe, repondent tres bien a ces idees fondamentales, et c'est la, a mon avis, la raison pour laquelle ils se sont developpes nlus vigonreusement et qu'ils accomplissent une action plus complete et plus efficace. Detaches de la complexity des sections professionnelles et rendus autonomes seulement en ce qui cone-erne la partie instruc- tive (comme les ecoles agricoles de Milan et de Palerme) ou resultant de transformations de la Maison principale de Reeduca- tion (cornme 1'ecole de Pescia), ces Instituts maintiennent intacts les cours scientifiques , de meme que les rapports techniques et la direction sanitaire speciaJe a ces Etablissements, que nous a-vons voulu appeler "Ecoles de Reeducation Drofessionnelle " et dont Palerme et Milan sont le plus parfait exemple. II y a dans ces Instituts un tout organique, fonctionnant avec harmonic', dans lequel F assistance aux invalides est rendue com- plete par le juste equilibre entre le but, les moyens et les competences qui y concourent. Et c'est ce type d'institution qui, a mon avis, devra etre con- seille et repandu, en en organisant I'msta-Hation ou en en favorisant le developpement pres de plus grands centres de Reeducation comme Bologne, Florence, Rome, Naples ou ne manquent ni la richesse des moyens, ni 1'activite de personnes devouees qui permettront de faire naitre et de developper vigoureusement d'aussi importantes oeuvres de prevoyance sociale. II nous reste a examiner le contenu du programme professionnel que nos ecoles agricoles de Reeducation se proposent de suivre en Italic. D'apres ce que j'ai expose precedemnient en ce qui concerne les divers instituts, nous pouvons remarquer que le caractere et la matiere de 1'enseignement est a peu pres semblable dans chacun d'eux. Chez tous, rinstruction theoricopratique pre- domine et cela tient a une juste idee de ne pas seulement readapter au travail materiel l'organisme des mutiles, mais aussi d'elever la culture professionnelle pourcompenser 1'affaiblissement souffert. L'exercice de la culture et du travail des champs qui est fait dans toutes ces ecoles a davantage une valeur d 'instruction et d' experimentation des methodes de culture plus rationnels. que de veritable exercice physique reeducateur, car il est en effet evident, que cette partie de F agriculture plus materielle et plus fatigante trouvera l'organisme de nos invalides moins apte a 1'exercer. 201 Au eontraire, 1'enseignement de la fructiculture qui est donne dans plusieurs de nos ecoles, apparrait plus profitable ; mais il demande aussi des aptitudes physiques que n'auront pas les mutiles, specialement ceux de metiers inferieurs. Ce fait ne se produit pas dans les ecoles d' horticulture et de jardinage dont parlent les programmes des divers Instituts et que nous voudrions voir dirigees avec une intention vraiment serieuse et un but enfin professionnel. Malheureusement , nos etablisse- ments de reeducation restent encore bieri superficiels et n'ont qu'un developpement tres modeste. Ces branches secondaires de 1'agriculture, peu fatigantes et non tres dimciles a apprendre, peuvent etre presque toutes exercees par les invalides. De plus, elles leur off rent un emploi sur et un benefice appreciable, etant donne 1'absence relative de cultures horticoles dans de nombreuses regions de 1'Italie et 1'application plus rare encore que la floriculture rationnelle a trouvee jusqu'h present dans notre pays. Nous pourrioris dire de meme de renseignement pour 1' emploi des machines agricoles et de la motoculture dont 1' utilisation, peu repandue chez nous, porte un prejudice considerable a toute la production agricole nationale. Et puisque 1' experience faite dans les ecoles de France, a demontre la possibilite et la facilite relative d' adaptation des invalides a ce genre de travaux, il est a souhaiter qu'un tel enseignement qui est donne aujourd'hui dans quelques ecoles seulement se repande et se developpe chaque iour davantage dans nos Instituts de Eeeducation. A ce propos nous attendons beaucoup de 1'ouverture de 1'Ecole d'.Vncone qui se propose precisement de donner un developpement particulier aux applications de la mecanique agricole. Parmi les diverses industries agricoles, une de plus repandues est certainement celle de la production du lait et de la fabrication de laitages auxquelles tons nos etablissements agricoles pro- fessionnels out songe en installant une petite fruitiere. INIais sur ce point il s'agit de s' entendre : Croit-on quo pour enseigner la tenue du betail et I'utilisation du lait avec dc si modestes experiences, quelques ustensiles indispensables et une ou deux vaches dans une etable puissent snffire? Si Ton vent donner un enseignement veritablement profitable dans ces sections que Ton a pompeusement appelees " ecoles pour 1'industrie laitiere," aucun de nos Instituts n'a jusqu'a present des moyens et des installa- tions adaptes a ce but. II sera it pourtant important et tres utile d'exercer a cette Industrie une partie de nos mutiles agriculteurs , choisis parmi les plus travailleurs et les plus entreprenants , afin d'en faire de bons et habiles ouvriers qui trouveraient par la suite un bon emploi dans les nombreux etablissements de 1' Italic septentrionale et meridionale ou la fabrication du benrre et du fromage est si repandue et si florissante. 202 La tenue et 1'elevage des animaux de basse-cour comme F agriculture que Ton enseigne dans toutes nos ecoles, meme dans celles de faible importance (et il est facile de le comprendre vu la simplicite des installations) doivent etre consideres comme des rnoyens d'instruction complement aire des exercices agricoles et non comme un apprentissage professionnel exclusif. Us devront constituer un metier seulement pour les mutiles qui ne pouvant s' employer dans d'autres branches agricoles trouveront par ce moyen et sans fatigue une modeste source de gain lorsqu'il retourneront dans leurs families. II en est de meme pour tous les petits metiers de la campagne : sabotier, vannier, tonnelier, fabricant de chaises, &c., qui (etant consideres, la aussi, les cas particuliers) doivent constituer un enseignement complementaire des di verses branches de T agricul- ture generale. Et j'ai vu avec satisfaction comment plusieurs de nos Instituts, eux de Milan, Pescia, Palerme, suivent precisement ce que je conseille dans 1' orientation professionnelle des invalides qu'ils accueillent. / L' enseignement pratique de la recolte et de la conservation des fruits et de la fabrication de conserves alimentaires , qui est fait a Turin, Perouse et Palerme, est une tres bonne chose sous tous les rapports. Ses industries prennent en effet chez nous un developpement tou jours croissant et les invalides pourront s'y dedier avec grand profit apres la guerre, car il s'agit de travaux simples, peu fatigants et vite appris, tant il est vrai que generale- ment les femmes et les enfants y sont employes en Italie. C'est egalement tres bien de la part de 1'Ecole de Perouse de songer a faire apprendre aux invalides le metier de garde-forestier et de garde-champetre. En effet, pour ceux dont les conditions physiques le permettent (les mutiles et les estropies de bras) 1'exercice d'un tel emploi facilite par le prestige dont indubitable- ment nos glorieux blesses jouiront apres la guerre sera tres avantageux soit dans les entreprises privees soit dans celles de 1'Etat. Apres avoir ainsi expose sommairement 1'origine et le de- veloppement de nos institutions pour 1' assistance professionnelle des mutiles agriculteurs , apres en avoir decrit les differents types et marque les caracteres, analyse le f onctionnement , mis en relief les qualites et les defauts, apres cela dis-je, il pent etre utile de jeter un regard d' ensemble sur toute cette ceuvre developpee en Italie dans le champ de la reeducation agricole, de 1'apprecier aussi justement que possible et d'en tirer d'exactes conclusions. Si nous exarninons cette oeuvre, une chose apparait evidente et incontestable : 1' effort intense et remarquable que notre pays a fourni pour affronter lui aussi, le probleme de 1' assistance pro- fessionnelle. Effort d'autant plus louable qu'il s'est manifesto- et qu'il s'est developpe par des initiatives privees, sans aucune aide, ni encouragement, ni appui de la part de 1'Etat et qui: 203 prouve combien nous avons compris 1'importance de la question et la necessite de 1' affronter et de la resoudre. Toutfois les difficultes materielles auxquelles se sont heurtees des le debut ces initiatives privees, leur insuffisante preparation, 1' absence de toute direction initiale et de coordination, ne pouvait apporter, comme elle 1'a fait d'ailleurs, qu'un grave obstacle et un relachement dans cette oeuvre de reeducation. Et aujourd'hui, apres deux ans et demi de guerre, la part qu'apporte 1'Italie a la solution de ce probleme est encore bien modeste, et nous sommes loin d'avoir obtenu les resultats que, vu nos efforts, nous etions en droit d'attendre. Car, si nos institutions professionnelles semblent apres mille tatoiinements avoir trouve leur orientation pratique et leur direc- tion rationnelle (comme on 1'a vu du moins pour plusieurs d'entre elles qui pourront servir d'exemple a celle deja creees ou qui se creeront) le nombre de ces institutions et leur efficacite sont tels qu' elles ne peuvent constituer les bases serieuses d'une oeuvre reeducatrice pour nos mutiles agriculteurs. Mais un autre fait que nous devons relever augmente encore Tinsuffisance de nos organisations : Avec une douzaine environ d' annexes, de sections et d' ecoles professionnelles agricoles dont plusieurs fonctionnent depuis presque deux ans, en ayant environ 600 places a la disposition de nos invalides, il n'y a plus de quelques dizaines de mutiles qui out accompli ou sont en train d'accomplir leur reeducation .agricole. De quoi cela provient-il? D'un fait qui apparait immediatement si nous examinons la frequentation de nos Instituts : en effet 1'Ecole de Voghera dispose de 50 places et elle compte actuellement 9 eleves ; Turin , avec 50 places egalement, en compte 6 ; Perouse, avec 70 places, en hospitalise 31 ; Pescia, avec 170, en a 60 ; Leece, avec 50, en a 13 ; Palerme, avec 100 places, en a 30, et ainsi de suite. Done, nos Ecoles de Eeeducation agricole non seulement sont rares, mais encore elles sont pour la plupart desertes. Si nous examinons les causes de ce phenomene elles sont multiples et je me dispense de les enumerer il en est une qui me semble la plus important e et que Ton doit serieusement etudier : c'est que le recrutement des mutiles agriculteurs, pour les sec- tions et les ecoles d' agriculture, est fait dans les Instituts memes de reeducation professionnelle et est laisse au bon vouloir des Directeurs de ces etablissements et des eleves qui y sont recueillis. Or, si Ton tient compte de ce que les invalides arrivent dans ces Instituts, apres un long sejour dans divers hopitaux, las et peu portes au travail; qu'un nouveau sejour, si court soit-il, dans ces etablissements, les rend toujours phis incapables de s'occuper ; 204 que d'autre part, rentrainement de leurs camarades aux nouveaux et apparemment plus profitables enseignements techniques ou industriels les attire invinciblement ; que les membres dirigeants de ces Instituts, heureux, par un egoisme excusable, de voir leurs laboratoires et leurs ateliers frequentes et florissants, ne s'opposent pas a cet entrainement des mutiles, il est facile de voir les inconvenients de ce recrutement qui refrene et arrete encore les tendances naturelles de nos agriculteurs a retourner a la campagne. Et comment peut-on remedier a cela? D'apres ce que nous voyons de nos Institutions de Reeducation professionnelle pour les invalides de guerre, 1'ceuvre venue de ('initiative privee est maintenant dans une periode de perfec- tionnement tel qu'elle peut continuer desormais a se developper et a se perfectionner par ses propres inoyens. Je ne demande done pas aux associations gouvernementales et a 1'Oeuvre Nationale, qui les represente, des subventions materielles pour nos travailleurs de la terre mutiles. La sollicitude et la charite publique est si grande qu'elle pourvaiera comme elle a pourvu jusqu'a present aux besoins de cette pieuse assistance. Et il ne leur demande pas davantage, Dieu m'en garde, des lois ou des reglements a ce sujet. Mais ce que je demande, et que je desire voir etabli comme principe officiel et fondamental, c'est que tons les mutiles agri- culteurs soient rendus a la terre, a travers les ecoles de reeduca- tion professionnelle agricole et que pour cela les invalides soient envoyes dans ces ecoles, directement par les sections de concen- tration, a peine leurs conditions physiques le permettront. Si a ma proposition on objectait que nos ecoles sont actuelle- ment trop rares et trop faibles pour accueillir tons nos invalides de la campagne, je repondrais que, sous 1'impulsion du besoin et encouragees par la certitude que TEtat a confiance en elles, de nouvelles energies se leveraient, de nouvelles generosites se feraient jour; et le pays, qui a desormais senti toute la beaute et Fimportance de cette redemption morale et materielle de nos paysans invalides, saura encore une fois faire son devoir. 205 OUTLINE OF A SCHEME FOR TRAINING AND EMPLOYMENT OF DISCHARGED AND DISABLED MEN OF HIS MAJESTY'S FOftCES. BY KENNETH S. DICKINSON, F.C.S., M.P.S. ; Pharmaceutical Chemist ; Principal of the Chester and North Wales College of Pharmacy ; Late Sergt. R.A.M.C. ; Official Visitor to Hoole House Auxiliary Hospital, Chester. (N. and M. War Pensions Committee.) In any scheme which may be outlined for helping Sailors and Soldiers, disabled in the present war, or discharged from His Majesty's Forces at the close of it, there must always be kept before the eyes ol those who examine it the varying mental capacities of the men concerned. In pre-w r ar days, the Army standard of education was not a particularly high one, whereas the men of the present day Forces are culled from every imagin- able grade, from labourers and navvies to University graduates and professional men in the highest walks of life. Obviously, therefore, any scheme of training or of assistance to such men of the Dresent day Army must be of a very elastic nature if it is to be of any use to more than one grade of the men who will , now or later, require assistance. A second very material consideration, too, is as to the ultimate value to the Nation of any scheme which may present certain immediate benefits, since it would be obviously unwise to spend labour, time and money in the training of men in subjects for which there would later be little or no demand, or where the final value of their work depended upon contingencies which could not be foreseen. There would be too grave a risk of periods of trade depression, and consequently of some hundreds, or even thou- sands, of ex-Service men finding themselves without means of sustenance. Finally, this would mean, of course, that the country, which had spent a certain and considerable- -sum of money on the training of these men would have to come to the rescue and disburse still further sums to them as, and when, the need arose. Some twenty years ago, the question of " Small Holdings " was much to the front, and many reasons why men should be induced to return to the land were brought forward. The policy was not blessed with any great measure of success at that time, owing, mainly, to the difficulty experienced in obtaining suitable land at a reasonable figure. In cases isolated, it is true- where men were allowed a few acres of land at a fair rental, they almost invariably acquired in the course of a few years a very comfortable little homestead. 206 It is in an elaboration of that scheme and that policy that the writer can foresee a great possibility for the making of useful " Citizens " of men to whom the country owes so much. The subject needs a close examination from at least four points of view, namely : Q) The scope and functions of the scheme proposed. (2) The aggregate value of such men doing such work to the State. (3) The feasibility of training and employing a large number of men in such work. (4) The possibility of making such a scheme a prosperous, self-supporting organisation in the fulness of time. To take these view-points in order : Firstly : what, in as clear and explicit a manner as possible, is this proposed Small-holdings scheme ? It must be stated at the outset, in reply to this, that at such a ^tage little more than a hazy outline can be attempted. The co-operation of existing societies and associations, the finding of suitable organisers, the decisions respecting districts chosen for a trial of the scheme, all would affect to a certain degree the scope of the scheme proposed. But, in general, it is to offer to those men who want it, and are qualified to receive it, training in the most scientific and up-to-date methods of working a small-holding of, say, from one-and-a-half to three acres in extent. The train- ing of these men could be of three or six months' duration, in which time they might learn something of the drying of fruit, vegetables and drugs ; of the management of bees and rabbits for profit ; of intensive horticulture and of the best methods of marketing their produce. There already exists in this country an organisation which, with a very little adaptation, could be made to serve admirably both for the instruction of such men in such subjects and an e^ven more important consideration as a medium whereby the men could later keep in touch with the best markets. I refer to the " National Herb-Growing Association " and the " National Herb-Growing Industry, Ltd." The former is more of an edu- cational body, the latter acts in the nature of an agent, accepting vegetable products chiefly, at present, medicinal herbs from its members, selling them in bulk quantities to wholesalers, manufacturing chemists and the like , and forwarding the proceeds to its members again. Some men, who were started with a little land, would conceivably wish to be free from the trammels of any "Association." It should be left perfectly open to every man to regard himself as a free agent , and it would be found that , in a vast majority of cases, the men who decided to work entirely on their own initiative would soon develop original ideas, both as to the produce they should grow and the finding of a market for it later. Other men, of a less self-reliant type, would prefer to con- tinue to hold their land as workers for a Central Agency. The 'National Herb-Growing Industry'' would stand to them in 207 the place of a " Head," and could easily be adapted to issue in- structions as to what to grow, how to grow it, and how to deal with the produce afterwards. At the present moment, the pro- duction of medicinal plants is probably the most remunerative branch of the work ; it is, however, more than likely that it would be found advisable later to gradually allow this trade to return to those countries where both land and labour are cheaper than in England; and where the natural, physiographical conditions point to the cheapest production of such herbs, endeavouring, as the scheme matured, to make British ground yield, by intensive culture, the utmost possible result. There should be appointed a certain number of men, who, for want of a better title, I will call for the moment " Official Visitors," and on the capability of these men lies the greater portion of the success or failure of the scheme. These men, appointed and paid by His Majesty's Government, would need to stand in the place of ' ' Big Brother ' ' to the men who were placed in their area. Any attempt at "officialdom" w r ould hopelessly impair their chance of success. They would need to be men of wide and varied experience ; they would need to be able to give advice at one holding as to what best to grow ; at the next , as to how best to erect an inexpensive drying apparatus ; at a third , to settle a boundary quarrel with a neighbouring tenant ; and at a fourth, to advise on the care of bees, or the arrangement of a water supply from a stream near by. The positions would be regarded, and rightly, as positions requiring" great tact, ability and perseverance the measure of the Visitors' success being the increasing number of calls upon his services made by the men of his district. These men must therefore be selected with care, and their emoluments such as would secure the right type of man. That a successful, commercial proposition is here suggested is- open to no doubt whatever, since the thing has actually been done by individuals in pre-war days. There is, for example, a case which may be cited as that of Mr. A. This man, originally a City clerk, commenced bee-farming in a modest way in a tumble-down cottage, with a bare half -acre of ground. To-day his hives, commencing at four, now number seventy, and when all expenses are calculated, they average a net profit of 2 per hive per annum. This, with the odds and ends of foodstuffs he can grow in addition, is sufficient to provide for the needs of himself and his two sisters. Finally and by no means the least important there is the testimony of the man himself : "Getting peace and plenty from half an acre; and as for the girls, they laugh and sing all day long." Within a dozen miles v of this little cultivation lies another, similar one; this is run by two single men. It has proved itself a complete success, and these two men are in a fair way to a comfortable, steady income. Now, if these things can be done in one place, they can be done in another ; if one man can make a small-holding a success , another man can the admittedly varying mentality of the individuals being fully met by some such " Supervisors " or ' Visitors," as outlined above. 208 This must suffice, then, for a preliminary outline of the scope of the training suggested ; it is a scope which may be adapted , modified, extended in an exceedingly wide degree, according to what would seem best on a more close and critical inspection. The second aspect from which the subject must be approached is as to the ultimate value to the State of such men doing such work. To put the question more succinctly : " If England sets these men up with individual small-holdings of their own, will England ultimately reap any benefit?" To this there can only be one reply, and that an .emphatic affirmative. In the aggre- gate, the foodstuffs these men would produce would be enormous, and every pound of food grown in the country means a corre- spondingly less amount to be imported from elsewhere, and a corresponding saving to the country. This fact is a weighty one in time of peace, no less than in time of war; the present food- shortage serves but to emphasise its importance. Take the case of Mr. A., already outlined. Grant, first, that a certain number of ex- Service men have already been trained and set up in like manner, and their bee-farms are each fifty hives strong. Taking one year with another, the hives will average 40 Ib. of honey aione per annum and fifty hives would, therefore, yield some t2,000 Ib. of honey alone, which, omitting for the moment the wax obtainable, is a very considerable source of income. Suppose that only 500 men were so trained a very modest figure that would mean the sum of one million pounds of honey produced in England, at a pre-war value of some 50,000, and a present day value of quite 125,000. This, be it noted, from one item alone. Honey is imported from Chili, Peru, California, Jamaica in huge quantities ; none of it is equal to the English in flavour, nor can it command so high a price ; and the consumption of honey is limited solely by the supply. There is a ready market for tre- mendous quantities of it at the doors of the men who cultivate the industry. An acre of Belladonna shows to-day a net profit of 80 ; an acre of Chamomiles yields 75 ; these and many other drugs, readily cultivated in England, have been habitually purchased from the Central Empires for many years past ; they could be a part of the general scheme for the men under discussion. There is the question, too, to be considered that the land which is divided up into smaller sections, each section worked to the utmost of its yielding power, is obviously of more value to every- one concerned than that same land as a negligible portion of a great estate, or employed simply as pasture land over a great period of time. Such a body of men, doing such work, would materially affect the nature of the country's requirements, and would provide it at the same time with a large quantity of pure, wholesome foodstuffs, with no, or at most a very small cost of transport. Another aspect of the value of men engaged in this way to the Nation, and one of no small importance, is in the probable stimulus that the healthy, open life would provide to the National 09 Birth-rate. It is a well-known fact that the average family of a farm-hand is very much larger than that of the city dweller, such ac a clerk or shop-keeper, and, the conditions being so much more favourable, the coming generation would be of a better physique, and hence better able to shoulder the immense burdens that will undoubtedly fall to their lot. If the scheme were adopted, it has already been shown how the men could be trained by a modification of the plan now in force in the " National Herb-Growing Association." Here ladies are accepted for a certain length of time to work at a central drying and sorting depot, and when proficient are employed at other provincial centres. The commercial part of the work is under the auspices of a daughter society, the " National Herb- Growing Industry, Ltd." These could be incorporated as they stand, on negotiation, in all probability, or their methods fol- lowed as the needs of the scheme seemed to permit. (The \vriter would state here that he speaks of the Association and Industry .aforementioned entirely on his own responsibility, and that he has no authority whatever to use their name or to pledge their word for anything they might or might not agree to. He joined their Association in January of this year, in order to gain a first- hand knowledge of their working for the purposes of this paper ; beyond that, he does not know anything of their desires or in- tentions for the future.) There seems no reason whatever to anticipate any difficulty in the training of these men, either in general management of a homestead, or in specific culture, whether that culture be of Bees, Rabbits, Fowls, Garden Produce or Medicinal Herbs. As to the prospects of making such a scheme a self-supporting one, the question hardly needs asking. If it be asked, the answer lies in the fact that men have tried it, and have made it pay entirely on their own responsibility; surely, then, a State- aided attempt on a larger scale should result in a still greater measure of success. That the men w r ould welcome the offered opportunity is w^ell known ; the writer has constantly heard men expressing their determination to "Go on the land ' ' after the war is over, and they are free to do so. If these men cannot find the land they want in this country, they will go abroad for it. Surely it would be to the country's benefit to keep her men at home, and, by helping them at the commencement, and putting them in the way of earning a decent livelihood at the same time, increase the productiveness of their Mother-Country. Organisation, probably on the profit-sharing lines, so success- fully worked by Lord Leverhulme at Port Sunlight, would come as a natural sequence, and the men, properly " nursed," w r ould "be cheerful, healthful, useful members of the community. The scheme is not only a ' ' feasible ' ' one it is a most neces- sary one. Contracts have been accepted by the National Herb- r and the continual engagement 218 of larger forces, the number tends to increase. Thus, for the period 9th February to 8th March, 1918, the number of registra- tions was 10,888, or a weekly average of 2,722; while the placings for the same period were 5,106, or a weekly average of 1/276. Tables showing the registrations and placings for each division throughout the period are appended. In another return the numbers of men registered and placed are shown under the headings of their respective industries. It will be observed that about 50 per cent, of the discharged men who registered applications for employment at the Ex- changes found through the Exchanges their first employment after their discharge. From the available evidence it appears that the remaining 50 per cent, is made up of men who have been able to obtain employment through their own efforts, and of men who find that they are not sufficiently recovered from their dis- abilities to take up employment. Note upon the Determination of the Rate of Wages to be paid to Disabled Men. In the summer of 1916 the Statutory War Pensions Committee invited the Board of Trade, which was at that time responsible for the Employment Department, to make some provision for giving authoritative advice with regard to the rate of wages which should be paid to disabled men. At the beginning of 1917, the War Pensions Statutory Committee was merged in the Ministry of Pensions, and the Employment Department was transferred to the Ministry of Labour. The Ministry of Pensions confirmed the request of the Statutory Committee, and as the result the Employment Department formed experimental Advisory Wages Boards in the 19 principal towns of the kingdom. These Boards consist of representatives nominated by Employers' and Work- men's Associations in the area, and are prepared, upon the appli- ation of any person interested, to advise with regard to the rate of wages which should be paid to any disabled ex-sailor or ex-soldier. In considering the advice which they should give, the Boards have no regard to any pension to which the man may be entitled, and they endeavour to assess the industrial value of the man as compared with a normal workman employed upon the work which the disabled man proposes to take up. The Boards have no powers to enforce their decisions. Up to the present time large use has not been made by em- ployers and workpeople of the experimental Advisory Wages Boards. At the same time, an increasing demand is being made for machinery of this character to assist employers to ascertain the appropriate wages to be paid to disabled men, and there is no doubt that at the conclusion of the war very much greater use will be made of such machinery. Since the Advisory Wages Boards were set up the Ministry of Labour have formed Local Advisory Committees in connection with each Employment Exchange. These committees find it 219 necessary to form " Trade Panels " consisting of employers and workpeople in the principal local industries. It is obvious that these Panels are particularly well suited to advise upon the question of the wages to be paid to disabled men. It is proposed, therefore, to invite the Local Advisory Committees throughout the country to make themselves responsible for giving advice of this kind. The work of the Experimental Advisory Wages Boards will thus be merged in, and extended through, that of the Local Advisory Committees. TABLES. A. SUMMAEY BY DIVISIONS SHOWING THE KEGISTEATIONS AND PLACINGS OF DISCHAEGED SOLDIEES AND SAILOES FOR THE PEEIOD IST APRIL, 1915 STH MAECH, 1918. Division. Number of men registered. Number of men placed. 55,723 25,119 South-Eastern . . ... 17923 9267 South-Western West Midlands East Midlands 17,768 16,930 10,088 14,056 8,396 9,019 6,078 6,751 North-Western Northern 29,005 8,429 14,044 3,881 Scotland 12000 5347 Wales 11 219 5090 Ireland ... c .. 10942 2991 United Kingdom 204,083 95,983 N.B. Registration and placings are only recorded as of discharged men when they are first placed in civil employment (a few days' casual civil work being ignored). When once a discharged man has been placed, he counts as an ordinary civilian for the purpose of Employment Exchange Statistics. B. EETUEN SHOWING KEGISTEATIONS AND PLACINGS OF DIS- CHARGED SOLDIERS AND SAILORS BY TRADES FOR PERIOD FROM IST APRIL, 1915, TO STH MARCH, 1918. No. of men registered. No. of men placed. Building Carpenters, Joiners, &c. Bricklayers 1,147 647 605 331 257 102 Painters, Decorators, &c Plumbers, Glaziers 1,625 300 800 143 220 No. of men registered. No. of men placed. Building continued. Other skilled occupations 477 Labourers 4,357 Construction of works ... ... ... ... 2,418 Sawmilling 528 Shipbuilding Platers, Riveters 392 Shipwrights 114 Labourers ... 2,856 Mechanical Engineering Moulders (Iron and Steel) 461 Smiths 586 Erectors, Fitters, Turners 3,349 Metal Machinists 2,266 Wiremen 639 Other skilled occupations 2,743 Labourers 14,335 Making of Vehicles 797 Cabinet Making, &c. 477 Mining and Quarrying 1.979 Miscellaneous Metal Trades 1^448 Textiles- Cotton 1,245 Wool and Worsted 452 Other Textiles 528 Dress Boot and Shoe Workers 634 Others 682 Conveyance of Men, Goods, and Messages On Railways ... ... .,. ... ... 1,705 On Roads, Seas, Rivers, &c 46,168 Agriculture 2,077 Paper, Prints and Books, &c 533 Wood, Furniture, Fittings, Decorations 232 Chemicals, Oils, Grease, Soap 12,146 Bricks, Cement, Pottery, and Glass 302 Food, Tobacco, Drink, and Lodging Bread and Biscuit Makers 739 Others 836 Skins, Leather, Hair, &c. ... 389 Precious Metals, Jewels, &c. 194 Instruments and Games ... ... ... ... 56 Gas, Water, Electrical Supply, and Sanitary 429 Service. Commercial 12,934 Domestic Laundry and Washing Service 333 Others 8,809 General Labourers 50,343 Shop Assistants 2,181 All others 15,938 TOTAL 204,083 264 2,804 1,653 321 196 67 1,790 263 291 2,098 1,441 334 1,498 10,364 469 194 648 965 533 212 307 315 175 924 19,209 559 207 108 6,230 170 328 359 161 71 21 332 4,847 145 3,674 21,797 660 6,999 95,983 N.B. Regisbrati ms and placing* are only recorded on this form when the man is first placed in civil employment (a few days' casual civil work being ignored). When once a discharged man has been placed, he counts as an ordinary civilian for the purpose of Employment Exchange Statistics. 221 TRAINING AND ITS RESULTS. BY MRS. WOOD, London Local Pensions Committee. ; ' The noblest charity is to prevent a man from accepting charity, and the best alms are to teach and to enajble a man to dispense with alms." (TALMUD.) I have been asked to prepare a paper on "training," but dealing only with the period when the disabled man passes out of tutelage and enters into competition in the labour market, so that, properly speaking, it appears to me that this should be termed " employment " rather than training. I feel considerable difficulty in contributing any suggestions worthy of consideration for two reasons : 1. That the real problems connected with this phase of pensions' work will not arise until after the conclusion of war conditions, and are, therefore, conjectural at present. 2. That the training of disabled men is still so much in its infancy that there has not been time for material evidence to form, nor opportunity for observation to establish, the crucial points connected with it. It would seem obvious, therefore, that any discussion on this subject must be confined to generalities, and aim at foreseeing, and, if possible, forestalling certain probable difficulties, and since prevention is proverbially better than cure, the time of the con- tcivnce will not have been altogether wasted if this is achieved. When does the problem of a disabled man's employment begin? When he is disabled; not, as so often appears to be thought, when he emerges from a course of training. Training is simply a means to an end ; therefore, the attention of all who deal with the men, from the hospital visitor, who talks in general terms to the technical experts who discuss the man's choice in detail , should be directed almost solely to the achievement of this end. The real problem is not so much what a man can learn, or what trainings can be provided by energetic departments, but what will best secure regular employment for each individual. When the men requiring or desiring training could be counted in units the question of the patronage of the trades which they were to enter might appear immaterial, but when the candidates number scores and hundreds it is obvious to all that the interests of the commercial and labour worlds are so vitally concerned that they must be considered; and further, though it is certain that under existing conditions the associations both of employers and employed could be largely ignored, and men could be placed irx employment without their consent and co-operation, if our men are to have the best chance of success in life, they must be 222 absorbed into the recognised corporate life of the trade they have entered as quickly as possible. The attitude of trade organisa- tions, therefore, is clearly one of paramount importance, for if the trade has controlled the general scheme of training and decided the number of men admitted to the course, the trade can reason- ably be expected to provide employment of a permanent character,. and in that last sentence lies the whole test of the soundness of any training schemes, for we are engaged in equipping men for their whole future. Assuming that trade control has been secured, the next problem is the selection of candidates for the various sources of training. It is undeniable that this question, like most other problems that have been conceived of the war and born in haste, has not been scientifically treated. Makeshift measures devised by those who wanted to help, and saw a need without realising the pitfalls, have, as is not uncommon, complicated a question already full of difficulties, and since it is usually easier to set a ball rolling than to stop it, the unnecessary problems so created have now woven themselves into the fabric of our work, and become an integral part of the whole matter. Practice is held to be better ^than precept, but I am increasingly convinced of the desirability of first founding the practice on some reasoned and logical " pre- cept." Now, this is precisely what has not been done in regard to training. An obvious, but almost entirely neglected, pre- caution would have been the deliberate and careful drafting of men into trades allied to their former occupation. Up to date, if a carpenter wishes to become a motor driver, or a plumber a dispenser, the instinct of most of those dealing with this question has been to give him the tuition he wanted, if possible ; and you will find that a War Pensions Committee that takes up a firm attitude in this matter comes in for much shall we call it? criticism in the vernacular ! I have even heard it argued in this connection that there is nothing in the Warrant to justify the refusal of training to a man who has already a skilled occu- pation to which he can return. Now this question will affect the future employment of trainees to an extent it is impossible to exaggerate. The debt owed to the disabled cannot be re- paid, but it can be acknowledged by a constant and unceasing endeavour to safeguard their material future in every way pos- sible, and this will not be done by encouraging dislocation of trade. The training of men who are already equipped with tools they can use in the labour market would benefit nobody, and could not but adversely affect the general question of em- ployment after training. It should, it seems to me, therefore be accepted, firstly, that a man having a skilled trade he can' return to should not be considered eligible for training; secondly, that in the choice of a new trade , primary and invariable considera- tion should be given to the finger posts of his past ; the materials he has worked on , the tools he has been accustomed to handle , the general characteristics of his former calling furnish the best foundations on which to build afresh. Expert workers reap bitter harvests from the unwise advice given to men by uninitiated enthusiasts who descant in glowing terms to some horny-handed: 223 son of toil of the glories of diamond polishing or lacquering, and :the employment of the trainees would undoubtedly be furthered if each man's thoughts were from the outset guided into a channel tributary to his upbringing and custom. Sometimes such a connection is obvious, sometimes difficult to find, but the search for it should never be abandoned until every clue has been sifted and tested ; and if each trade or group of trades could re-absorb men previously employed in one or other of their branches, the problem would dwindle to manageable pro- portions, and this would also tend to prevent the appalling over- crowding of certain occupations, especially of those where no trade control has been secured, and where there is nothing there- fore to check the tidal wave one watches horrorstruck but impotent. For instance, probably every worker has found that there are one or two professions endowed with a sort of halo by those outside them. Leave the candidates for training unguided, and 90 per cent, of them will demand Motor Driving, Electrical or Clerical Training, whilst probably not more than 5 per cent, of them are suitable for any of these, or will ever stand a chance of holding their own in an overstocked and keenly competitive market. And, like the stone thrown into the pool with its ever widening circle of ripples, so a lack of discretion and firmness in the initial stages when the choice of training is under dis- cussion, will wreak harm far beyond their first obvious results. An " overstocked and highly competitive market " means struggling by all and any means to keep a footing, and remember our trainees will all have their pensions. Beaten in fair com- petition, that pension may be used as a weapon to enable them to fight, and there we are immersed in the whirlpool every thoughtful man and woman is striving to avoid. A pensioned man has, in the eyes of the labour world, the same ominous possi- bilities as female labour, child labour, or alien labour. A further safeguarding of the employment question would result in the finding of some solution for the problem of those who can never compete on fair terms, however scientifically treated. The ranks of these are supplied mainly from two channels those who are handicapped by the severity of their disablement, whose plight arouses keen and instant sympathy, and those who are not fortunate enough to make such appeal, namely, the men whose physical strength was their only real asset, who return from war service with this asset seriously im- paired, and whose intellectual standard, age, and upbringing- render them practically untrainable. Unless the State steps in and provides specially equipped workshops, agricultural colonies and the like, it is difficult to see what can be done for these un- fortunates. More has been done abroad than in England in this direction, anyhow for the first category, and it has been found possible, by means of specially devised tools and appliances, to employ severely disabled men both on the land and in special factories. It is held by some that there would be great opposition io such a suggestion, because these establishments would un- doubtedly have to be subsidised, but since the cost of production 224 would be so high as to exclude the possibility of their entering into competition on a commercial basis, I do not see why any criticism based on the fear of unfair competition, could not be met. Even when all possible preliminary care has been taken in the guidance, selection and training of individuals, since it is im- possible permanently to earmark certain trades for disabled men T the time will come when they will have to face competition, whether they are absorbed into the ranks of an established industry or encouraged as pioneers of a new trade. War conditions have engendered a touching belief in the value of tabloids, our nourishment, our medicine, our holidays, our trainings, everything except our taxes and our committees are taken in compressed form. And so every disabled man is taught a new trade on the cramming system. It is inevitable that this should be so, for the full-grown man, probably with dependants relying on his earning capacity, cannot afford to give years to learn his craft, like an apprentice who enters the arena as little more than a child. The rapidity with which men skilled in one trade can acquire the technicalities of another is a constant source of surprise and wonder, but, all the same, certain difficulties have already shown themselves. A man working in a technical institute under supervision , with his income assured , and his work subject only to instructive and helpful criticism, has a security and peace of mind which cease as soon as he becomes a com- petitor in the labour market. Bereft of the instructor's support T he becomes less sure of himself and works slower ; working only on one process perhaps for some time, he loses what he thought he had learnt of another, and wiien called upon to practise it finds he needs almost to relearn it : thus, a man who topped the class in the technical institute finds- himself handicapped when pitted against men with years of experience and skill. Person- ally, I believe it will be found necessary to bolster up most trainees when they emerge from training in a technical institute r and that the recognition of a sort of kindergarten period in tho man's workshop experience will be found essential. To what extent employers will be prepared to countenance this after the cessation of hostilities remains to be seen, for it must not be for- gotten that at present we are only faced with the task of fitting men to take up jobs which will otherwise probably remain nn done, whereas we shall then be faced with the fitting of men to compete with other sources of supply, and the employer who recognises his debt to the disabled man may find himself handi- capped in production, through the complications of questions of insurance, compensation, &c., coupled with the alternative supplies of labour wiiich the less conscientious are prepared to take advantage of. It has been suggested that every big firm should be approached and asked to absorb a definite percentage of disabled men, ant"' if sufficient support were given to such an idea it might be of substantial assistance in relieving anxiety as to the permanent provision for the men whose future we are all anxious to secure : 225 such support would undoubtedly be easier to obtain if the sug- gested principles as to the selection of men were generally accepted. It may be asked how the machinery of Local War Pensions Committees which has been devised in this country, is concerned in this matter. I should say that they ought to act as junctions in what may be described as shunting operations. The Local War Pensions Committee is, after all, more often than not the first responsible authority with executive powers to come into contact with a discharged disabled man. It is up to the War Pensions Committee, therefore, to see that the schemes of training are based on a sound , well reasoned general policy ; that this policy is carried out, that the best possible advice is available to direct the man's thoughts, that the means for providing the training recommended are available, that the whole question of training is considered in conjunction with that of employment, and, therefore, that other State Departments already occupied with that subject generally are brought into such close relation- ship that their valuable experience and organised machinery are available for the benefit of these men. The importance of dealing with all social problems on a human basis is more and more acknowledged, and those whose privilege it is to work for the war disabled have their great opportunity in the fact that their duties bring them into immediate and intimate relations with the daily lives of the men and their families from the time the nation's service first claims those men, and the War Pensions Committee whose job is properly done will find that its official functions are soon lost sight of, that it becomes a sort of domestic William Whiteley, universal provider of all that is needed, because its visitors and workers are absorbed into the homes they go to until they are no longer giving, but sharing. If proper use is made of these opportunities, the disabled man will not only go to his Local Committee, but he will go with the confident expectation of getting practical help inspired by sympathetic interest; and if his family have already told him that the com mittee, or as it will more probably be described " the pensions* lady," has helped them to surmount this or that difficulty, has smoothed the awe-inspiring intricacies of official correspondence, and has mysterious but infallible powers behind her which are demonstrated in various but gratifying manner, that man will probably be prepared to listen to the visitor's advice, and can thus be put into the right train and speeded on his journey. lG.->24 226 STATE AND LEGISLATIVE PROVISIONS FOR THE PLACING OF WOUNDED SOLDIERS IN ITALY. BY DIEGO MAETELLO. General remarks. If the question of placing wounded soldiers has constituted and constitutes for all the belligerent countries one of the most interesting sides of the complex problem of pro- viding assistance for those rendered unfit by war, it has assumed particular gravity in Italy, where, though faced with a fewer number of disabled men, the general economic disturbance is greater, and there is a minor possibility of utilising the human labour apart from the diverse forms of industrial and commercial activity. Fortune, however, has willed that the students of the problem, perceiving these great difficulties from the first, should have directed the professional re-education of the disabled men towards those trades which can be most readily practised in the home, so that, on the completion of the first cycles of re-education, the number of the disabled men to be placed was less than what might have been reasonably presumed. It might have been still less had not all those obstacles of a highly different nature so well known to the students of the professional re-education problem prevented a vaster and more immediate placing of the disabled men in the agricultural schools. In any case the question of placing at once found all the various committees and local institutions for the assistance of those dis- abled in war well prepared, upon whose help it has now been demonstrated that one must rely for the success of the work. They provided an abundance of means and enthusiastic fervour, constituting offices and special commissions, and co-ordinated their own action with that of the other organisms that might be able to help them, organisms such as the public offices already having for object such form of assistance, the commercial and industrial organisations, the trade guilds, the committees of industrial mobilisation, &c. Then, in the process of time, the necessity of harmonising such action and co-ordinating it with a greater unity of direction was recognised, and for the work of the National Federation of the Committees, a central office for employment was constituted that quickly gave truly remarkable results, thanks to the help accorded by the various Ministers, especially the Minister of Munitions, who has charge of the organisation of all the war industry. To these various initiatives later came that of the National Association of the Disabled in War. Among the different forms of assistance provided for their own members, they had not over- 227 looked the great essential item, viz., the employment of its members. The intervention of the Government and the legis- lator, however, was not quite so ready. This is, perhaps, a phenomenon common to all other countries, which might be explained by the natural spontaneousness of private initiative as against the inevitable slowness with which the bureaucratic machine moves. The legislator whose duty is normally to check, guide and integrate the manifested activities of the national life is forced to proceed with this machine. Though delayed, this activity is not, however, less worthy of note, first for the principles which have inspired it, and then for the complexity of the dispositions with which it has materialised, dispositions that in their one aim of defining and guaranteeing those positions of right with which it is thought to be a duty to invest the glorious men disabled in war, as a tangible pledge of the nation's gratitude. It is on this work that we intend briefly to dwell, leaving to others the task of illustrating how much has been done in the same field of work by spontaneous private initiative. Legislative precedents. Legislative remedies in the matter of employment at first were, as was natural, sporadic and fragmentary. The dispositions contained in the Eoyal Decrees, March 12th, 1916, No. 307, and April 9th of the same year, No. 400, belong to this first period. By these decrees, to the derogation of the prohibition of recruiting new personnel in the public adminis- trations, a prohibition, be it understood, to protect the' public exchequer and at the same time to safeguard the rights acquired by the various classes of Government servants there was con- ceded the faculty of assuming temporarily, with the simple object of guaranteeing the continuation of the public services, the necessary number of substitutes. At the same time it was deter- mined that, in the procedure of engaging such substitutes, the preference should be given to those who had , been disabled in war. Henceforth there were repeated demands on the part of those who had the wellfare of the disabled at heart that their future should -be better provided for; and since, in the meantime, the number of re-educated disabled, calling for their place in life again, was gradually increasing, the Government, ever aiming at a solution of the problem, with the presentation of a project of law containing greater and wiser provisions for the placing of such men, provoked the promulgation of the Eoyal Decree, August 10th, 1916, by which, while for the first time giving a series of organic regulations for the assistance and protection of the disabled, disposes that the institutions, on determining on such form of assistance, not only should see to a more rigorous application of the two above Decrees, but should also take care that the disabled, as soon as trained, should be admitted into the Army and Navy as well as to public employment. The institu- 16524 H 2 228 ti-ons should, furthermore, see to their re-admission to private firms, invoking in regard to the disabled the dispositions provided by the legislator in favour of those recalled to the colours, dis- positions of which more will be said when the laws instituted for the national work for the assistance of the disabled in war are taken in examination. To give practical application to these Decrees the Government provided for the drawing-up of temporary instructions by which it aimed at regulating the relations between the Institutions for Assistance and the Minister of War for the keeping of a general current list of the disabled ready for employment, and also between the said Minister and the other public bodies for the eventual assumption of temporary personal, giving preference to the disabled. The said instructions furthermore disposed that the inspectors of industry and of labour should interest them- selves in favouring the filling-up of vacancies in industrial estab- lishments through the local employment bureaux. It was also fully established that, wherever these disabled men were employed, they were not to be placed in competition with the other workers, especially as regards wages. Thus the formulated principle was consecrated, not without discussion, at the Congress of Paris : Equal production, equal salary. But specially worthy of note in such temporary instructions is the disposition in force according to which, for the first time, came to be formally prescribed the sending out, first of all, to the various sections of concentration and to the various training schools later, according to the regional circumscriptions, it was established that the disabled should be sent to the sections and schools instituted in the Army Corps territories where the respec- tive families had their habitual residence. Thus indirectly and automatically were created those favourable conditions of atmos- phere upon which to a large extent depends the success of the work of employment. The new law. These, in brief, are the dispositions pub- lished by the Government on the subject of the finding of employment whilst awaiting the approval of the Chambers of the project which was presented in June, 1916, and which, after various parliamentary incidents which we cannot go into here, finished by becoming law 25th March, 1917, No. 481 of the Opera Nazionale per la Protezione e 1'Assistenza degli Invalidi della Guerra (National Committee for the Protection and Assistance of Disabled Men). As is known, the new law started a national corporation, supplied with ample faculties and destined essentially to co- ordinate, integrate and discipline the work carried out by the Local Committees, to whom the real task of administering assistance is entrusted. The greater part of the dispositions contained in the text of this law are therefore intended to discipline the constitution, the 229 attributions, and the working of the two orders of institutions, and also to establish the relations of interdependence of the same. At the same time there are those rules which are intended to determine and protect the different rightful positions created for the disabled men, also under the preceding legislative dispositions. The finding of employment, as all the principal other forms of assistance, has therefore been entrusted to local committees and institutions. The law has not thought fit to create any new organisation, and we think this opportune : it has limited itself to ensuring the regular, working of the organs already existing, completing them wherever deficient, substituting them wher- ever unequal to their aims, creating them wherever they had not been instituted, controlling and co-ordinating their action and consistency, lastly coming to their aid with those grants which the legislation already in vogue with regard to labour, agriculture, industry and commerce could offer. By co-ordinating the dispositions already published with other new ones, the law governs in a practical manner the favourable treatment to be granted to the disabled men both in public and private employment. Such dispositions, which we will now rapidly examine, have for substance the following principles : Continuance of military service, re-admission into public offices, facilitations for the application for new posts , re-employment with private concerns. Retention in the Army. According to the new law, soldiers, who in accordance with the dispositions in vogue have been declared disabled, may, when their disablement allows them to, remain in the Army if the Military Authorities consent. Such a disposition was expressly placed before all others, almost as an honour, it being a unanimous conviction, as affirmed in the senatorial report, that the unfit who have already worn the honourable military uniform should wish, when they can and when they are allowed to, to belong to the Army or Navy, as they have well deserved. But this not only succeeded in performing a duty towards these disabled men, but evidently aided in a great measure to the discipline and contributed to the credit of the Army, as the permanency of the glorious heroes of war in its ranks con- stitutes a precious element of incitement to action and fervid love for one's native land. > For the practical actuation of the new law, the Decree of the 14th of June, 1917, No. 1032, was published, and this established a distinction between soldiers who, in spite of their disablement, can continue in active service and those who are instead only able to undertake sedentary work. The former ma} 7 , almost without exclusion of rank and in an unlimited number, after the suspension or repeal of every pro- vision for pensioning or permanent discharge, be taken back into the Army, passing, however, into the reserves. 16524 H 3 230 For both these categories, however, their respective rights to advancement hold good; and both, during the whole of the period they are serving, will have the right to receive, over and above the privileged pension, the salary due to the officers in permanent active service of equal rank of the same corps. Both of them, in addition, although being able to remain in the service right up to the age limit generally prescribed, may at any time ask to be pensioned, and they will in any case have the right to add the privileged pension already obtained to the pension due to them for the period of service subsequently given. Special detailed rules, of course, regulate the manner of estab- lishing the physical fitness of the applicant as well as the terms of the request to be reinstated into the Army. Facilities icitli regard to the re-admission and admission into public offices and works. The facilities which the law grants in this section may be divided into three categories : the right to re-admission into the offices, the bestowal of posts without com- petition and the preference in competition where talent or attainments are equal. With regard to the re-admission into the offices, the law pro- vides that the disabled man shall be re-admitted into public offices where they were employed at the time of their being called to the colours for the present war and for the non-militarj* at the time of the act of war which caused their wounds, providing they have re-acquired the capacity to lend useful service. It should be noted in this regard that the project of law limited this right only to those soldiers who had been trained and exclusively with respect to the post previously occupied. The Parliamentary Commission very wisely suggested that the original text should be modified in the sense of extending the privilege to the non-military rendered unfit by acts of w r ar and to consent to the re-admission being effected, according to the physical conditions of the disabled man, either for the post which he alreadj^ held or for one under the same conditions more adapted, provided it be of equal rank or grade. Another wise provision is that regulating the application of the law under examination, on the basis of which the disabled man who resumes his old post, or is admitted to a post of a correspoding rank, in every respect continues his former service. Nor less wise is the proviso in virtue of which the posts already held by disabled men may not be permanently occupied until a definite decision has been given on the request of re- admission on the part of the unfit person or until the period granted for the presentation of the request has already elapsed without such a petition having been made. Of course the re-admission to service is subject to the appli- cant being recognised as being physically fit, for which purpose a medical certificate will be required, and, if necessary, special examinations as well. 231 The bestowal of posts without competition was limited, on the basis of the Decrees which were mentioned in a former passage, to certain cases. It was, thanks to the unanimous insistence on the part of the various interested institutions, that the legislator was induced to extend this privilege to fixed posts, limited, naturally, only to posts of a lower category, it appearing neces- sary to tranquillise with regard to their future those who had sacrificed themselves so much for their country and who have, besides, almost always given such tangible proofs of tenacity and love for work in the apprenticeship lasting for some time in the training schools. With this object the law provides that, as a rule, there should be indicated the kind of employment which, derogating from the existing laws, the Government could have conferred upon dis- abled men without competition, with the exception, however, of the posts of a higher grade and of the administration. In the regulation published in August, 1917, there were inserted the tables giving, for the various Ministries, the different grades, of employment to which the disabled man might have access by direct application, either to the central offices or to the pro- vincial ones ; for each grade there is given the number of posts to be assigned to disabled men both in proportion to those free and in proportion to the total number for each category, so as to avoid, in connection with the more or. less complex nature of the employment, any danger of perturbing the course of the public service. And since preceding dispositions prohibited, during the period of the war, the admission of new employees, it was also very wisely decided that exception should be made in favour of the disabled men in order not to delay their chance of reaping the benefit of the privilege sanctioned by the legislator. The procedure for the admission is very simple. The appli- cants simply have to present their petition to the " Opera Nationale," furnishing such documents as prove that they possess the qualifications prescribed for each of the posts in the respective administrations ; the latter then choose from the various appli- cants those whom they consider most adapted by their qualifica- tions for the vacancies. Preference in competitions and special competitions. Another facility granted by the law is that on the basis of which the condition of being a disabled man constitutes a right to pre- cedence, in the case of equality of talent and qualifications, in the graduation of the competitions for admission to public employments. And a last facility is that consequent on the faculty conceded to the single administration departments to establish rules and regulations for the bestowal on disabled men, by competition, of employment not included in the table of which mention is made above, provided they are not of the higher grade or 232 connected with the accounts department ., on special conditions . not excluded the eventual reservation of a part of the said posts exclusively to the disabled man. Facilities of a general character, always in connection with the re-admission and admission into public offices and works, have also been granted both by law and by rules and regulations. Among these the following are worthy of mention : (a) The faculty granted to the public administration to derogate, when it is considered opportune, in the interest of the disabled men from the age limit estab- lished by their respective regulations for the nomina- tion and admission to the competitions. (b) The regulation in view of which by preference and pre- cedence shown the disabled men for admission into . public offices, they are placed before all others. (c) The right to add the privileged pension to their salary, during service, and to the civil pension when pen- sioned off. (d) The possibility of obtaining bonds for those employees for whom it might be required , by allotments from the war pension or from corresponding temporary allow- ances, in such a measure, however, as not to exceed one-third of the sum annually paid under this heading. Admission to private concerns. With regard to the treatment to be received by disabled men in connection with their re -admis- sion or admission into industrial concerns and commercial offices, the legislator was confronted with much greater difficulties, as it was a question of invading private territory. As is known, the question has been long discussed also at the Congress at Paris, which finished by deciding that it should be left to the legislator in the various countries to determine whether firms could be forced to employ disabled men. limiting themselves to expressing the wish that a moral obligation might be felt on the part of the private firms to engage the disabled men in a number proportionate to the importance of the respective concern. The question was resolved in a different manner in the different coun- tries ; in some, as in France, it was established that the industrial and commercial firms should not be able to obtain a concession, monopoly or subsid}* from the State, or from public institutions unless they reserved a certain number of situations to the dis- abled men according to the limits of their obligations. This necessitates complex regulations, with detailed instructions and tables to establish according to the capacity, infirmity, depen- dents, &c., the right to the different posts. Before such complications and difficulties the Italian legis- lature did not think fit to study the problem radically, and con- sidered it to be sufficient to extend to the disabled men the regulations which by a Decree of May, 1916, had been adopted in favour of the employees of private firms called to the colours. On the basis of this disposition, in the firms who habitually kept more than two employees, who, after having been in the same 233 firm for at least one year, are called to the colours, the employ- ment contract holds still, although suspended until the end of their military service. The disabled men who find themselves in this position have, therefore, the right to be re-admitted to the occupation or position occupied previous to being called up. It is, however, necessary that they should give proof of the re-acquired physical ability necessary to carry out the duties entailed, and that they should forward their request to the firm within one year from the cessation of war, both in the interest -of the private firms, on which for reasons of social utility a restriction of privilege is imposed, and of the employees who may have been taken on for a temporary period in place of those -called up. It is to be noted that such privilege is also due to the disabled men who may have been discharged previous to being called up, should they be able to prove that the discharge was determined by the express* desire to evade the obligations of the law ; and let it be noted that the obligation, in the case of transfer, is assumed by the purchaser or licensee of the firm. Instead, principals who do not employ more than three persons are not affected, provided they themselves are called up. Of course, the larger extent of favour accorded either in virtue of local customs or by spontaneous concessions on the part of the firms remains unchanged. Still dealing with the question of the employment by private firms, it is well to notice the regulations with which the Italian Government, bravely facing a problem long discussed elsewhere, has decided that the institutions who take out insurance for workmen against accidents whilst at work, should in their relative contracts insure, without exception, all the workmen engaged on the contract, including the disabled men, without right to exact an extra premium except a slight increase to be established by the competent Ministry when the number of disabled men exceeds 10 per cent, of the total number engaged in the industrial factory or on the contract for which the insurance has to be effected. Conclusion. From the foregoing it appears that the legislative dispositions can be grouped into two distinct classes ; the first intended to govern the working of the central and local organs already constituted, or about to be constituted, in order to obtain unity and practicability of action ; the second intended instead to specify and guarantee the single, rightful and favourable positions created for the disabled men, especially in the matter of public employment. This second class of regulations and dispositions has, without doubt, minor importance, as the opinion in every country is now agreed that the smallest number possible of disabled men should be allowed to enter public service, exceptions to be made for those who, on account of the seriousness of their wounds, cannot be considered capable of earning a livelihood in another manner. The carrying out of these decisions has been entrusted, princi- pally, to the various Ministries, and, although the legislation in question is of very recent date, it cannot be denied that it is in -a great measure complete. 234 The work effected by the Ministry of Munitions is, for instance, worthy of special mention ; it has even gone far beyond the restricted circle of its duties, organising a vast service for the finding of employment, instituting schools and special workshops for disabled men, furnishing machines and material gratis, study- ing every possible opportunity for perfecting working instruments, tools, &c. The first class of dispositions is, however, very much more im- portant, as, for instance, that on which really depends the solution of the complex problem of finding employment. As has been said, our legislation, in agreement on this point with that of other countries, has not thought fit to create special organisations. It has entrusted to the " Opera Nazionale," already entrusted with all the other forms of assistance to the disabled men , also the task of finding employment, determining that advantage should be taken, also in this respect, of the work of the local committees. On the organisation of the work and on the aims to which it should be directed the legislator has not thought fit to impart special instructions ; nor, it should be said, did that enter into his attributions. But it is just in this very important and delicate circle that the sagacity of those representing the " Opera Nazionale " will be tested. In order to avoid that all the efforts accomplished up till now should be frustrated, and if it is really desired to create a morrow on which the illusions of to-day should not fall to the ground if, in short, it is really desired to provide lastingly and usefully both for the disabled men and for the country, it will be necessary for the new organisation to take advantage of all the means which have been so providently furnished by the law in order to avoid that the action of the local institutions becomes inconsistent, chaotic and sterile. It is, too, easy for empiricism to reign in a circle of activity such as this. It is necessary that the experience of the past and the fruits of the studies completed should be taken as a guide in the direction of the action of those organisations. It is necessary that with each of these the grave and serious task should be entrusted to com- missions and special offices, composed not only of willing persons, but also of men familiar with all the difficulties connected with the labour problem. The action of these offices will be multiform and complex. They should above all have a precise idea of the importance of their duty, and should be well acquainted with the conditions of the centre in which they have to accomplish their task, so as not to cause a loss of balance between the offers and requests of situations regarding each special category of industrial or com- mercial activity. They should then not only intervene when the training has been effected, but start right from the beginning of the time when assistance is granted to the disabled man, deciding technically the profession which can be followed by the disabled 235 man in relation to the exigencies of the different species of work and of the diminished physical conditions : they should inform the disabled man as to the real conditions regulating the work in the factories, overcome all prejudices, convince them of the utility of training, of the right they hold to war pensions, &c. When the training has been accomplished, the offices should have care that the necessary period for the medico-legal arrange- ments should be reduced to a minimum, so that the pupils may be employed as soon as possible. Arrived at the moment of the choice of calling, they should take into account, opportunely graduating them, all the co-efficients which may contribute to such a choice and which have already been brought to light by the students of the problem ; and also they should preferably employ them in their former profession and possibly in the same country in which they previously followed it or wherein their families reside ; reserve the posts which require less effort to the more seriously wounded ; concern them- selves with the stability of the employment offered to them : induce them, where necessary, to take a period of complementary training; afford them, in short, all the assistance which may serve to facilitate their return to new life and work. And all this should be done, at the same time trying to take advantage of the already existing means, avoid duplications, co- ordinate their action with that of other public and private organisations, thus awakening the attention and interest in the problem of all those who may be of use in the resolution of the same. This is the labour programme which should be the aim of the new institution created by the Italian legislature, if it is desired that the gratitude of the country should be really translated ? even in the national interest, into a concrete and lasting benefit. CONGRES INTER-ALLIE POUR L'ASSISTANCE AUX INVALIDES DE GUERRE, LONDRES, 1918. L'Oeuvre des Commissions Regionales Italiennes pour le Placement et la Tutelle apres la Reeducation. PAR M me LE DOCTEUE OLGA MONSANI. La derniere, par ordre de temps mais non pour son import- ance, est la partie de 1' assistance aux grands blesses qui se rap- porte a leur placement. Quelquefois on doit s'en occuper des leur depart de 1'hopital, si le soldat croit pouvoir reprendre an moins partiellement son ancien travail, ou se mesurer a une certaine tache sans une preable reeducation professionnelle. Les initiatives privees ont devance 1'oeuvre da legislateur et celle qui vient de s' organiser 1'CEuvre Nationale pour ce qui se rapporte au placement des invalides de guerre reeduques ou non. Et cela est naturel. Les lois reglent selon des principes generaux les faits qui chaque jour se repetent ; et un pouvoir central comme celui de 1'QEuvre Rationale nait le jour ou on sent la necessite de coordonner et harmoniser entre elles les institutions du meme genre eparses dans les differentes regions d'un pays. D'abord lorsque les premiers invalides laisserent nos hopitaux r lorsque les premiers notes peuplerent nos maisons de reeduca- tion professionnelle, les differents Comites et pour eux leurs membres les plus influents ou ceux de meilleure volonte s' em- ploy erent pour trouver du travail a ces blesses. Mais les mois s'ecoulerent : notre guerre prit des proportions bien plus vastes ; nos hopitaux compterent par centaines les soldats qui n'etaient plus aptes aux armes. Les Comites pour 1' Assistance aux in- valides de guerre, qui s'etaient formes dans les principales villes d'ltalie, avaient deja pris en consideration deux des principaux problemes qui se presentent a qui veut recuperer la plupart des energies morales ou materielles de nos blesses : la question de la pro these et celle de la reeducation professionnelle. En troisieme lieu il fallut considerer la question a laquelle aboutissent les autres : le placement. Ce fut le Comite Florentin qui, le premier, a la fin de notre premiere annee de guerre, en decembre 1915, reunit une Com- mission speciale qu'on appela de patronage et de placement. Cette Commission, sous la direction d'un des apotres les plus ardents de la reeducation professionnelle, le Professeur Ettore Levi, commen^a son apprentissage dans Thopital de Villa Bondi, qui bientot eut aussi des ateliers pour la reeducation. L' appren- tissage fut assez long. La Commission de Patronage et de Place- ment se developpa ainsi en mme temps que les autres ceuvres 237 pour 1'assistance aux invalides de guerre de Florence, et son travail s'harmonisa avec 1' ensemble de ces oeuvres. Dans les annees suivantes, les autres Comites italiens for- merent des Commissions analogues et aujourd'hui nous en avons outre celle de Florence, a Genes, Milan, Padoue, Palermo et Turin, tandis que dans d' autres villes comme Ancone, Bologne, Livourne, Modene, Naples, Parme, Pise, Spezia et Eavenne les Comites pourvoient au fur et a mesure au placement des invalides qui rentrent chez eux, sans qu'une commission speciale s'en charge. En general les membres des Commissions de placement sont choisis parmi les personnes qui s'occupeiit des invalides soit dans les hopitaux soit dans les maisons de reeducation et parmi celles qui ont le plus de relations dans le monde du commerce, de 1' Industrie ou qui disposent d'un certain nombre de relations per- sonnelles. Le nombre de ces membres varie d'une ville a 1'autre, mais en general il est plutot restreint. Et cela est utile, car, dans les commissions executives comme celles-ci, il est preferable d' avoir un petit nombre de personnes bien appuyees sur un cercle de relations assez etendu. Ces personnes doivent rester le plus longtemps possible en contact avec les soldats blesses, meme pendant leur traitement et leur reeducation pour chercher a les persuader et a les acheminer au travail. Dans cette oeuvre elles sont aidees et dirigees par les medecins qui en general ont beaucoup d'influence sur 1'mvalide qu'on veut recuperer. Je ne sais exactement ce qu'on fait dans les autres villes d'ltalie pour cette partie delicate de 1'assistance qui revient aux Commissions de Patronage et de Placement. A Florence, oii j'ai vu effectuer ce travail des le commencent, on n'attend pas que 1'invalide soit parti de 1'hopital et vienne chercher du travail. Je crois qu'on fait de meme, dans les autres villes, ou qu'on le fera des qu'il sera possible. A Florence, les membres de la Commission, avec la permission des autorites militaires, se rendent plusieurs fois par semaine dans I'hopital ou sont reunis les mutiles. Us s'occupent de tout ce que les mutiles peuvent avoir a reclamer des administrations militaires pour eux-memes, des comites civils pour 1'assistance aux families &c., et au fur et a mesure que s'approche le jour de sortie de ITiopital pour ces mutiles, on discutent avec eux sur les conditions qui les attendent dans la vie civile qu'ils doivent re- prendre. On leur dit tout de suite qu'a tous moments on sera pret a les aider, a leur donner les informations, les secours dont ils pourront avoir besoin. Pour les estropies on a adopte d'abord le meme systeme que pour les mutiles ; mais les resultats ainsi obtenus etaient par- faitement negatifs. Pendant la periode de traitement, quand 1'estropie ne sait pas encore parfaitement le degre, 1'invalidite qui mi incombe, il est pen inclin a admettre la possibilite d'un travail plus ou moins charge et souvent il craint que la reeduca- tion puisse lui enlever le droit a une pension de guerre plusiorte. 238 La Commission Florentine pendant de longs mois continua a se rendre aux hopitaux des estropies, mais il lui fut impossible de gagner la sympathie et la confiance de ces derniers, comme elle avait obtenu celle des mutiles de Villa Bondi. Une premiere experience non-reussie ne devait pas nous decourager : en effet une autre solution fut vite trouvee et qui a donne jusqu'a present d'assez bons resultats. Un changement psychologique profond se produit dans 1'in- valide estropie de la veille de la reforme au jour suivant. Une fois la derniere visite medicale passee, une fois la pension accordee et acceptee, le sol'dat qui sait desormais sur combien il peut compter commence a regarder 1'avenir qui 1'attend. II ne veut pas y songer avant. Tout de suite apres, oui ! Une fois que la Commission Florentine eut fait cette constation elle demanda aux autorites militajres d'envoyer les soldat s invalides, a la veille de leur depart de 1'hopital et apres leur reforme, au siege du Comite, pour etre interroges par les membres de la Commission. C'est peu en comparaison de 1'obligation d'un sejour plus ou moins long dans une maison de reeducation, mais c'est deja quelque chose. II semblait d'abord que les autorites militaires auraient eu des difficultes a nous accorder cela. II n'en a pas ete ainsi. La decision a ete prise rapidement et depuis un an elle donne ses fruits. Chaque jour un nombre assez considerable de soldats reformes vient devant la Commission et ce sont desormais les soldats memes qui nous demandent des informations, des avis &c. Dans plusieurs cas 1'oeuvre de la Commission a ete providentielle. Sauf de rares exceptions la Commission ne conseille jamais a un soldat de se rendre immediatement a une maison de reeduca- tion. Nous savons qu'il desire surtout rentrer chez lui. Et encore, a notre avis, il ne serait pas utile. La puissance de readaptation au travail de 1'invalide est immense quand c'est 1' amour pour sa famille qui 1'y pousse. L'invalide qui retrouve sa maison, son champ, son atelier peut souvent se rendre tres utile dans sa famille d'une fa9on que ni lui, ni nous n'aurions pu prevoir. II serait nuisible de le distraire de cette premiere et simple solution du probleme de son existence. Mais il y a aussi tous ceux qui ne trouvent pas chez eux et dans leur pays une faon de se rendre utiles et ceux-ci doivent savoir que les maisons de reeducation existent et en quoi elles consistent. On doit donner a tous 1'adresse du Comite d' assistance le plus proche et tous doivent savoir que s'ils ne reussissent pas dans leur tenta- tive individuelle , si 1'oisivete leur pese, ils peuvent eloigner le fantome du desespoir, car soit dans leur region, soit dans celle ou ils ont ete soignes il y a toujours quelqu'un pret a les aider. Dans le second semestre de 1917 un millier environ d'invalides sont passes au siege du Comite Florentin. Les resultats obtenus sont deja reconfortants et on peut esperer qu'ils seront meilleurs en avenir. II resulte des rapports des Comites italiens que cinq cents invalides par suite de blessures 239 de guerre sont places. Ce chiffre est bien loin de representer le nombre d'invalides reellement au travail. Tous ceux, et ils sont les plus nombreux, qui sortent de 1'hopital en declarant pouvoir se passer de la reeducation et trouvent effectivernent a se placer en debors de notre aide, n'y sont pas compris. En tenant compte de tout ceci, le nombre de ceux qui ont ete effectivement recuperes au travail est certainement plus considerable. Le placement est assurement plus facile dans les centres in- dustriels; les Comites de Turin, Milan, Genes et meme Livourne l'affirment. Dans ces villes la recherche de la main d'ceuvre, meme des invalides, est superieure a 1'offre. Le bulletin publie a Home par les soins de la Federation des Comites contient tous les mois une liste de places offertes aux invalides de guerre dans les centres sus-nommes. Une partie de ces places reste souvent inutilisee, car les soldats reformes ont en general un vif desir de rentrer au pays et les Commissions de placement se gardent bien de les en detourner. On est generalement d'accord en Italie sur 1'utilite de remettre autant que possible 1'invalide de guerre dans le milieu d'ou il est sorti, de le rendre capable d'un travail analogue a celui auquel il s'adonnait avant la guerre, ou au moins a un metier qu'il puisse exercer dans son pays. Pour les soldats qui ne restent pas dans la ville ou ils ont ete soignes on se met en rapport avec les autorites des lieux de leur residence : maire, prefet, cure, medecin, ou avec les institutions locales de bienfaisance qui peuvent 1' aider sur place. Naturellement ce travail de placement ne se fait pas d'une fagon identique dans toutes les villes d'ltalie, mais les principes qui le dirigent sont a peu pres les memes. Le document fonda- mental est une fiche individuelle qui contient les indications necessaires sur les conditions physiques et psychologiques du candidat et aussi sur son precedent travail, sur ses aptitudes et sur sa capacite. Ces renseignements sont etablis d'apres le jugement soit des directeurs de 1'hopital ou de la maison de re- education d'oii le soldat sort, soit de 1'avis des membres des Com- missions de Placement, parmi lesquels se trouvent des medicins specialement competants en matiere d' accidents de travail et de reeducation professionnelle des invalides. Ces fiches forment le noyau d'une statistique qu'on pourra completer le jour ou le recensement des invalides, que 1'CEuvre Nationale vient d'initier, sera complet? Cette statistique sera la base d'un travail neces- saire de tutelle que les Commissions de Patronage et de Place- ment devront continuer meme longtemps apres la reeducation et le placement. L'ceuvre des Commissions est plus ntile pour les placements dans la ville meme ou elles sont constitutes et surtout dans les milieux industriels et commergants. Pour les emplois dans les administrations publiques on s'en est occupe jusqu'a present, mais dorenavant 1'CEuvre Nationale a pris pour elle de faire suivre et appuyer les demandes qui lui sont adressees soit a travers les Comites regionaux, soit directement des invalides. De ceci, comme de tout ce que 1'CEuvre Nationale a fait et se propose de 240 faire en matiere de placement M e D. Martello de la Commission de Milan cfira plus largement dans son rapport. Les Commissions de Patronage se tiennent naturel lenient en rapport avec toutes les autres institutions analogues. Dans les villes industrielles elles utilisent des listes d'emplois regulierement transmises par les Comites de Mobilisation Industrielle, et en meme temps elles maintiennent d'etroites relations avec 1' Association Nationale parmi les invalides de guerre, ou parvien- nent aussi des demandes et des offres d'emploi. Sou vent cette Association est represented dans les Commissions memes, de faon a eviter d'inutiles dispersions de forces et de facheuses repetitions, dans le meme centre, d' institutions ayant les memes buts. Pour la qualite des placements en Italie on peut dire d'abord que les invalides provenant de centres ruraux retournent pour la plus grande partie au travail des champs, sauf dans le cas de mutilation tres grave qui empeche la reprise meme partielle de ces travaux. En ce cas ils apprennent un metier qu'ils puissent utilement exercer a la campagne comme le cordonnier, le sabotier, le tailleur, le vannier, &c. Les invalides des villes, qui ne peuvent reprendre leur ancien metier, out tous plus ou moins 1' obsession de devenir employe de 1'etat, ou d' avoir une place de concierge, ou de garcon de bureau &c. Les Commissions cherchent a les persuader de s'adonner a un travail plus avantageux, soit pour eux-memes, soit pour la societe. Cette persuasion obtient souvent d'assez bons resultats, et aussi il n'est pas rare que des invalides qui s'etaient d'abord contentes d'un petit emploi et s'etaient refuses a la reeducation ne la recherchent ensuite sous la force imperieuse des necessites quotidiennes. Ceci nous conduit a la conclusion qu'il est neces- saire de suivre les invalides apres leur placement et de former des repertoires methodiques qui permettent de retrouver rapide- ment ce que Ton a fait pour chacun d'eux et de faire periodique- ment des recensements dans toutes les regions. Qu'on me permette de citer encore 1'oeuvre de la Commission Florentine, pour la seule raison qu'etant la plus ancienne elle a eu le temps d' organiser son travail meme pour la tutelle apres le placement. En aout 1917, c'est a dire apres une annee et demi de travail, elle fit une premiere recherche des invalides dont elle s'etait occupee jusqu'alors. On put ainsi constater : 1 Combien d' invalides parmi ceux places etaient encore au travail. 2 Quelles etaient les ameliorations obtenues dans leur situation soit au point de vue economique, soit a celui de leurs aptitudes au travail. 3 Combien parmi ces invalides n' etaient pas contents de leurs conditions et desiraient entrer dans une maison de reeducation pour une nouvelle orientation professionnelle. Cette experience bien que faite en proportions reduites nous apprit combien il etat utile de rechercher de temps en temps nos 241 proteges et nous esperons pouvoir le faire regulierement et avec les moyens necessaires, de fa$on a n'en laisser echapper aucun. Avec ceci on passe de 1' exposition de ce qui a ete deja fait, a la conception de ce qu'on pourra faire et de ce qu'on fera. II ne sera pas inutile de profiter de ce congres pour signaler deux ques- tions pour 1'avenir. Je veux dire la question du travail temporaire dans les etablissements industriels et la question de 1' emigration. En general les etablissements industriels qui prennent des nouveaux venus et des apprentis mettent comme formule a leur contrat pour la duree de la guerre. Ceci semblerait devoir pro- dnire un chomage assez inquietant le jour ou les soldats actuelle- ment aux tranchees reviendront chez eux, etant donne aussi 1'etat abandonne de certaines industries qui t>nt ete interrompues par la guerre et qui ne pourront etre reprises aussitot apres. Cependant cela ne doit pas nous inquieter outre mesure. Mal- heureusement il y aura dans les equipes de travailleurs qui reviendront du front des lacunes qu'il faudra combler, et surtout nous croyons que le magnifique essor industriel de 1'Italie pendant la guerre n'est pas destine a une fin, mais qu'il va se transformer on passant de 1'etat de guerre a 1'etat de paix. D'autre part nous pouvons deja signaler des initiatives pour la formation de maisons d' Industrie et de commerce creees expres pour donner du travail aux invalides de guerre et elles semblent etre destinees a bien reussir. L/a question de 1' emigration doit etre consideree pour les invalides qui s'etaient specialises en certaines industries agricoles, de construction ou de manufacture, surtout en Amerique. Ces bons Italiens, qui sont accourus a 1'appel de leur patrie en danger, voudraient souvent, malgre leur infirmite, tenter de nouveau la voie ou ils s'etaient engages avant la guerre. Souvent aussi dans le pays ou ils avaient emigres ils gardent un cercle de relations plus intime meme qu'avec la famille restee au pays. Certaines lois sanitaires reglaient avant la guerre 1' admission des emigrants dans les pays d'outre-mer. II serait peut-etre opportun de revoir -cette legislation et d'etablir des accords pour faciliter partout le travail a ceux qui etant de bons ouvriers avant la guerre peuvent et veulent encore faire honneur a leur patrie hors de ses frontieres. Nous sommes surs que, partout, apres cette guerre qui a reuni tous les peuples civilises dans une seule lutte pour un seul but, on accordera aux soldats qui ont donne a notre cause leur belle jeunesse toute la sympathie et la reconnaissance qui leur sont dues. 242 SECTION 3, A. Medical Treatment, the Blind and the Deaf. HOME OF RECOVERY FOR SHELL SHOCK CASES. BY SIR JOHN COLLIE, M.D. *Ali cases of functional nervous diseases discharged from the Army come before the Special Medical Board, Lancaster Gate, London, or one of its branches, and it is the duty of this Board to examine the men, assess their disability, and select those whose condition requires institutional or other treatment. Much judgment and discretion" are necessary to specify which form of treatment is most likely to prove of greatest service in any given case. Up to the present we have relied for treatment chiefly upon our homes of recovery. Of these homes the first to be instituted was that at Golders Green, London, N~.W., where much useful work has been done. We are also attacking the problem in another direction, e.g., by means of psychotherapeutic out- patient clinics. It has been made abundantly clear that neurasthenic patients do not do well in their own homes where they are surrounded by the wrong sort of sympathy and possibly domestic worries. The first home of recovery at Golders Green was opened on the 31st May, 1917, with 100 beds, and this is now extended to 140 beds. Since October 1st, 1917, 245 patients have been admitted, and the results have been highly successful. Since that date 196 patients have declined admission for various reasons, as, for example, a dread of further hospital treatment (many have been in hospitals for many months prior to discharge from the Army), the reluctance to leave home and family, or, in some cases, to the fact that the men have found some employment and prefer to continue at work. During the seven months from October, 1917, to April, 1918, inclusive, 246 patients were discharged from the first home of recovery, and of these 190 were able to work, and of the remain- ing 56, 32 were found to be unsuitable for treatment; 17 resented treatment these cases are always hopeless ; 3 left for good family reasons, and 4 were discharged for disciplinary reasons. Of the 190 who derived benefit, 7 attained the pre-war standard, one was fit for work, but needed training in lip-reading, 39 were fit for employment but preferred to make their own arrangements, 69 returned to their former employment, 45 went to new work found for them by the authorities at the home, and 29 left to be trained in skilled trades. The principle guiding the treatment at Golders Green is to use every effort to change the patient from a morbidly introspective 243 man to one of normal mental outlook, and to make him fit to bear the strain of life. That this principle is correct is proved hy the fact that so large a proportion of the patients do return to work, and become again useful citizens. It is a curious and interesting fact that success largely depends upon the first interview between the Medical Superintendent of the home and the patient. This interview takes place im- mediately upon the man's arrival, and may last an hour or more. The man is encouraged to give the Superintendent his full confidence, to relate in minutest detail all his troubles and worries, and generally to feel that the doctor is a friend to turn to for help. The patients are encouraged to take a personal interest in the welfare of the home, and to take up some form of light, congenial work. They are put on " their honour " to use every effort to bring about their own cure. The importance of work as a remedial agent cannot be emphasised too highly. A neurasthenic never recovers until he has some other occupation for his mind than his introspective thoughts. The forms of work offered to the patients at Golders Green are (1) engineering, (2) carpentry, (3) basket-making, (4) bootmaking, and (5) intensive culture in the French garden, also ordinary gardening. Of these carpentry is the most popular, and it is in this branch that the men work the longest hours. The hours worked in the workshops during the seven months October, 1917, to April, 1918, inclusive, are as follows : Engineers,* 3,221; carpentering, 8,099; basketwork, 3,066; boots, t 855; garden, 3,246 total, 18,487. The successful carrying on of such a home depends upon many considerations. Firstly, it is essential that the medical superin- tendent shall be a " strong " man, and keenly enthusiastic in his desire to help the men, capable of winning their confidence and of being to them a guide, counsellor arid friend. Secondly, that there shall be an officer who will undertake the purely adminis- trative details and relieve the medical superintendent of every- thing but his exacting medical duties. He should help in maintaining discipline ; for the patients should not feel too much that the doctor is a disciplinarian, if so, his influence on the men may be diminished. Thirdly, that the whole staff, sisters and nurses, shall work together harmoniously, and pull together as one team, and fourthly, that their efforts shall be assisted by the patients, who must take a personal interest in the welfare and tone of the institution. Indeed, it is essential that if even one patient resents treatment (and such cases are not uncommon, owing to the nature of their disease) he shall be removed, for his malign influence will assuredly affect the smooth working * Engineers' shop was closed for 10 weeks, February to April, f Bootshop only opened April 1. 244 of the entire home. At Golders Green the patients co-operate very heartily in the good management of the institution. They have their own Committee for organising games, &c., and adopt their own methods of discipline, as, for instance, sending " to Coventry " any inmate who offends against their view of what are the canons of good taste. Everything in the environment of neurasthenic patients must be redolent of hope ; the men must see their comrades improve day by day and week by week, and in this way gain confidence that they also will improve. One case remaining stationary does much harm. Hypnosis is not used at Golders Green as a means of treatment, because it has been foiind to be of little value in the treatment of such cases. In the hypnotic state a man may easily be induced to use limbs which are functionally paralysed, but it has been found that it is difficult to get the patient to continue to do the same on his return to ordinary consciousness. Hypnosis has, therefore, been replaced by a system of re- education the man is encouraged to make the necessary effort, first with and afterwards without assistance, just as one might teach a child to walk. What may be described as rapid cures are unknown at Golders Green. Real and enduring cures take several weeks. There are many cases where a man has been brought to the home in a bath-chair, not having walked for months and within a few minutes has been induced to walk upstairs. But that is not a cure, for without unremitting attention and encouragement he soon relapses into his former condition. Our second line of attack is, perhaps, the most hopeful, because it has the great advantage that it can be taken advantage of whilst the men are following their employment. Originating as an off-shoot of the Special Medical Board for Functional Nervous Diseases, a clinic for the out-patient treatment of neurasthenia has been established at Lancaster Gate, London, and the results have been entirely satisfactory. It is found that the men appre- ciate the treatment whole-heartedly, and that no difficulty is found in securing their regular attendance. There have been many striking cases at the clinic, and the following are of special interest : An officer, who was discharged from the Army under very distressing circumstances, was exceedingly emotional when first he attended the clinic, and talked much of suicide, fre- quently bursting into tears. After a short course of psycho- therapeutic treatment his attitude entirely changed, he rapidly progressed towards recovery, and is now doing good work. A man, who had several flesh wounds of the calf, could not put his heel to the ground, and had not done so for two and a half years. He walked very badly as the result. There was a contracture of the leg muscles. Ordinary 245 remedial treatment had been of no avail. In the gymnasium attached to the clinic, after five hours' treatment, the leg became normal, and has remained so since. A man, who had been in the retreat from Mons, wa* brought to the clinic in a wretched condition. For more than three years he had sat all day in a condition of stupor, and during the night used to to walk in his sleep. His friends proposed to put him in an asylum. At- the clinic the cause was found to be shock caused by a German atrocity. After two attendances he began rapidly to improve^ his incoherent speech became normal, he declared himself better than he had been since he joined the Army. He is now in the best of health. The success of this line of treatment has been so great that already we must take steps to increase our staff of doctors to> cope with the work, and the day is not very far distant when other clinics must be started in London and in the Provinces. Indeed, it is my hope that we shall have a clinic for psycho- therapeutic treatment in most of the large towns. 246 SUR L'ORGANISATION DE L'ASSISTANCE MILITAIRE NEVROLOGIQUE EN ITALIE, AVEC RAPPORT SPECIAL AUX " CENTRI NETJROLOGICI ET EN PARTICULIER AUX " PADIGLIONE BIFFI A MILAN. PAR PROF. E. MEDEA (Milan). Le Prof. Tamburini de Rome, nomme, des le commencement de la guerre, inspecteur-general des services neuro-psy chiatriques , a publie dans le mois d'aout 1916 (Bivista sperimentale di fremiatria, Vol. XLII, Jan. 1) un article sur 1'organisation du service neuro-psy chiatrique de guerre en Italie. Dans cet article on parle des "Services neuro-psy chiatriques des Armees " ("Reparti nevro-psichiatrici delle Armate), des " Services neuro- psychiatriques de rinterieur " (Eeparti psichiatrici e nevrologici delle zone territoriali) et aussi de restitution des " centres nevrologiques " (Centri' nevrologici) qui a cette epoque etaient en fonction seulement dans 8 villes d' Italie, loin du front. Je vais, dans mon rapport, dormer tres rapidement un apergu de 1'organisation des " Centri nevrologici," telle qu'elle est actuel- lement, tout en me permettant de faire remarquer que le premier de ces " Centri " en ordre de date a ete celui que j'ai 1'honneur de diriger a Milan au Pavilion Biffi et qui a commence a fonctionner regulierement depuis le mois de juin 1915. Maintenant presque dans chaque Corps d'Armee on a institue un Centre Nevrologico qui regoit les blesses du systeme nerveux central et peripherique et les soldats qui presentent des troubles fonctionnels du systeme nerveux soit d' ordre general (hysteriques , neurastheniques, etc.), soit partiels (paralysies contractures , formes physiopathiques du type Balinsk-Frornent) . Naturelle- ment ces Centri sont organises un peu differamment selon les differences dues aux conditions du lieu ou ils se trouvent, mais general leur fonctionnement se fait de la fa con suivante : Chacun des centres a un service pour neuro-organiques blesses et pour fonctionnels : en general ces deux sortes de malades sont divises dans des hopitaux differents ou dans des services separes dans le meme hopital. Dans quelqu'un de ces centres, comme, par exemple, au Padiglione Bif&, on regoit et on traite aussi les maladies nerveuses organiques des militaires qui sont tombes malades pendant le service au front. Ce qui carac- terise surtout les Centri Nevrologici c'est leur particuliere physio- nomie neuro-chirurgique : soit dans le meme batiment soit par des arrangements avec des hopitaux contigus, le nevrologiste vlirecteur du centre a la possibilite de. se servir des rayons , dans un but diagnostique et eventuellement therapeutique et de faire operer ses malades par un ou plusieurs chirurgiens specialises pour 24T les interventions chirurgiques le cerveau, la moelle epiniere, les nerfs peripheriques. C'est sur 1' entente parfaite entre le nevro- logiste et le chirurgien que repose la surete du succes dans le traitement des blesses du systeme nerveux ; le nevrologiste doit toujours donner, apres un examen minutieux, son conseil au chirurgien a propos de 1' intervention et doit toujours etre present a 1' operation. En effet ses connaissances physiopathologiques et 1' etude qu'il a faite du malade lui permettront toujours de donner au chirurgien des conseils tres utiles pendant 1' operation meme. Malheureusement je n'ai pas eu le temps de recueillir des renseignements sur le fonctionnement particulier de chacun des Centri, mais je peux dire, ayant visite plusieurs d'entre eux et possedant des nouvelles assez detaillees des autres, que partout leur fonction est tres utile et que les resultats repondent a ce que la Direction de Sante Militaire esperait d'obtenir avec leur con- stitution. Ces Centri actuellement en fonction sont les suivants : (1) Rome avec deux Sections : organiques a 1'Hopital de Merode (Prof. Bastianelli) et fonctionnels a la splendide Villa Wurts ou Gianicolo (Prof. Fabrizi) ; (2) Milan avec deux Sections, chacune desquelles a un service pour organiques et pour fonc- tionnels : 1'une est dirigee par le Prof. Besta, 1'autre par moi. Chacun de nous a son chirurgien de choix, respectivement les Proff. Bossi et Crosti, et je crois de pouvoir assurer que le fonc- tionnement du Centre Nevrologique de Milan dans ses deux Sections est regulier et satisfaisant ; (3) Pavie a, dans le College Borromeo, un Centre tres bien organise, dirige par un de nos plus grands savants, mon cher maitre, le Prof. Golgi, avec 1'aide d'un nevrologue, le Prof. Sala, et d'un chirurgien, le Prof. Verza ; (4) Un nouveau Centre vieiit d'etre installe a Genes (Prof. A. Morselli) ; (5) Sienne a un Centre dirige par le Prof. Fragnito qui sert pour la Toscane et Emilie ; (6) le Centre d'Ancona est dirige par le Prof. Modena ; (7) le Centre de Bari est dirige par le Prof. Boschi ; (8) le Centre de Naples par le Prof. V. Bianchi ; (9) le Centre de Catania (pour la Sicile) par le Prof. d'Abundo. II y a encore a rappeler 1'existence de Centres de premiere concen- tration a Milan (Boveri), a Bologne (Neri), a Keggio Emilie (Consiglio). Les evenements de la guerre ont deplace le Centre de Treviso (Gatti) et de Ferrara (Boschi). Naturellement je m'occupe ici seulement des fonctions neuro- logiques sans parler du service psychiatrique qui est en general assez bien organise dans les Asiles d'alienes de chaque province. Le Prof. Golgi, avec les Proff. Sala et Verga, vous parleront de 1'organisation vraiment remarquable du Centre de Pavie ; jc vous parlerai tres rapidement du fonctionnement de mon service, la Padiglione Biffi de Milan avec ses annexes. Le service est divise en trois sections : le Pavilion Biffi pour blesses neuro- organiques plus serieux, I'hopital de S. Sofia pour organiques moins graves, le Eicreatorio S. Carlo pour fonctionnels. Le pavilion Biffi qui fonctionnait deja avant la guerre comme service neurologique civil de I'hopital Majeur de Milan, est doue de plusieurs laboratoires pour recherches sur le liquide rachidien, 248 pour 1 'etude hystologique du systeme nerveux, pour grandes coupes du cerveau , microphotographie ; uri autre laboratoire sert pour 1'ergographie, la graphique des tremblements, des reactions vasomotrices (gant de Patrizi) etc., etc. Au point de vue therapeutique, deux salles d'hydrotherapie avec tons les appareils necessaires, plusieurs appareils pour 1' electro therapie dans ses formes differentes (faradisation, gal- vanisation , courants sinusoidales ; arsouvalisation , f ranklinisation , bains electriques, etc., etc.). Tous ces appareils ont ete con- struits en Italie et precisement 1' installation hydrotherapique a Pavia, 1'electrotherapique a Milan. Une installation meccano- therapique, suffisante pour un service de nevrologie, a ete ajoutee dans ces derniers mois. Nous avons tous les appareils pour les methodes de reeducation a la Frenkel, etc. La possibilite de faire un grand nombre d' applications electro- therapiques a la fois nous permet de donner un grand developpe- ment au traitement ambulatoire de pjusieurs blesses qui suivent le traitement tout en restant chez eux eri licence de convalescence, dans le but de ne pas occuper un lit inutilement les blesses organiques des nerfs des bras par exemple sont traites en grande partie ambulatoirement ; au contraire je tiens toujours dans I'hopital pendant le traitement les fonctionnels pour des raisons trop faciles a comprendre. II faut maintenant donner quelques renseignements sur les resultats obtenus dans mon service. En commencant par les cas de neuro-chirurgie, je dirai seulement les conclusions auxquelles 1' experience de ces annees de guerre nous a autorise a arriver. Pour ce qui a rapport aux interventions sur le cerveau, on a opere chaque fois ou il y avait des phenomenes de compression oil lorsqu'on supposait 1' existence d'une leptomeningite ou aussi d'une partie ou d'une leptomeningite ou aussi d'une meningo- encephalite circonscripte. A propos des esquilles osseuses ou metalliques , nous insistons encore une fois sur la tolerance du cerveau envers les esquilles metalliques : au contraire les esquilles osseuses sont toujours dangereuses et il faut les enlever le plus tot possible (abces tardifs etc.). Dans plusieurs cas ou il y avait perte de substance cranieuse, le prof. Crosti a pratique assez souvent la cranioplastie (methode autoplastique de Leotta) avec de bons resultats. Les interventions sur la moelle epiniere ont ete faites chaque fois ou il y avait la possibilite de porter le diagnostic d'une com- pression (esquilles osseuses ou metalliques etc.) ou d'une lesion partielle de la moelle (meningite serieuse traumatique avec for- mation de cystes, partie ou leptomeningite etc.). II faut dire qu'on a le devoir d'operer chaque fois ou Ton a la persuasion que la lesion de la moelle ne soit pas complete : pourtant il faut avouer que les lesions de la moelle sont parmi les plus tristes de la guerre. Nous avons eu a soigner un grand nombre de cas de lesions des nerfs peripheriques : plusieurs de ces cas se sont ameliores par le simple traitement electrique : pour les autres il faut toujours 249 etudier dans tons les details le cas avant de le proposer au chirurgien pour 1' intervention et il faut toujours exciter le nerf decouvert soit electriquement soit mecaniquement pendant 1' inter- vention, pour donner au chirurgien des conseils sur la modalite de 1' operation (nevrolyse resection etc.). Avec ces precautions diagnostiques et operatoires, on aura la possibilite de fa-ire toutes les operations necessaires, de ne pas faire d 'operations inutiles et de faire ce que reclame vraiment 1'etat du nerf blesse. A propos des f onctionnels , sans parler des cas plus simples de contracture ou de paralysie hysterique, il faut attirer 1' attention sar les cas nombreux du type physiopathique (Babinski et Froment) : a propos de ces cas nous croyons a la possibilite d'obtenir des ameliorations et des guerisons pourvu que les malades ne soient pas envoyes trop tard, qu'ils ne soient pas immobilises pour un temps trop long, et que Ton s'occupe beaucoup d'eux. Nous voulons ajouter que nous donnons a tous les soldats qui en ont besoin des appareils pour empecher les positions vicieuses des membres (appareils pour les paralysies du radial, du peronier etc.). La reeducation a une grande place dans mon service : c'est surtout a travers le travail, bien dose et organise dans un but medical, que la reeducation s'accomplit : les soldats tressent des paniers, font des pantoufles, des reseaux pour camouflage etc. Les travaux en petites perles ont pris un grand developpement , qui servent tres bien a exciter les maladies a faire des petits mouvements, et a developper leur gout artistique, et qui, en leur permettant de realiser un avantage materiel assez considerable, sont de grande utilite pour 1'ordre, la discipline etc. Dernierement nous avons organise un atelier pour reliure des livres qui donne de tres bon resultats. Dans notre service nous avons introduit aussi 1' instruction elementaire pour les malades qui, a cause du traitement doivent rester quelques mois a I'hopital, et les succes obtenus par nos eleves sont des plus satisfaisants. Nous voulons bien faire comprendre que les travaux et les laboratoires institues dans notre service ne doivent pas etre confus avec les laboratoires pour mutiles, estropies etc., qui se trouvent, pour Milan, a 1'Institut de reeducation de Gorla (Prof. Galeati). Nos laboratoires sont destines aux malades pendant le traitement et ont un but de reeducation de la volonte, des groupes mus- culaires etc., les laboratoires de Gorla ont pour but de faire apprendre aux mutiles, estropies etc., un metier nouveau qui puisse leur servir dans la vie. ^Nous savons que la Direction de Sante Militaire a I'intention d'ouvrir, pres de chaque Centre nevrologique, une Maison de travail destinee surtout aux soldats qui presentent des troubles 250 fonctionnels et a propos desquels on a note le danger de les envoyer en licence de convalescence, car on a vu une quantite de rechutes dans ces cas. Nous croyons que 1'institution de ces Maisons de travail, sur- veillees par des officiers intelligents et energiques et toujours tenues sous une direction nevrologique , pourra donner de bons resultats. Nous insistons pourtant encore ici sur un point que nous croyons trea important : il faut que les blesses du systeme nerveux, organiques ou fonctionnels, soient envoy es aux " Centri Neuro- logici " le plus tot possible, sans passer a travers une quantite de formations hospitalieres ou ils ne peuvent pas etre suffisamment bien diagnostiques et traites : pour les fonctionnels surtout il faut des le commencement les diagnostiquer et les placer d'une facon appropriee, sans quoi on perd du temps precieux et on permet la stabilisation de manifestations tres difficiles a vaincre dans les hopitaux de 1'interieur. Nous sommes d'avis a ce propos de tenir le plus pres possible du front les fonctionnels sans manifestations psychiques generales graves (contractures , paralysies partielles, etc.) ; ils gueriront beaucoup plus rapidement et plus facilement que dans les "Centri" de 1'interieur pour des raisons assez faciles a comprendre. 251 THE NEUROLOGICAL CENTRES IN ITALY. By Professor CAMILLO GOLGI, Director of the Neurological Centre at Pavia. (Translation.) In order to accomplish the task entrusted to me that of making a brief expose of all that has been achieved in Italy with regard to the development and organisation of the so-called Neurological Centres I must begin by a description of the Neurological Centre of Pavia, that I have the honour of directing. Setting aside any personal reason connected with the respon- sibilities I have assumed with regard to the assistance of our wounded soldiers, this Centre of ours has a special claim on my attention, if for no other reason, because the methods adopted for its development and organisation have caused it to be accepted as a model for all other institutions of this kind that have since been founded by our Government. It may be said that Pavia started having a Neurological Centre for the treatment of all wounds, and their effects, in any way are connected, directly or otherwise, with the nervous system, from the very beginning of our war. Within three or four months of this event, there already existed a veritably specialised section of .this kind, at the time that the Borromeo Institute acted as generalised hospital. The constitution of this rudimentary section was accomplished without any settled idea of making a Centre of it for the treatment of said wounds; it was done with the sole object of providing, when required, for the treatment of individual cases, as they came along, profiting by all that was being done elsewhere for these wounds, especially in England and in France, and of the results of the experimental science (laboratory observations, and also clinical observations) on the subject of the regeneration of the nerves. During these three years of work, in the course of which the special categories of the afore-mentioned wounds were multiply- ing, the Neurological Section of Pavia continued to specialise, as is indicated in the title conferred on it of " Neurological Specialising Section." But, as a result of this increase in the quantity as well as the quality of the work, this institution not only had to be gradually enlarged, until it could accommodate about 450 patients, but it also had to modify its organisation; said modifications culminated with the constitution of the present " Neurological Centre " (Ministerial Circular Letter, January, 1918), which is sub-divided as follows: (a) The Neuro-Organic Branch; (b) The Branch for the Mental and Neuro -Functional Maladies. 252 Later indication of its developing in other and even more special directions are shown by the Ministerial Circular Letter referring to the institution of the physio-therapeutical centres of the army corps, for the treatment of temporarily disabled soldiers. In this letter the Government sets forth in detail all the regu- lations relative to the constitution and organisation of said centres. The creation of these new centres was the consequence of the necessity that had arisen of providing with all the possible means suggested by science and by practice for the training and functional recovery of those soldiers who, as a result of wounds received at the front, were suffering from a diminution of their physical powers. This important administration, known as the Physio-Thera- peutical Centre, has been constituted as follows : 1. Hospital Section : (a) Neuro-Pathological Branch; (6) Branch for Orthopedical Surgery. 11. Physio-Therapeutical Department. III . Meccano-Therapeutical and Electro-Therapeutical De- partment at the disposal of the other Branches. I am able to state, with particular satisfaction, that the scientific organisation of this complex institution has been achieved by means of our obtaining the collaboration of eminent men belonging to our University (Pavia). I will limit myself to mentioning the neuro-pathologist, Pro- fessor Guido Sala, one of the most eminent neuro-pathologists in Italy, and the surgeon, Major Professor Giovanni Verga; the latter is a young man that has won high renown as a result of his writings, that are of interest not only from a scientific, but also from a surgical, point of view. I will only say a few words of a general character with regard to the special sanitary scientific organisation of the Neurological Branch (Borromeo Hospital). It is useless to dwell on the truth of the universally accepted principle, that the treatment of the effects of nervous wounds demands " a close collaboration of the neurologist with the surgeon." This fundamental principle is not only strengthened by our daily experience, but it has further proved that in the action of the surgeon and of the neurologist there must exist something more than the plain collaboration, in the sense generally attributed to this word. This " something more " is, in my mind, ideally stated by the imagery of our colleague, Professor Burci : "in the work of the neurologist and of the surgeon devoted to the treatment of the effects of nervous wounds," he said, " there must exist a true simbiosis." All those who have occasion to observe the clinical manifestations of such wounds, and eventually to summarise the salient points of the resulting operation, must inevitably realise how true is the conception of the psychological amalgamation existing between 253 the neuropathologist, who carries out his diagnostic analysis on the basis of the most precise anatomical knowledge, together with the certainty as regards the physio-pathological characteristics of nervous wounds, and the surgeon who not only must be thoroughly grounded in anatomy and in the physio-pathological laws that refer to the nervous system, but must bear in mind the not infrequent changes that may impose themselves during the per- formance of the primitive plan of operation, and the correspond- ing need that may arise for creating- unforeseen operatory ex- pedients. I do not hesitate in affirming that the conception of 41 simbiosis," expressed by our colleague, Burci, is ideally per- sonified by the afore-named colleagues. All the work that has been done during the past three years in the Neurological Branch (Borrorneo Hospital) has been gone into by both my colleagues Sala and Verg-a who have described it in their special Summaries and Reports. Whilst I note the intensity and importance of all that has been accomplished by the two eminent colleagues, the proofs of which are to be found in the number of operations performed, and of actual results that have been achieved (complete recoveries and improvements), I feel that it is not quite superfluous that I should recall the fact that one of the reasons that this Institution was able to undertake this kind of treatment from the very beginning, and that it is no small factor in the splendid results that have been obtained, that, in pre-war days, our University, a.nd more especially the Laboratory directed by me, was specially devoted to scientific experimental studies of wounds of the central and peripheric nervous system, and more especially of the regeneration of the nerves. These studies were recognised as being of the greatest import- ance by the entire scientific world, especially as they carried with them the solution of certain problems connected with this vital question, that for centuries had been matter of controversy. In consideration of the enormous importance attributed to them in the scientific world, I must quote the works of Marengli, of Purpura, of Perroncito, of Guido Sala, of G. Yerga, &c. The researches of A. Perroncito come well to the fore in the history of the research on the regeneration of the nerves : his name is connected with a thorough knowledge of the most precise and demonstrative facts on the central origin of the nervous fibres, as proved in experiments on nerves that had been severed for the purpose. These studies and experiments, as a whole, resulted in the creation of precepts that were put into immediate practice for the treatment of nerve wounds ; amongst others, the necessity became evident of carefully considering the local condition of the severed nerves with regard to the development of the regenerative pro- cess, and that the operation must aim at substituting the cicatrix constituting barriers very nearly insurmountable for the fibres that reach out from the central stump, to operatory cicatrix which 254 will permit these same fibres to advance from the centre towards the periphery. My attention is further recalled to another question that has ever appeared to me of the greatest importance7 I am referring* to the impossibility of being able to take any surgical action (needless to say, in cases where it is needful) because of the opposition to which the soldiers resort against the performing of operations which, according to all the known principles of science and of surgery, would result either in the perfect renewal of the functions, or, at any rate, in a more or less degree of improvement. To my mind, this argument is by no means resolved, and deserves the most serious consideration, not only from the point of view of the individual, but also from that of the interest of society in general. As far as any special arguments in favour of this may go, I will refer to what I have already said at other sittings : "II Reparto Neuropatologico Specializzato ' tDollegio Borromeo ' in Pavia," Pa via, Tipografia Cooperative, 1917. " Per la Protezione ed Assistenza Degli Invalidi Delia Guerra," Roma, Tipografia del Senato, 1917. Finally, it may not be judged superfluous that I add a few words with regard to the economic side, connected with the special plants working in this Institution (Meccanotherapeutic, electrotherapeutic and radiologic). I do this all the more willingly that there have been assertions made, to the effect that these plants demand enormous disburse- ments, most difficult to meet. The entire meccanotherapeutical, electrotherapeutical and radiological plant did not cost us more than Lit. 60,000; and this was for a set of machinery which, according to the unanimous opinion of the technical commission, is excellent from every point of view, and thoroughly adapted to every scientific and practical need. 255 Summary. "THE NEURO-ORGANIC SECTION OF THE NEUROLOGICAL MILITARY CENTRE AT PAVIA." BY PROFESSOR GUIDO SALA, Chief Neurologist of the Neuro- Organic Section, Neurological Military Centre of Pavia (Directed by Senator Prof. C. Golgi). This special Section , which has been organised as the Specialised Neuropathological Section ever since October, 1915, has been gradually enlarged to the point that , at the present day , it can receive over 430 soldiers for treatment of the wounds and organic affections of the central and peripheric nervous system. This Section, conformably with the orders of the Ministry of War (General Direction of the Military Board of Health) is set aside for the soldiers belonging to the Army Corps districts of Alexandria and Turin (Piedmont), and is also used as a first grade section for observation and selection. The institution contains all the most modern appliances for physical therapeutics which are required for diagnosis and for the treatment of the different diseases to which the nervous system is subject. There are the several halls for radiological and electrodiagnostical exam- ination, and for electrotherapeutical treatment, as well as con- venient operating theatres, where operations are performed on peripheric nerves and the central nervous system. The electrotherapeutical plant consists of : 6 complete fittings for galvanic current and for faradic current, connected with accumulator batteries. 8 complete fittings for electrical baths. 1 complete fitting for synucydal current. 1 complete fitting for high voltage current. 1 complete fitting for diatermia. 1 complete fitting for undulating current. All the machinery and the appliances constituting this plant are of home manufacture with the exception of the oppliances for diatermia (D'Arsonval System, from Messrs. Gaiffe, of Paris). The electrotherapeutical cabinets are working regularly every day without interruption, as they also serve the purpose of ambulatory service for the soldiers who have been taken into other Sections in this city and for soldiers on convalescent leave. On an average the cases treated amount daily to 350. This 256 therapeutical treatment is attended to by a trained staff under the continual supervision of the Director of the Section ; the latter is also in charge of all the neurological and electro- diagnostical examinations. From the very beginning it was considered absolutely indis- pensable that the surgeon and the neurologist should act in strict collaboration in all that concerned the surgical treatment. It has thus been possible to perform numerous surgical operations on the nervous system, especialty on the peripheric nervous system (over 200) with most satisfactory results. (See Eeport in Extenso of my colleague, Prof. Verga.) Every effort has always been made to avoid surgical treatment for such cases where there might be the remotest chance of success with an appropriate treatment of physical therapeutics. Indeed, in a great number of cases, as was to be foreseen, most satisfactory results were obtained by means of special therapeutic treatment happily blended (electro therapia , meccanotherapia , diatermia , medical gymnastics , hot baths , massage , strychno- arsenical treatment, &c.). These therapeutic treatments proved especially useful with regard to dystrophic processes and to paralytic conditions that were more particularly due to inertia, for patients that had been kept motionless, often most inopportunely, for long periods of time, their limbs encased in immovable appliances. In such cases, also, where the diseased parts were supported by a direct lesion of the nerve, especially if parcelled, very good results were obtained, especially when it was possible to begin the treatment in good time, with a rigorous method and for a sufficient period of time. The application of simple, light and economical prothesical appliances (model of Prof. Sala) have proved most beneficial ; these are used for correcting any impotency of movement and to' aid the renewal of muscular functions in paralysis of the radial nerve and of the popliteal external sciatic nerve. Several hundreds of these appliances have been set up and utilised. The most numerous wounds were those connected with the peripheric nerves (1,400). The nerves that were attacked the most often were, in their order of frequency , the radia 1 nerve (298) , the cubital nerve (249) , and the middle nerve (239) for the upper limbs ; the sciatic nerve (269) for the lower limbs. Were also to be noted the wounds of the brachial plexus (64) and of the sacral-lumbur plexus (15) ; wounds of the sympa- thetical cervical (7) , and a notable series of cerebral lesions (201) , and medullar lesions (72), of traumatics and of wounds and cerebro-spinal illnesses. Amongst the soldiers having cerebral lesions there were 20 cases of convulsive abscesses of a Jacksonian and generalised type, and 5 cases with forms of abscesses. 257 In spite of the gravity of such cases, a good number of these soldiers were discharged in a notably improved condition. Another special category of traumatised subjects of the nervous system are those men that are suffering from paralysis and from contractions of several kinds, and of a so-called reflex nature (200), the result of wounds that were often of very small account and, for the most part, not affecting directly the nervous system. For these men all the treatment up to now has not proved very efficacious, unfortunately, but new methods are now 7 being studied in this section in the hope of obtaining somewhat better results. 258 SUGGESTIONS AS TO THE BETTER TREATMENT OF OUR WAR NEUROSES. BY LT.-COL. J. W. SPRINGTHORPE, A.A.M.C. We entered upon this, the greatest war of all time, with enough of nothing; with the call "enlist," not "serve"; with seniority above efficiency ; with a machine that followed tradition and compelled delay ; with all other claims subordinated to the military ; and with a medical profession uninstructed in psychology, and, in most cases, unacquainted with psychopathic manifestations or their proper treatment. Is there any wonder that when we came to deal with the great question of war neuroses we made many and serious mistakes, and that, despite magnificent work in many quarters, very much still continues unsatisfactory, and will so remain until these basal factors are suitably dealt with. We have gradually learnt that not only are there not infrequent conditions which can and do seriously upset even the soundest mind in the soundest body, but, also, that people of a recognisable psychopathic constitution, even when not patently unfit to be mobilised for active service, give way sooner or. later generally sooner under the strain, the infection, the emotional stress, or the unprecedented concussion of this war. We have also come to see that the phases and degrees of disability are so complex that they demand expert differentiation ; that many probably the large majority of the seriously affected become unequal to a repetition of the strain, and that delayed or unskilful treatment perpetuates many symptoms, and even produces new ones. And we have also found that the number so disabled is exceedingly large, and that the difficulties in the way of their best care and treatment, and of estimating the duration of their disability and degree of their restoration are exceedingly great. In the face of a situation so grave for both individual and com- munity, we ought to ask ourselves the question : " Are we doing all we can to minimise the loss and the cost? " This paper aims at stating what seem to be some of our present defects, and at suggesting some of the apparent remedies. 1. Preventatively we should make universal the motto " Serve " as the method of response to the call of duty, and grade all, both those who have enlisted and those who have not, according to their best suitability. Then no longer would men of marked psychopathic constitution find their way into our firing line in such numbers, whilst others, admitted by mistake, would be promptly removed prior, and not subsequent, to their almost inevitable breakdown. This would mean not only an official classification as to what class of psychopaths should, and what class should not, be kept out of active service, but also a sifting 259 after entry , with consequential removal to some suitable form of Home Service. Have we done either satisfactorily up to date? I think not. Further, no one who has had experience would, I am sure, deny that cases of actual breakdown would be fewer and less serious if the psychopaths and neurasthenics, who have gained entrance, were more individually " placed " and trained, and more frequently rested than has hitherto been the custom. I am aware that this trenches upon military ground, but I am one of those who venture to hold that the net result would often be better if the medical position were more frequently and more forcefully brought under the notice of the High Command. 2. For the best results, it is self-evident that, prior to pro- ceeding to their units, the M.Os. should have as some officers in other departments now have such training and experience as will fit them to recognise and deal with the various phases of nervous vulnerability, and be provided with some official form along which to classify and some guiding principles along which to act. So far as I know no such training, experience, classifi- cation or form are as yet provided. What an increase in general and personal efficiency, what a prevention of unnecessary dis- ability are not hidden here? Similarly, the special hospitals to which the "N.Y.D.N." class of cases are now sent should be sufficient for all requirements, be staffed by specially qualified medical officers, and should have in operation one uniform approved method of history-taking whereby all pertinent facts, phases and combinations, with sequence, severity and duration of symptoms might became an invaluable record for future refer- ence. So far as possible, also, such hospitals should be away from the region of air raids, bombing, and excessive gun-fire, and certainly no excitable patient should remain longer therein than is necessary for due examination and record. Are all these ancillary methods in satisfactory operation? I am afraid not. 3. Subsequent treatment is even more important, and even more unsatisfactory. Some fortunate patients proceed by special " green and white " tickets, or the like, to special hospitals at the Base, or in England. But how many do not? And why not all ? In many cases , as I know from sad experience , patients specially diagnosed become practically lost in the forest of general hospitals for periods ranging up to four to six months (and in hundreds of cases, averaging over three) where general shall I call it, unobservant neglect, often takes the place of that individual expert attention, which makes all the difference in duration and prognosis. The results are often disastrous. Is not the continuance inexcusable? Other cases, apparently less fortunate at the beginning because less expertly diagnosed are even more unfortunate in their subsequent progress, and lay perdu in all sorts of places, under all sorts of non-neurological diagnoses and treatment, in numbers that are probably never known in their entirety, but that, even as known, are said to be in Germany " more frequent in the general wards of military hospitals than in the special nervous hospitals." And if more 260 frequent in Germany, probably still more frequent amongst us t Is there any reason why this should be? If sufficient special hospitals cannot be provided, why not special wards in specially selected general hospitals, where accurate diagnoses and suitable treatment can be adopted? Without entering into principles or minutiae, it may be claimed that treatment should be individual and expert that nothing less should be deemed satisfactory and that whenever the hospital is one in which the patient is to stay for any time , the necessary grounds , physiotherapy , workshops , amusements, &c., should be provided. As I write this, I have just admitted a patient, 85 days after his shock, with, through- .out, amidst other marked neurological symptoms, almost com- plete amnesia of his prior existence, who has been passed through six hospitals on the diagnosis of " P.U.O." and " trench fever,' r and who was never even questioned as to his memory, or treated for other than his fever ! The case is typical of many others. What are we doing to lessen them? 4. The future of the patient is often still by no means satis- factorily settled. There is, I believe, a general consensus of medical opinion that all cases of definite f ' shell shock ' ' and many of concussion, psychasthenia, hysteria, &c. (especially if markedly increased by the stress of war) should be dealt with as permanently unfit for Active Service, whilst other and lighter forms of neurasthenia, &c., may be regarded as fit for Home Service after a variable period. But in the present confused state of nomenclature and classification, no general rule can be formulated, nor uniformity of action adopted. We need some general form of nomenclature and classification, and some general official announcement thereon. There is also apparently a growing consensus of opinion thai no case of functional nervous disease should be discharged fron: the Army until both his medical and social status have beer finally determined, and that great loss is likely to accrue to botl State and individual whenever this rule is departed from. Am yet the present War Office dictum is : " Discharge as soon a, possible " ! If we, as experts, hold the opposite view, is it no incumbent upon us to place the non-military situation fairly an squarely before the authorities? 5. Pensions. Surely the proper way to regard Pensions is a the immediate financial side of Reconstruction or Repatriation (t use the Australian word). As such, they are fundamental! bound up with questions of treatment and training, and tt j sound principle is that of the alternative award in which tt 3 determining factors are the pre-war earnings, and the preset t'\ earning capacity. Speaking generally, a Pension should be a statutory right, ar not a mere grant. This is already the case in compensations f< industrial disabilities under the Employers' Compensation Ac and much good, both direct and indirect, would inevitably folk vj a change of terminology in the case of disabilities incurred war. Are not the war sufferers at least equally deserving? 261 It is claimed, further, that a low pension favours dissatisfac- tion, that a high one discourages re-education, and that no pension is best, with, in its place, upkeep during reconstruction and a grant at the end. The ideal, of course, would be to place the man as nearly as possible in the status in quo ante bellum ; and, if any man ever deserved such adequacy in compensation, surely it is the disabled soldier ! To give an amount in accord with the average cost of keeping up the previous position, and )roportionate to the difference between previous earnings and sent earning capacity in the labour market, might perhaps be tiled a financial revolution. But, unless some such satisfaction attained, the result, apparently, will be, present at the expense >f future saving, largety increased cost of administration, reduced standards of living, less number of marriages, deterioration of lome life, and smaller and less capable posterity. It is estimated lat in 1918 the actual British pensions will amount to some i'23,000,000 per annum, and it is claimed that an increase of 15 per c. nt. would pay for the above difference. Is it not worth it? The situation is one that should be fairly faced and the jst possible all-round solution arrived at. Meantime, it cannot be denied that the present amounts are juite insufficient, especially whilst, as now, the purchasing power of the sovereign has been reduced by more than one-half ; and that there should be a Court of Appeal outside the Minister, who, at present, is the sole arbiter in an appeal against himself. The methods of distribution, also, are frequently so imperfect, slow, and at times even unjust, as to call for some change, either in the direction of enlarging the powers of the Local Committees, of altering their personnel, or of replacing them by local officials directly under the Ministry of Pensions, as is the Australian prac- tice with satisfactory results. Nor is a final assessment uni- versally made, as would be more satisfactory, by a Board of Experts, who should enquire into previous working capacity, temporary needs and commercial value of present earning power, of which Board, of course, there need be not more than one medical member fit to examine the patient, and gauge the value of the report presented by or from his medical attendant. 6. Eeconstruction, however, should be the main, and Pensions the side issue. If carried into practice, this would mean a radical reform by the relegation of money compensation to the back- ground, and the advance of measures of re-education and training to the foreground. It is gratifying to notice how much is being attempted, if slowly, in this direction. So far as War neuroses are concerned, we have at present three object lessons going on side by side : (a) As at Maghull : a special hospital, expertly staffed, but with limited training facilities, sending back to work each month some 20 per cent of its patients, who are still under discipline, though, on the average, admitted some three months, instead of six or seven days, after the date of the origin of their disability. - 16524 I 3 262 (6) As at G-older's Green, a "Home of Kecovery," taking in patients discharged on pensions, generally without previous expert treatment, and any time up to two years after the origination of their disability, also expertly staffed, but with better training facilities. Here, during the past four months, after an average stay of 6 to 7 weeks, and at an average cost of less than ^619, of 163 patients received, 37 were discharged as unfit for treatment (19 being medically unsuitable, 12 resenting treatment, 2 for family and 4 for disciplinary reasons). Of the other 126, 4 go up to pre-war stan- dards, 1 requires only lip reading, 38 are fit for work, 46 return to former employments, 28 go to new work and 9 to training under a scheme of the Ministry of Pensions. (c) The much larger number of outside cases, prac- tically left to their own desires and devices, some few attending some treatment or training, as provided by Local Committees or outside bodies. Surely it is time that some uniform scheme was adopted and some supreme control set up, so that cases might be met and activities co-ordinated, improved and extended. 7. The war neuroses present, also, many questions of prognosis, and therefore of assessment, peculiar to themselves, such as are bound up in the consideration of the headaches, the mental inertia, the confusion, the lapses of memory, the defects in con- centration, and other persistent psychopathic conditions. These, however, seem matters of progressive experience and interchange of views, rather than of any present official pronouncement. 8. Finally, I beg very briefly to formulate some of the results of my own investigation of some 500 Australian cases during the past 15 months, in so far as they have a bearing upon the previous considerations. (a) Out of 500 mixed cases (less a few with hazy recollection), 308 had a good, and 106 a neurotic family history ; 253 a good, and 132 a neurotic personal history ; and 207 a good, and 57 a neurotic family and personal history. (6) Out of a series of 120 cases diagnosed as shell shock, 66 had a good antecedent, personal, and family history. (c) In one special hospital at the front, between 29th August, 1917, and 12th November, 1917, 45 per cent, of the cases were sent back to the base, and the majority of the others were mild, and " need never have been sent to them " ; in another, between 20th June, 1917, and 12th October, 1917, 824 out of 920 were evacuated to the base and 73 to duty ; and in a third, between 27th September, 1917, and 12th October, 1917, 551 out of 574 to the base and only 1 to duty. 263 (d) In 3 series of 30 consecutive cases admitted into our hospital, the average duration of stay in previous hospitals was 88, 90 and 92 days; and in the last series 10 were over 100 days in other hospitals , with an average of 149 days. (e) Many cases give a history of being upset by gun- fire, air raids, and bombs, and similarly suffer here. Very many come in with little or no history, and under all sorts of diagnoses, and not a few, sent back after months in hospital and command depots, break down even before they reach the firing line, or within a few days of doing so. (/) We find, of course, most, but not all hy steroid symptoms almost magically cured within a short period, but the psycho-neurasthenic much more persistent and requiring individual treatment along many different lines (cases arriving from special hospitals being not much better than those from general hospitals). Many of the symptoms of the shell shock syndrome, also, are still pre- sent, not only on admission, but when our limited means and times of treatment are ended. Taking the view that shell shock may be, and generally is the result of emotional overthrow rather than overwhelming motivity, and that the main places of attack are the frontal lobes and the medulla, our fear is that, subsequently, many such may develop psychical epilepsy or epileptic equiva- lents, and already w T e have a number of cases of definite petit mal and post epileptic automatism. 9. The Classification which we suggest for general adoption is as follows : (a) The elimination of (1) organic brain conditions, (2) the sound but temporarily " knocked out," and (3) the malingerers, in whom " the party's criminal will " feigns symptoms that do not exist. Then we have still to discriminate (6) The neurasthenic where physical strain or in- fection lights up a psychopathic disposition. (c) The psychasthenic where psychical strain has upset an allied disposition. (d) The neuromimetic (badly called the hysteric) with dominant ideas, producible, and removable by suggestion. (e) The traumatic where there has been concussion, local or general, of all degrees of severity, with the usual symptoms. (/) Shell shock where high explosives have produced a syndrome of symptoms more by emotivity than by commotivity, the latter altering, lessening, and even arresting the characteristic symptoms. 16524 I t 264 These varieties may be found separate or combined. Differentiation requires experience and expert knowledge. But it is essential for early and satisfactory treatment. I append a specimen of a card recommended by me for use by the different medical officers concerned. 10. Finally, the definite prognosis and assessment values of this new syndrome seem still unsettled. Our Australian policy is to board all cases of definite shell shock as soon as possible for Australia, as permanently unfit for Active Service in the future, and to treat the other classes of cases as, at least, temporarily unfit for Active, though, in many cases, probably fit for Home Service, either here or in Australia, after a period and a treatment that are determined from the circumstances of the case. J. W. SPRINGTHORPE, Lt.-Col. March 28th, 1918. Specimen of proposed card for use of Medical Officers. (Front of card,) By Order NEURASTHENIC, HYSTERIC, AND SHELL SHOCK CARD. This Card is to be signed by M.O.s in charge of any cases of Neurasthenia, Hysteria, or Shell Shock, in Hospitals or Command Depots, and for- warded with the History Sheet. will be held responsible tor its complete- ness and accuracy* (Back of card.) NEURASTHENIC, HYSTERIC, AND SHELL SHOCK CARD. Strike out each item that is nut applicable. Name of Patient Rank Unit Reg. No In the family there has been Prior to enlistment patient ... The patient himself hadlnot On Hysteria Epilepsy Insanity Neurasthenia- Nervous breakdown Nervous instability was : Highly strung Alcoholic had: Nervous breakdown Fits Injury to skull Syphilis Insanity Sunstroke become : Nervy under strain of service He had: Neurasthenia Hysteria Shell shock with Wound Burial Gas Concussion At As a result he became He still has He has developed Other special points noted are Dazed Unconscious Maniacal Dumb Deaf- Stammering Blind Amnestic Had : Tremors Headaches (frontal : occipital') Insomnia Bad dreams Vertigo " Turns " Head-ache Confused Dull Tremors Vertigo Bad dreams Insomnia Defective Memory- Power of Concentration Sight Hearing Stammering Sweats Flushes Palpita- tions Gastric Respiratory Locomotive troubles " Turns " Is : Dumb Neurasthenic Hysterical Neurasthenia Hysteria Myoclonic spasms Delusions Epilepsy Petit Mai Mental Wasting Hyper-thyroidism Hyper-Adrenalism Defensive Reflex acts (jumps, flinches, etc.') Signed as true and i Place Q correct. Signature )at.e... Rank... 2CG THE CARE OP THE TUBERCULOUS SOLDIER. BY MAJOR P. HORTON-SMITH HARTLEY, C.V.O.,M.D.,F.K.C.P.,; Honorary Adviser on Tuberculosis to the Ministry of Pensions ; Senior Physician to the Brompton Hospital for Consumption and Diseases of the Chest. In the paper which I have been asked to read to-day I propose to bring before the Conference the steps which are being taken in Great Britain to treat and assist the soldier who has acquired tuberculosis in the service of his country or whose disease has been aggravated thereby. Our Allies may have adopted methods which differ in part at least from those in vogue in this country, and a consideration of such differences may be of material value in indicating the directions which our further efforts should take. A year ago, in an article published in the journal " Kecalled to Life,"* I sketched out the proposals and plans which the Ministry of Pensions then had in view. In the present paper, based on my former article, I propose to bring the position up to date, to state what is being done and to indicate what there remains to do. The problem, as you are aware, is a vast one. Up to the end of last year about 20,000 men had been invalided from the British Army suffering from pulmonary tuberculosis, and each year the war continues large numbers will be added to the total. The national importance of the problem is also heightened by the fact that too often a case entails suffering not only upon the patient himself, but also upon those near and dear to him, thus augment- ing suffering and greatly increasing the cost of treatment. Need for Careful Examination of Recruits. In considering the subject, we must first ask ourselves whether every care is exercised to limit the problem by seeing that men already suffering from tubercle are not admitted into the Army. In the past this has not been the case. Men have been passed into the Army who had previously been inmates of sanatoria, and liad suffered from consumption. Of these, not all break down again, the result depending much on the hardships to which they may or may not be exposed, but many certainly do succumb after :i longer or shorter interval, and are invalided from the Service, thus entailing great expense to the country in treatment allow- ances and pensions. It is clearly wiser, therefore, to exclude such men from the Army, leaving them to continue their work, which may be of great value to the country, in their more sheltered civilian capacity. Great care must be exercised, therefore, in examining recruits. Histories of previous pleurisy and haemoptysis must be carefully enquired into and investigated, * " Tuberculosis in its relation to the War," Recalled to Life, No. 2 (p. 254) ar re 267 and the assistance of Tuberculosis Officers and others who have experience in the diagnosis of diseases of the chest invoked in any case where doubt or difficulty arises. The need of care in this respect is now more generally appreciated, but it must be constantly borne in mind in the interest both of the country and of the individual recruit. But if all such cases of obvious tuberculosis could be eliminated from the Army we should still have a vast problem to deal with, for to the war itself must be' attributed a large proportion of the cases of phthisis with which we have to deal. Modern research teaches us that nearly every adult is already infected with tubercle. Under normal circumstances the natural immunising processes are sufficient to prevent the spread of the infection, and most of us carry the poison through life without harmful suit. But under the strain of active service it is different. The soldier's strength becomes sapped by exposure and strain and his vitality diminished, and under these conditions the tuberculous 'ocus, which might otherwise have remained for ever dormant, akes into life, and signs of active disease, for the most part ,ffecting the lungs, make their appearance. Direct infection has no doubt also played its part in the spread f tuberculosis, which we are considering. The close proximity man to man, inseparable from life in tents and the unavoidable vercrowding sometimes met with in billets or huts, must have resented many opportunities for massive infection and con- quent danger when a case of consumption has developed under ch conditions. Need for Early Diagnosis. The next point which must be borne in mind is the necessity for early diagnosis, when once signs of pulmonary tuberculosis 3gin to manifest themselves, if we are to obtain the best results treatment and prevent the further spread of the disease. [n view of the insidious onset of the malady in so many cases "is is by no means easy, especially under conditions of active irvice. The members of the Royal Army Medical Corps must, lerefore, ever be on the watch for the disease, and when signs )f lassitude, cough and wasting make their appearance the man lould at once be placed under observation, his temperature igistered, and the sputum tested, not once, but many times. If lis is done, in most cases the disease will be recognised early, and appropriate treatment will have the best chance of success. Let us now consider what is being done in this country to secure for the soldier who has developed phthisis the treatment best suited for him in the different stages of his illness, and in the following pages pulmonary tuberculosis or phthisis will be especially considered, this being the chief problem with which we have to deal. It should be added, however, that treatment for surgical and other forms of tuberculosis is provided by the National Health Insurance Commissioners. 268 Treatment of Early Cases of Pulmonary Tubercu- losis. Sanatorium Treatment. As soon as it is evident that the patient is suffering from phthisis, or even when this is strongly suspected, he is sent home to one of the military hospitals in this country. If there is no doubt about the diagnosis he comes before a Medical Board, and in due course is invalided from the Army, his further treatment being undertaken by the Civil Authorities. Before being dis- charged, however, from the military hospital, and in order to avoid delay in procuring him suitable treatment, steps are taken to arrange with the ' ' National Health Insurance Commissioners ' ' for his admission to a sanatorium, if he be an early case, or to a hospital if his disease be more advanced every discharged soldier, whether insured or not, whose tuberculosis has, in the opinion of the Invaliding Board , been either ' ' caused " or " aggravated ' ' by military service, being now entitled, under arrangements recently made, to such form of treatment as his case requires. For this purpose a form (National Health Insurance, A.F.O. 1835) , entitled ' ' Application for Sanatorium Benefit on Discharge from the Army," is filled in, giving the man's name and intended place of residence on discharge, together with certain medical details in regard to his case. It is signed by the officer in charge of the military hospital, and forwarded to the National Health Insurance Commissioners of England, Scotland, Ireland or Wales (at the addresses given on the form), according to the part of the kingdom in which the applicant proposes to reside. Arrange- ments are then made by the Commissioners (under financial agreement between the Commissioners and the Treasury) whereby the soldier, now invalided from the Service, is transferred, pro- vided he be an early case and accepts the treatment, to a sana- torium, and this is, so far as possible, the institution with which the Insurance Committee of his place of residence has habitually made arrangements, and consequently, as a rule, not far from the patient's home. Before leaving the hospital the case is also brought to the notice of the Local War Pensions Committee of the area in which the man will eventually reside. These bodies have now been estab- lished all over Great Britain, and one of their most important duties is to keep in touch with discharged soldiers and to assist them when in difficulty, and to obtain for them such treatment as they may from time to time require, In the early period of the war not a few men refused sana- torium treatment in their anxiety to return home and see their relations and friends, from whom they had been long separated. This difficulty has been overcome by granting the soldier a fort- night's leave on full pay and allowances after leaving the military hospital and before entering the sanatorium. In other cases, refusal of treatment may have been due, in part at least, to insufficient care on the part of hospital authorities in impressing upon the patient the necessity of accepting sanatorium treatment 269 in the early .stages of his disease. To give another chance to such patients, the Ministry of Pensions has made financial arrangements with the Insurance Commissioners whereby, if .such a case is brought to their notice by the Local War Pensions Committee or otherwise within six months of discharge from the Army, sanatorium treatment will be given with as little delay as possible. Allowances during Sanatorium Treatment. It was clearly useless, however, to expect men who may not feel very ill, and who are capable of some work, to accept sana- torium treatment should they feel that their families are in want as a result of their absence from home. It was decided, there- fore, that whilst a man is at a sanatorium he shall be considered " totally disabled," and he is in consequence given an allowance at the maximum rate of pension which, in the case of privates, amounts to '21s. 6d. a week (less a deduction of Is. per week in respect of maintenance), together with a separation allowance of 135. 9d. per week for wife, and of 5s. per week for the first child, 4,9. 2d. for the 'second, 3s. 4d. for the third, and 2urvu jusqu'ici. Quelques ecoles ont meme deja pourvu a la fourniture successive de la maniere premiere, au fur et a mesure que s'en est fait sentir sur le besoin, comme elles ont pourvu egalement au changement et a la reparation des instruments de travail qui pour quelque raison que ce soit etaient devenus d'un usage difficile ou impropre. Cette fonction pourra cependant etre organisee d'une maniere plus reglementaire et plus profitable. Etant donnee la cir- constance que certains metiers sont enseignes, d'apres les memes methodes. dans toutes les ecoles, une entente entre les directions de ces ecoles et les patronages constitues aupres d' elles sera opportune et facile, soit pour 1' appro visionnement en commun des matieres premieres et des instruments de travail, soit pour 304 i'echange de service dans leur fourniture, au cas oii un ouvrier aveugle reeduque dans une ecole viendrait habiter un endroit beaucoup plus voisin de la residence d'une autre ecole et dans d'autres cas'ou cet echange de services -pom-rait etre utile. Son travail acheve, 1' aveugle trouve difficilement a vendre par lui-meme les brosses, les balais ou les filets qu'il a fabriques, soit parce que la consommation en est trop reduite dans 1' endroit ou il habite, soit parce qu'il lui manque, pour quelque motif dependant des circonstances de personne et d'ambiance, la possibilite d'en organiser la vente. Voila une autre , fonction a laquelle pourvoient deja en partie les ecoles de reeducation, mais qui pourra egalement etre organisee plus parfaitement et avec des resultats plus avantageux^ specialement si Ton arrive aussi dans ce but a 1' accord desire entre les diverses ecoles. L'on pourra, soit etablir des contrats avec une ou plusieurs maisons qui s'engageront a acquerir annuellement en tout ou en partie les produits d'une categorie determinee, fabriques par les soldats aveugles, soit instituer une agence speciale qui se mette en relation avec des etablissements ou magasins qui s'occupent deja du commerce de tels produits pour leur proposer la vente des quantites qui seront au fur et a mesure envoyees par les aveugles reeduques. Cette oeuvre servira non seulement a faciliter 1'ecoulement des produits, mais encore a empecher que, par la difnculte de les vendre ou sous 1' impulsion d'un besoin urgent, les ouvriers ne se trouvent obliges de les ceder a trop bon prix. Pour les soldats reeduques qui voudraient entrer a travailler comme salaties dans les ateliers ou comme stipendies dans un emploi quelconque, le patronage a egalement a remplir une fonction necessaire et de la plus haute utilite. Quelque institut de reeducation a deja commence depuis les premiers temps a s'occuper du placement de ceux qui peu a pen sortaient de 1'ecole : il a, par exemple, envoye un delegue charge d'etudier les condi- tions du travail et la possibilite du placement dans le pays ou le reeduque avait sa famille et desirait s' etablir, ou bien, il en a recommende 1' admission dans quelque atelier de la ville ou residait 1' institut. Mais c'est la encore une fonction qui reclame une meilleure organisation-. Le patronage pourra se servir aussi des bureaux de placement ordinaires institues par les organisations professionnelles ou par accord entre ouvriers et patrons ou par initiative des institutions publiques, mais il aura ensuite, dans ce cas, evidemment une tache particuliere importante et delicate en rapport avec les conditions toutes speciales ou se trouve I' aveugle en comparaison avec les autres ouvriers et employes : et cela, soit pour lui faciliter la recherche d'une occupation qui lui soit adaptee et en proportion de 1'habilete acquise, soit pour faire en sorte que sa capacite productive, meme en cas d'inferiorite avec celle des ouvriers qui voient, soit cependant appreciee dans son integrite et remnneree dans une mesure correspondant a sa valeur effective ; de maniere que ni les aveugles n'aient a subir une injuste exploitation ni 1'ouvrier qui voit ne 305 puisse trouver en eux, meme s'ils sont en petit nombre, das concurrents de nature a provoquer la baisse des salaires. II ne suffit pas, naturellement, d'avoir pourvu a un premier placement. Celui-ci pourra bien rarement etre stable ; il ne sera meme postres frequent qu'il puisse valoir pour une periode de longue duree. II pourra sou vent, au contraire, n'etre qu'un essai relativement court. II pent arriver que 1'etablissement ou 1'atelier ou 1'aveugle, ouvrier ou employe travaille vienne a se fermer ; que celui-ci ne trouve pas dans 1'endroit ou il est occupe une ambiance convenable ; que le travail choisi ne corresponde pas a ses aptitudes ; il peut arriver enfin que , par une de ces mille circonstances qui surviennent meme a ceux qui voient, 1'aveugle se trouve desoccupe. Dans tous ces cas, il devra sentir, prompt et vigilant, 1'appui du patronage, chaque fois qu'il ne reussira pas a se trouver par lui-meme une occupation convenable. Mais cet appui n'obtiendra pas toujours le resultat souhaite, soit parce qu'une crise se sera manifested dans certains genres de metiers, soit qu'il y ait exuberance de main d'oeuvre, soit pour toute autre cause. Tant que durera la guerre et tant que son souvenir recent demeurera aigu et emouvant, 1'aveugle pourra peut-etre compter, dans ces circonstances, sur la pitie et sur la reconnaissance qui lui sont dues et esperer quelque preference sur ceux qui voient, mais, par la suite, il ne devra compter que sur la valeur de ses capacites professionnelles et il sera con- sequemment sujet, comme tous les ouvriers, a 1'alea d'un chomage momentarie. Le patronage doit se preparer a faire face a cette eventualite moyennant le placement des aveugles dans une maison de travail pour voyants comme celle que la Societe Humanitaire a entre- tenue a Milan, jusqu'a 1' entree en guerre de 1' Italic, pour y accueillir les ouvriers temporairement desoccupes, ou dans une rnaison de travail expressement instituee pour y faire travailler, a titre temporaire ou definitif, les ouvriers aveugles qui ne pourraient trouver ou ne voudraient chercher du travail ailleurs ou encore dans un atelier, comme celui qui existe reja sons le nom de " Laboratorie Zirotti," a 1'institut des aveugles de Milan, ou Ton emploie dans divers metiers les ouvriers aveugles de la ville qui n'ont pas d' autre occupation. Quelle cooperation devront preter, pour 1'obtention de tous es resultats, les sous comites ou les correspondants choisis dans les divers chefs lieux de province et dans les villages et cites ou resident les. aveugles? II est facile de le comprendre. II leur appartient de suivre avec une attention vigilante et affectueuse 1'aveugle dans son activite, de lui offrir un appui dans les moments ou il courra le danger de se sentir vaincu par les difficultes qu'il rencontre sur son chemin, de lui donner aussi les conseils et les concours pour lesquels il n'est pas necessaire de recourir au patronage ; il leur appartient ensuite de transmettre a ce dernier les demandes des aveugles, en les accompagnant des indications opportunes, de donner au patronage toutes les informations requises sur 1'asiduite de 1'aveugle au travail et sur le profit qu'il en retire, sur les conditions du marche local, en ce qui concerne 306 le placement de la main d'oeuvre, le reapprovisionnement de la matiere premiere, 1'ecoulement des produits etc. Ces informations devront egalement servir au patronage pour 1' attribution des p'rix d' encouragement, dont 1' institution s'est deja demontree si opportune comme un stimulant a 1'activite de certains reeduques qui, peut-etre, sous 1' influence deprimante du milieu ou ils retournent vivre, specialement dans les campagnes r se trouveraient tentes de negliger les nouvelles aptitudes au travail qu'ils ont acquises et de se contenter de vivre du montant de leur pension et de 1'aide qu'ils peuvent attendre de la solidarite de leurs amis et de la pitie de leurs concitoyens. L'oeuvre des sous-comites et correspondants locaux sera de la plus haute utilite pour tout ce qui concerne le confort et P assistance de 1'aveugle reeduque, meme dans les diverses con- tingences de sa vie familiale. II y a deja beaucoup d'aveugles, par exemple, qui ont senti le besoin d'illuminer d'un sourire d' amour les tenebres de leur vie et qui ont trouve une creature qui a accept e bien volontiers de devenir leur compagne affectueuse et devouee. II peut y avoir dans ce cas mille doutes et problemes a resoudre : Est-ce que je fais bien de me marier? Est-ce bien la personne qui puisse me donner la compagnie, Faffection, 1'appui dont j'ai besoin? Dois-je 1'introduire dans la famille de mes parents ou former un nouveau foyer? II y a ensuite la question et le choix du trousseau, de la maison, du mobilier ; et, plus tard, la naissance d'un enfant, etc., etc. Voila autant de cir- constances ou la parole et le conseil d'une personne amie peuvent rassurer 1' esprit de 1'aveugle et lui indiquer son chemin. Mesures a prendre pour Plnstallation de 1'Habitation de POuvrier aveugle autonome. Une tache peu lourde, mais cependant utile et delicate, que le patronage devra assumer est 1' installation de 1' habitation de tons les aveugles reeduques qui ne pourraient pas trouver moyen d'exercer 1'habilete acquise dans la localite ou reside leur famille et qui se trouveraient consequemment dans la necessite de se transferor dans quelque centre plus important ou mieux adapte. Cette tache pourrait meme assumer une ampleur et une import- ance plus grande si, au lieu de pourvoir cas par cas, au fur et a mesure que s'en manifesto le besoin, le patronage voulait prendre 1'initiative de pourvoir au placement, dans les plus grandes villes et plus specialement dans les cites ou ils ont deja ete reeduques, de tous ces aveugles qui n'ont aucuns desirs, motifs ou interets speciaux de retourner ou de demeurer dans le lieu de leur ancienne residence. Et, de fait, il est tout nature! que dans ces villes les aveugles reeduques pourraient etre mieux proteges et guides, qu'ils n'y subiraient pas 1'influence deprimante, comme il a ete dit de certains petits villages ou la defiance precongue sur la capacite lucrative des aveugles, d'etranges prejuges moraux et des manifestations plutot nuisible de compassion et de sym- pathie eiivers ces infortunes, semblent plutot inviter 1'aveugle a 1'oisivete ; qu'ils y trouveraient enfin dans les ateliers et dans les emplois un placement plus facile, et tout an moms de precieux . 307 ^vantages pour Tacquisition de la matiere premiere et 1'encoule- ment de leurs produits. Nous avons deja ecrit sur ce sujet dans le journal de Milan, li Corriere della Sera " du 27 septembre 1917, ou nous proposions la construction, a Milan, d'une serie de maisonnettes contigueg,, d'un seul etage chacune, a mettre a la disposition des soldats aveugles reeduques, qui n'auraient pas trouve 1'ambiance favo- rable dans les villages ou ils seraient retournes et qui desireraient s'etablir, pour les motifs indiques ci-dessus, dans quelque grande ville. Outre les a vantages relatifs a 1'exercice de leur metier, ils pourraient encore en retirer bien d'autres de cette installation. "Leur vie, ecrivions-nous alors, serait moins triste, vivant en voisinage, ils pourraient se reunir dans leurs heures de liberte, alimenter leur vie intellectuelle par de bonnes lectures, participer -comme citoyens a la vie politique, donner en somme a leur vigoureuse jeunesse cette plenitude de developpement spirituel et materiel a laquelle elle a droit." Et pour subvenir a la difficulte du transfert quotidien des maisons aux etablissements et aux bureaux situes dans les divers endroits, eventuellement eloignes d'une grande cite, je proposals 1'acquisition d'une automobile speciale qui servirai a transporter chaque matin les aveugles au lieu travail et a les reconduire a leur maison le soir. Fonctions du Patronage relatives a la Collectivite des Aveugles reunis dans les Maisons de Travail. L'oeuvre du patronage se rattache surtout, d'ailleurs, au fonctionnement des maisons de travail expressement organisees pour les aveugles de guerre. Avoir cree pour eux ces maisons n'est qu'un premier effort qui engendre immediatement la necessite d'un devoir ulterieur d'assistance. Aussi grand que puisse etre le capital recueilli pour la fondation des maisons et ieur fonctionnement, il faut naturellement eviter de le depenser trop vite : il est necessaire pour cela de veiller a ce que le travail fourni par les aveugles reunis dans ces maisons ait une valenr economique qui ne soit pas inferieure ou, du moins, pas trop iriferieure aux salaries qui devfont leur etre assignes dans une in csure correspondante aux besoins de leur subsistance. De tout -ce que nous avons dit plus haut, Ton doit certainement deduire, en effet, que la deficience de la capacite productive des aveugles ivlativement a celle des autres ouvriers, deficience accrue par le manque de collaboration avec ceux qui voient, ne permettra pas, dans la plupart des cas, que les marchandises fabriques par eux aient une valeur d'echange superieure ou egale aux salaires qui dovront leur etre attribuees, plus le coiit de la matiere premiere et les frais courants necessaires au fonctionnement des maisons de travail. Cela parait d'autant plus evident, si 1'on pense que ceux qui chercheront specialement de 1' occupation dans ces maisons sont ceux qui n'auront pas trouve d'autre condition plus convenable, c'est-a-dire, presque toujours, les moins habiles, IPS moins intelligents et, peut etre, les moins conrageux. Du reste. 308 , meme les maisons de travail pour les desoccupes qui voient sont constamment passives et presentent meme souvent des passivites vraiment impressionnantes. C'est a la direction de maisons de travail qui seront institutes qu'il appartiendra de veiller au choix des travaux les plus adaptes a la capacite des aveugles, a ce que leurs produits trouvent 1'ecoulement le plus facile et le plus sur, qu'ils ne soient point sujets a 1'alea de la mode ou trop exposes aux autres fluctuations du marche ; de diriger chacun des aveugles vers le travail auquel il sera particulierement plus et d' organiser de la fa9on la meilleure et la plus productive leur collaboration. Mais, meme dans le choix des travaux a executer dans les maisons, 1'oeuvre de la direction pourra utilement s'appuyer sur celle des patronages qui pourront lui donner des indications fournies par 1' experience qu'ils auront acquise dans leur oeuvre d' assistance aux ouvriers aveugles autonomes, surtout a ceux qui travaillent a domicile. En outre, les patronages pourront en certains cas approvisionner les maisons de travail des matieres premieres qu'ils fournissent deja aux autres ouvriers aveugles, comme Ton pourra eventuelle- ment leur confier la vente des produits fabriques dans les maisons elles-memes. Les patronages pourront aussi exercer ces memes fonctions pour les cooperatives de travail entre aveugles, sauf certaines differences de formes et d'intensite determinees par la nature diverse des deux institutions, comme nous 1'avons deja releve plus haut. 'Surtout les patronages, qui devront avoir, par delegation des pouvoirs publics eux-memes, la fonction de {'assistance aux aveugles reeduques et qui seront consequemment reconnus comme les tuteurs legitimes et naturels de tons les interets materials et moraux a la defence desquels les aveugles ne veulent ou ne peuvent veiller par eux-memes, pourront s'occuper de stipuler, pour les maisons de travail ou pour les cooperatives de travail entre aveugles, des contrats avec les etablissements prives et surtout avec les institutions publiques qui s'engagent a acquerir d'une maniere continue toute la quantite ou une partie fixee, de produits (Jeterminee- qui seront fabriques dans ces maisons oil par les cooperatives. L'Etat, par exemple, pourrait s'engager a acquerir toutes les brosses et balais, dont il est a presumer que le nombre ne serait pas excessif pour les besoins des services publies existants dans une grande ville et dans les villages les plus voisins, et, quant aux brosses, pour le nettoyage des chevaux de 1'armee. Si 1'Etat ne pouvait les acquerir toutes, une partie pourrait etre offerte a la commune de cette ville, et, a 1'occurrence, a d'autres communes voisines. L'Etat pourrait aussi s'engager a acquerir des maisons de travail tout ou la majeure partie des filets dont il a besoin pour wagons de chemins de fer, et ainsi de suite. Nous ne sommes certainement pas favorables aux formes de monopole et d'exclusivite concedees par 1'Etat, qui vient a limiter ainsi sa liberte d'acquisition et le choix des produits les plus con- venables par leur qualite et leur prix ; mais le cas qui se presente est si special, qu'il justifierait une situation de privilege. II s'agit ici de personnes qui. pour la defense du sol de la patrie et de son- 309 independance, ont sacrifie leur integrite physique, modestes heros a qui nous devons tous la reconnaissance, envers qui la nation a contracte une obligation sacree d' assistance que le verse- ment d'une pension ne suffit pas a compenser ! Qui done pourrait trouver in juste ou trop onereux que 1'Etat leur accorde une preference dans la fourniture de certaines marchandises ? Qu'ii leur concede, par exemple, une exclusivite, ou meme, au cas ou 1' exclusivite ne semble pas opportune, necessaire ni possible, car la quantite des produits fabriques par les invalides de guerre ne serait pas suffisante aux besoms de 1'Etat, qu'il etablisse pour les produits par eux fabriques un prix quelque peu superieur a celui qu'il serait possible d'obtenir d'autres f ournisseurs ? L'Etat ne doit etre exigeant que sur la qualite, qui doit repondre aux necessites de 1' usage de maniere que n'en souffre point le service auquel les marchandises doivent etre employees ; mais une superiorite de prix ne semblera certainement illegitime n'. inopportune. Comme on le voit, les occasions et les formes dans lesquelles les patronages peuvent offrir leur assistance aux aveugles re- ediques sont infinies. Mais cette assistance leur sera d'autant plus utile qu'ils s'efforceront de le faire en sorte que leur inter- vention ne limite pas la liberte des aveugles, ne suffoque pas leur initiative, n'engourdisse pas leur activite. Nous avons le devoir d 'aider ces heros malheureux centre les obstacles que la vie presente a chacun, mais pour eux plus nombreux et plus graves; mais nous n'accomplirons ce devoir comme il faut si, en leur apportant notre assistance, nous ne saurons respecter leur personnalite et le sentiment de leur independance, de leur dignite, de leur hnmanite. Conclusions. Pour toutes les considerations ci-dessus exposees considerant : 1. Qu'il convient de rendre autant que possible 1'invalide a sa precedente vie de travail, force vive dans la Societe de travailleurs , renouvele dans la confiance et dans la conscience d'etre une energie socialement utile et individuellement capable de faire respecter sa dignite persormelle de travailleur ; 2. Que 1'invalide aveugle, bien qu'etant incontestablement un individu diminue et incomplet, n'en soit pas moins pour cela un travailleur appreciable, du moment qu'il a revele, dans 1'exercice du travail manuel, des qualites precieuses, insoupgonnees avant la guerre, alors que 1' education professionnelle des aveugles manquait des secours didactiques necessaires pour mettre ces qualites dans leur pleine valeur et leur pleine efficacite ; 3. Qu'il serait consequemment incompatible avec le veritable interet materiel, intellectuel et moral de 1' aveugle reeduque de Je confiner, sous le pretexte de sa faiblesse, dans une sphere d' action etroite, ou s'ajouterait a 1' inconvenient de sa propre cecite, celle de tous ses compagnons de travail, et ou la monotonie 310 d'une vie de travail sans luttes, serait comme une autre ombre etendue sur son ame, soustraite prematurement aux echos et aux debats du monde de ceux qui voient ; 4. Que, seule la preoccupation de 1'embarras eventuel ou 1'aveugle de guerre arriverait a se trouver au cas ou il voudrait associer son activite a celle des gens qui voient, et la supposition de la negligence et de 1'abandon dont il serait bientot victime, ne suffiseront pas u justifier le renoncement a une experience qu'une intense propagande vraiment humanitaire entre travailleurs et entrepreneurs ' l voyants " pourrait rendre possible avec le triomphe consequent de la plus complete reintegration de 1'aveugle de guerre dans la vie commune ; 5. Qu'enfin, s'il peut suffire a l'aveugle-ne, habitue a vivre separe en partie du monde qui 1'entoure, la consolante distrac- tion des travaux varies qui enrichissent le monde de sa pensee pauvre d' images, une telle distraction ne peut suffire egalement .aux exigences spirituelles de celui qui peut voir encore avec les yeux des autres, car il a 1' experience de la lumiere et de la beaute .et un riche patrimoine d' images dans le cerveau que seul peut tenir vivant le contact avec ceux qui voient, tandis qu'il se dissiperait dans la convivence habituelle avec des . aveugles seulement. On enonce le vosu : Que le travail individuel autonome de 1'ouvrier aveugle soit favorise, soit a domicile, soit dans les ateliers parmi ceux qui voient (moyennant 1' application du principe de la division du travail), soit dans les emplois, comme le moyen le plus propre a susciter chez 1'aveugle les energies personnelles et a aiguiser en lui le sentiment de la responsabilite, a lui permettre de faire apprecier ses qualites de travailleur et de participer a la vie du monde qui 1'entoure, encourage a reprendre son ancienne activite. DOTT. PEOF. LAVINIA MONDOLFO, Direttrice della Scuola di Eieducazione per Soldati ciechi annessa all' Istituto dei Ciechi di Milano. Maison de Convalescence et de Travail pour les Militaires aveugles. Florence, via S. Marta, n. 14. Annexe IV. 1. La distribution dans les divers ateliers et ecoles des 146 militaires aveugles hospitalises dans la maison jusqu'au 31 mars, 1918, peut se resumer comme il suit : Travail de 1' osier, 65 ; travail canne mais, 66 ; charpenterie, 3 ; I'cconvrage des chaises ordinaires, 10; recouvrage des chaises en 311 canne d'Indes, 8; travail de nattes et corde, 7 ; cages "pour huile r 15; filets de peches, 5; reliure de livres, 3; balances, 3; objets en plumes, 5; couverture de dames-jeannes, 23; agri- culture, 25; travail brosses et sparterie, 15; bonneterie, 7; massage, 6; lecture et ecriture "Braille," 86; dactylographie, 65 ; musique : piano, 6 ; orgue, 2 ; autres instruments, 36. Du jour de 1'ouverture an. 31 mars, 1918, la " Maison " a hospitalise 146 militaires aveugles dont : No. 59 furent congedies apres avoir accompli leur reeducation ct Xo. 37 en sortirent pour les motifs suivants : No. 20 pour de graves motifs de famille ne rjurent achever leur reeducation : No. 6 furent transferes dans d' autres instituts ; No. 4 furent eloignes pour des motifs d'indiscipline ; No. 1 parce que irreeducable ; No. 6 durent retourner en traitement a I'hopital. De maniere qu'au 31 mars, 1918, No. 50 soldats se trouvaient presents dans la " Maison." Annexe N. 3. Ecole de Reeducation de Naples. Jusqu'au decembre, 1917, 23 militaires aveugles avaient ete hospitalises a 1' Ecole de Reeducation de Naples, dont 10 donnes comme reeduques et 13 en reeducation. Resultats obtenus satisfaisants : Tous les reeduques travaillent, excepte un qui est riche, et tirent profit de leur travail. Le patronat les suit, les aide en ce qui a rapport avec la matiere premiere et les commandes. Les enseignements consistent en travaux de vannerie pratiques et de luxe, de nattes pour fenetres, de reliure de livres, de tapis, de cocco, de nattes, de corbeilles et bandes de sparterie. 312 REPORT ON THE DEAF. BY J. DUXDAS GRANT, M.D., F.E.C.S. ; Major (ret.) late P.O. Rifles ; President, Special Aural Board (under Ministry of Pensions). Since the memorable meeting pt Paris in the May of last year much blood has been spilt, much maiming and mutilation has taken place, and yet the end of this murderous war seems almost as far off as ever. The moral of this is that, however great our efforts have been to reconstruct and re-establish those sufferers who are about to be, or have actually been, discharged from the Navy and Army, these efforts will have to be continued with equal, and even with redoubled, energy for a very considerable time . Our French Allies. ow r ing to their throwing enormous bodies of already conscripted and trained forces into the field before we were able to do so , were in possession of much valuable experience in regard to the recruiting, training, maintaining and treating their men which we , with our ' ' contemptible little army ' ' of pro- fessional and voluntary soldiers, could study and apply with advantage to our own conditions. Similarly, with regard to the maimed and mutilated, we were able to get from them a good lead,* though, as may be seen from Sir Alfred Keogh's admirable paper read, before the Inter- Allies' Conference and published in the Eeports, we had made not merely a good start, but a great advance in a relatively short space of time. It may be admitted that we were rather behindhand with the deaf as compared w T ith the blind, maimed and neurasthenic, but perhaps the reason is not far to seek. In spite of some sensational statements by writers in the Public Press, the numbers of the really deaf were comparatively few, and their helplessness in obtaining paid work was not very considerable. The more obvious claims of those otherwise afflicted in large numbers called for the first consideration. The earliest step in dealing w T ith the deaf was taken privately in Edinburgh, where the Edinburgh Lip-Reading Association established a class on May, 1st, 1917, under the tuition of Miss M. E. B. Stormonth, of the Edinburgh School Board. A small number of men were with some difficulty collected from all parts of the United Kingdom, and were lodged or billeted through the generosity of the associa- tion. The teaching was excellent and the results most satisfac- tory, but, of course, the scope of the voluntary association s activity was necessarily a limited one, and, as Miss Stormonth said, State recognition was indispensable. The matter was taken up most earnestly by Sir Alfred Keogh, the Director-General of Medical Service, and enquiries w r ere set 313 on foot as to the extent of the needs of the deafened men and the best means of supplying them on the part of the authorities. I had the honour of preparing for Sir Alfred Keogh the section dealing with the deaf in his Report to the Inter- Allies' Conference. and subsequently of visiting the French institutions in which the deafened soldiers and sailors received the necessary education in lip-reading. Arrangements similar to those which I witnessed in France were proposed and approved, and are now in full force. I have been allowed to describe this work in considerable detail in the third number of the ' ' Review ' ' in your hands , under the title of "Recalled to Life," and I shall not, therefore, impose upon you a repetition of what is now ancient history. Suffice it to say, that the purely official part of the work is controlled and financed by the Treasury, through the Ministry of Pensions, while the absolutely necessary amenities which are indispensable to the successful working of a school of lip-reading for ' ' free ' ' adults is generously subsidised (apart from some private support) from a fund manipulated by the Office of Liaison between the War. Office and the Ministry of Pensions through its chief, General Sir George Bullock, who has taken up the work begun by Sir Walter Lawrence. The number of men so deafened by the incidents of military service as to be in need of training in lip-reading was found to be considerably less than had been supposed, and the number of those willing to undergo such training was very much less still, owing to the abnormal demand for labour and the readiness with which even the deafest men found lucrative employment. I shall revert to this point further on. Meanwhile, every effort has been made by means of advertise- ments, circulars, letters and personal visits to bring before the sufferers the benefits of lip-reading, and to organise courses of instruction conducted by highly qualified teachers. Although the number so deaf as to require lip-reading was not great, it was observed by the officers of the invaliding boards that there was a vast number who suffered from minor degrees of deafness and diseases of the ear attributable to or aggravated by military service. It was, therefore, felt that facilities should be afforded for them to receive the necessary treatment without interference with their daily occupation. Experience has also shown that in the examination of men for assessment of the degree of disability produced by deafness or disease of the ear there were many cases of exceptional doubt or complexity such as to call for special investigation with more detail and deliberation than was possible before the invaliding board. It has been found desirable to provide the means for the carrying out of this more special examination by a board of expert aurists convened for the special purpose. 314 Again, before a man is started on a course of instruction in lip-reading it is considered necessary for him to be examined by experts with regard to his suitability for such instruction, or else for medical treatment, or, it may be, for both. Aural surgeons are properly associated with an expert in lip-reading instruction for the purposes of such an examination. The Special Aural Board under the Ministry of Pensions. To fulfil the purposes above detailed, the Minister of Pensions was pleased to appoint a Board consisting primarily of four aural surgeons (Arthur Cheatle", F.R.C.S. ; Hunter Tod, F.R.C.S.; Sydney Scott, F.K.C.S., and George Cathcart, M.D.), and a specialist in instruction in lip-reading (Mr. Sibley Haycock), with the writer as President. Their activities were in the first instance confined to London, but subsequently they were ex- tended to the various areas into which the United Kingdom is divided for the purposes of pension distribution. These areas are each under a representative of the Ministry, and in each there have been appointed aurists and lip-reading specialists who are members of the Aural Board, but acting only in their own areas. The following is a list of these aural surgeons, with the lip- reading specialists , appointed to the different ' ' areas " : ENGLAND: Northern Area, James Don, M.D., with Mr. D. Baldie; Yorkshire, G. Wilkinson, F.K.C.S., and E. W. Bain, F.R.C.S., with Mr. G. W. Greenslade ; N.W. Area and Cheshire, Sir William Milligan, M.D., and T. Guthrie, F.K.C.S., with Mr. W. Nelson; E. Midlands, F. W. Bennett, M.D., with Mr. A. J. Storey and Mr. W. Carey Koe ; W. Midlands', Wm. Lamb, M.D., and C. G. Buss Wood, F.R.C.S., with Mr. J. Brown; S. Midlands, W. H. Bowen, F.R,C.S. ; East Anglia, E. W. Everett, M.B.C.S., with Mr. O: H. Illingworth ; Home Counties, N., Aural Board, London; Home Counties, S., A. J. Hutchison, M.B., with Mr. J. 0. White and Mr. A. M. Sleight; Southern Area, Central, N. MacGillicuddy , M.K.C.S., W. Prior Purvis, M.D., and Arthur Roberts, F.R.C.S., Ed., with Mr. E. Townsend and Mr. Sibley Haycock; South-Western Area, P. Watson- Williams, M.D., R. A. Worthington, F.R.C.S., and C. E. Bean, F.R.C.S., Ed., with Miss M. Linton Robertson, Mr. P. Dodds, and Mr. Robison. SCOTLAND : S.E. Scotland, A. Logan Turner, M.D., with Mr. J. S. Barker and Miss M. E. B. Stormonth ; S.W. Scotland, Albert Gray, M.D., with Mr. W. H. Addison. WALES :N. Wales, W. Permewan, F.R.C.S., with Mr. S. Coward; S. Wales, D. R. Paterson, M.D., with Miss Williams. The headquarters of the Board is established in a commodious house allotted to- it by the Crown, and situated at No. 28, Park Crescent, London, W. The business is mainly transacted by a secretary, Captain Ingram, who in the present instance happens to have been a teacher of deaf-mutes in Canada before he joined the Army. 315 For the purposes of putting lip-reading instruction within the reach of all who have been discharged from the Army and Navy on account of deafness or ear-disease, the secretary receives lists of such men from the invaliding authorities, and sorts them out according to the areas in which they are domiciled. He then forwards these lists to the representatives of the Ministry in their respective areas, so that the men may be called up before the official aurists and lip-reading specialists for examination as to their eligibility for training in lip-reading, for treatment of their ears, or both. To the large number who are in the London area circulars and letters are sent direct from the headquarters, and many are visited by the secretary or other helpers, who explain to them the advantages of lip-reading. The actual instruction is carried on in the class-rooms at the headquarters, and classes are held there morning and afternoon for those who are prepared to have whole-time training, and in the evening for those who wish to follow their occupations during the day. This has been recognised as a branch of national educa- tion, and the Board of Education has generously co-operated with the Ministry of Pensions by providing the teaching staff under the guidance of one of its medical officers, Dr. Alfred Eichholz. The organisation and technical direction of this work has been entrusted to Mr. Sibley Haycock, Principal of the National Association for the Oral Teaching of the Deaf, Fitzroy Square, from the teaching staff of which institution the actual teachers have been supplied. As regards the duration of the course, opinions differ, and on the whole our French colleagues consider less time necessary than we do. The Germans, on the other hand, ask for at least five or six months. We look upon three months as being an ordinary full course, but in a good many cases a second course is necessary, especially for those who have been deafened through epidemic cerebro-spinal meningitis. The probability is that the nature of the language and pronunciation of the different nation- alities are answerable for these differences. In the pronunciation of French the lips and face come very much into play, whereas in German there is a very extensive guttural element. There is no fault to find with the English language, but the reproach of our French friends that we " swallow our words " is not without foundation, and our habitual mumbling makes us difficult to understand by lip-reading. I may again here recall a personal experience at the Institution ues Sourds Muets in Paris, where, when in conversation with some deaf French officers who, in addition to their own language, knew English and German, I found that they could understand my German better than my English. I quote this not as a proof, but as an illustration of what I have above stated. From the nature of things, then, we might expect our results to be somewhat less brilliant than those obtained in France, and for that matter even in Germany, but we have every reason to be pleased with what our teachers of lip-reading have effected. 316 As a type of the results obtained in France, we have before us those reported from the Institution at La Persagotiere at Nantes. In 73 cases they are noted as : Perfect in 37 Very good in ... ... ... ... ... 10 Good in ... ... ... ... ... 11 Fairly good in ... ... ... ... 5 Mediocre in ... ... ... ... ... 5 Not re-educable in ... ... ... ... 2 Here we have the fine "logical sub-division for which our French friends are so noted, but in our rough, practical w y ay Dr. Eichholz has made a simpler set of categories which are worth considering in detail. They are as follows : (1) Entirely satisfactory. These include cases whose lip- reading attainments place them practically on the level of hearing people ; .that is to say , they lip-read a stranger as though they were practically in full posses- sion of ordinary hearing pow r er. (2) Satisfactory. This category includes cases possessing a useful acquirement of lip-reading, and who respond either (a) after not more than a single occasional repetition, or (b) after they have repeated the ques- tion as lip-read in order to make certain that they have understood rightly. (3) Fair. These cases are able to respond to simple sentences only, and require questions to be repeated from three to five times before they apprehend rightly. (4) Unsatisfactory. These cases respond merely to single words after frequent repetition. They are apt to suffer also from neuro-muscular changes, resulting in flattened or rough voice. Out of 16 who had completed the full-time day course the results were as follows : Entirely satisfactory ... ... ... 5 Satisfactory ... ... ... ... ... 1 Fair ... ' 4 Unsatisfactory ... ... ... ... 2 Unclassified ... ... ... ... ... 4 20 students still in attendance may be classified as : Entirely satisfactory ... ... ... 3 Satisfactory 4 Fair ... ' ... 11 Unsatisfactory ... ... ... ... 2 It is probable that a considerable proportion of these will im- prove the categories before the present . course is completed, pro- vided they attend with due regularity. 317 -Of the 35 who have attended the evening classes there are : Entirely satisfactory ... ... ... 19 Satisfactory ... ... ... 5 Fairly satisfactory ... ... ... ... 2 Unsatisfactory Unable to be classified owing to short attendances ... ... ... ... 9 Other classes have been formed under the London County 'Council and in Manchester, Brighton and Exeter, and others are in course of formation at Eeading, Bristol, Bradford and Plymouth . It will be obvious to all that the learning of lip-reading is most fatiguing and a great strain on the power of attention and mental concentration. While men are still in the Army and under mili- tary discipline when undergoing instruction, as in France, it is perhaps easy to get them to tolerate the necessary control, but our men have been already discharged and are in the enjoyment of their newly recovered liberty. It is necessary, therefore, to make their schooling agreeable to them, as there is :a strong temptation for them to exercise their free agency in the way of rejecting further instruction in order to take up the lucrative occupations which, as we have already said, are now open even to the Very deaf. With this view, the headquarters has been invested with many of the characters of a " club," and in the intervals of cessation from teaching the men enjoy the luxuries of a handsome recreation room, where they can smoke, read and play games, including billiards on a small table, as also of the billiard room, in which there is a full-sized table fitted for pool , pyramids and other varieties of billiards. There is also a small library from which books can be borrowed for home-reading. An interesting experiment has been made with the cinemato- graph, through the kindness and generosity of Messrs. Pathe. Mr. Haycock was filmed w r hile uttering a string of phrases com- piled by him as illustrating ordinary conversation of a simple character, and the students in the class were invited to repeat them aloud as they " lip-read " on the screen. The result was extremely good, and the experiment proved most enlivening and stimulating. At the same entertainment Mr. Lalor, the accom- plished American comedian, now in London, who is a master of clear articulation and facial expression, stood in front of the audience, with a strong light thrown upon his face, while he narrated a number of snappy little historiettes. The laughter on the part of the deaf students show r ed at the same time their powers of lip-reading and the appreciation of good-natured wit. It is intended to have this gentleman's acceptable performance reproduced on the film, and to solicit similar contributions to the experiment from other exponents of the art of the raconteur. Of equal importance is the provision of facilities for meals, and a good mid-day dinner is provided at rather under cost price, as 318 also a tea and hot soup in the evening. The catering and waiting is in the hands of a body of voluntary lady-helpers organised and directed by Mrs. Dundas Grant. The care devoted to the maintenance of the comfort and con- tentment of the men is believed to have been of great help to the teachers in making their eminently successful work all the more easy and effective. The results in the case of those who have accepted training must be considered extremely good, but the numbers are r to say the least, surprisingly small. Has the machinery been installed to no purpose? A thousand times "No." It has already been pointed out that at the present time there is quite an abnormal demand for the labour, even of the very deaf, owing to the drain on the supply of labourers for military purposes. When, however, peace is again restored and demobilisation takes place, there w T ill be a rush for work, and the hearing men will unintentionally but inevitably oust the deaf ones from their occu- pations. Only those who have neutralised their disability by learing lip-reading are likely to retain their hold, and for them the work we have done will prove a great blessing, while our doors will still be open to those who, under the stress of necessity, are then wise enough to ask for our help and teaching. They will come in large enough numbers to justify the elaboration of our machinery, and reward us for our labour. A singular cause of disinclination to learn lip-reading has recently been disclosed , namely , an erroneous idea which has been circulated to the effect that a man's pension is diminished if his earning capacity is increased owing to his acquisition of lip- reading. It can only be said that this is entirely incorrect, and its circulation is calculated to do enormous injury to those w T ho may be deterred from acquiring this profitable accomplishment. No man's pension is diminished because he is taught a trade or supplied with an artificial arm or leg, and it cannot be too strongly impressed upon all concerned that no man's pension is diminished because he has learnt lip-reading. In point of fact, the learning of lip-reading is considered an evidence of the genuineness of the man's deafness and of his being, therefore, entitled to his pension. For the treatment of men discharged on account of deafness or diseases of the ear, but who are able to follow their occupa- tions, special clinics have been organised under the direction of the President of the Special Aural Board. In London there are three, situated respectively in the far west at Hammersmith, in the far east at Stratford-by-Bow and in the centre at the Central London Throat and Ear Hospital, King's Cross. Each of these is open once a week at six o'clock in the evening, so that the men can attend them after their daily work. For those w y ho require operative or other in-patient treatment, accommodation is afforded at certain general hospitals, for which payment is made by the Ministry of Pensions, under special conditions. 319 The work of the Board has some peculiar difficulties which must be obvious to those experts who realise that it has to deal with cases which are passed on to it on account of exceptional complexity or doubt. It involves questions of diagnosis of the utmost delicacy, and assessments of degrees of disability on which the future of the injured man and the interests of the community alike depend. A few words in regard to these difficulties and the methods of overcoming them may not be out of place. The diagnosis of organic deafness, apart from the statements of the patient in response to the ordinary clinical tests, presents difficulties of its own which call for all the care, ingenuity and experience a skilled expert can bring to bear on it. The chief undeniable causes are injuries directly involving the internal ear or diseases such as cerebro-spinal meningitis and mumps. The history of such cases, and still more particularly the direction of wounds and the position of fractures of the cranial bones, as indicated by radiograms, give positive evidence of great value. The respective positions of the wounds, of entrance and exit, may indicate the passage of the missile through or near one or both internal ears. Radiography sometimes re- veals a fracture implicating the internal ear, even in cases in which the candidate has been suspected of concocting a history to bolster up a simulated deafness. The history of genuine traumatic rupture of the tympanic mem- brane from explosion is 'of ten most typical. I shall not here detail its characteristics. As a rule, deafness coming on after cerebro-spinal meningitis is due to extension of the infection to the internal ears, and a history of this disease may be generally accepted as conclusive evidence of the existence of genuine deafness and of its nature. We know, however, that in many cases of epidemic cerebro-spinal meningitis deafness does not ensue. We have, indeed, had a case with such a history and with deafness, but the methodical examination of the ear showed a middle ear catarrh coincidental with the meningitis. This disease is, nevertheless, one of the main causes of the most extreme deafness. The condition of the equilibria! portion of the labyrinth, as indicated by the positive or negative reaction to cold or heat helps us materially, as though the cochlear portion is often damaged without the equilibrial being affected, it is very rare indeed for the equilibrial to be damaged without the cochlea suffering at the same time. Absence of the induced nystagmus would indi- cate that the deafness is due to damage to the cochlea, the presence of this reflex would not exclude it. Functional deafness has received much study since the begin- ning of the war, and is now understood better than formerly. The reflexes, excited by sounds (especially if unexpected), were formerly taken to indicate that the alleged deafness w r as not 320 genuine but simulated; but now we know better, and we realise that the occurrence of these reflexes may indicate merely that the deafness is of functional and not of organic origin. It need hardly be said that this knowledge increases the difficulty in detecting simulation of deafness. In regard to functional deafness, there are many questions of great interest wliich have been much discussed, and need not, therefore, be considered in an assembly to whom they are very familiar. I should like, however, to refer to a paper by Major Hurst which has not been very widely circulated, in which he seems to localise the site of the break in functional continuity of the nerve-strands in this form of deafness. The eligibility of men for learning lip-reading is best dealt with by the aurist and lip-reading specialist in conjunction. It is most important at the outset to eliminate those cases in which the deafness is of functional origin, and for this the aurist is answerable, so that the subject may be handed over to the neurologist or psychiatrist instead of being merged into a lip- reading class with the sufferers from deafness of organic origin. When, however, there is a suspicion that the deafness is simu- lated, the question may sometimes be cleared up in the lip-reading class, when the simulator's pretence to have learned lip-reading may be checked by further observation under conditions on which we need not here dilate. It is practically impossible for anyone with really good hearing to acquire skill in lip-reading, so strong is the tendency to follow the line of least resistance. Such acquisition may be accepted as an indication that the deafness is genuine and not simulated, though it may be only functional and not of organic origin. Among the evidences of suitability for lip-reading we must first recognise deafness of a considerable degree ; there is no doubt that the very deaf, other things being equal, learn lip-reading better than those in whom there is a considerable remnant of hearing, although it must be admitted that a small remnant is no disadvantage. As a rough-and-ready rule, the degree of deaf- ness should be such that ordinary conversation cannot be heard further than one foot, or loud conversation certainly not further than three. I consider one of the most valuable criteria to be the spontaneous acquisition of lip-reading to a greater or less extent, as it indicates, first, a high degree of deafness; and, second, such a capacity as to promise considerable success. It is also necessary that there should be a reasonable amount of intelligence and nerve-power. As regards intelligence, this must not be taken to mean a high degree of education, because it is found that some individuals of comparatively poor education acquire lip-reading, within the limits of the vocabulary ap- propriate to their station, more rapidly than others with much higher educational training. A calm common-sense power of grasping in a synthetic mode what the speaker means to convey is more useful than a critical anxiety to analyse the component sounds before accepting their significance as a whole proposition. 321 The cairn common-sense to which we have referred is scarcely to be looked for in those who are still suffering from the nervous weakness which the strain of war produces in certain tempera- ments, and it is often necessary to postpone instruction in lip- reading for otherwise eligible subjects until they recover from their coincidental neurasthenic troubles. There is still another consideration, and indeed the primary one, namely, whether their deafness is likely to improve under treatment. Our first duty, as Sir Alfred Keogh emphatically insisted, is to cure them if by any means it is possible. Happily, the resources at our disposal in our own special clinics and else- where have in many cases produced the most desirable results, even in the face of difficulties which the initiated can easily divine. On the whole, this part of the work has not presented any very great difficulty. The most responsible function of the Aural Board is the re- inspection of those cases of applicants for pension, which, in the opinion of the aural surgeons attached to the Invaliding Boards, present characters of unusual doubt or complexity, as well as cases in which the claimants appeal against the previous assess- ment, and are referred to the Board for further consideration. As regards the assessment of the degree of disability, we are faceo 1 with special difficulties. Presumably we have in the first instance to gauge the degree to which the man is disabled in regard to his normal earning capacity. Logically, we should have to collect statistics of a large number of deafened men and find out the amount of their earnings. Next, to do the same with an equal number of normal men of similar rank or station. Needless to say, we have no such material at our disposal, and we have to work by a somewhat arbitrary scale. The unit is total disablement ; lesser degrees are estimated in percentages, in reality, in tenths. Our Warrant counts total deafness of both ears as 70 per cent, of total disablement, and taking this as our basis, we are left to work out the percentages for lesser degrees according to the best of our judgment without any hard-and-fast rule. Uniformity of assessment by different boards can, there- fore, scarcely be expected, but on the whole a very reasonable approximation is attained, as is shown by the many assessments and re-surveys which have passed through our hands. To help towards uniformity and to facilitate assessment, we have endeavoured, in the light of these reports and of our own observations, to draw up a scale founded primarily on the degree of the deafness as such. I offer this scale provisionally for your consideration : Per cent. (1) Total deafness both ears ... ... ... ... 70 (2) Total one, nearly total other (shout close to ear) 60 (3) Extreme both (shout from 1 to 2 ft. off on both sides) ... ... ... ... ... ... 50 (4) Total one, moderate other (loud voice 9 ft. off) 40 16524 T, 322 Per cent. (5) Extreme one, moderate other ... ... ... 30 (6) Total one, normal other ... ... ... ... 20 (7) Moderate both or either ... ... ... under 20 (for gratuity) (8) Incapacitating vertigo 50-60 It will be seen that we make special allowance for cases labelled somewhat loosely as "incapacitating" vertigo. Taken au pied de la lettre, the allowance will seem by no means excessive, and indeed too meagre. Each case has to be taken on its merits, in the light of the frequency, severity and genuineness of the attacks. Such cases would generally be recommended for in- patient treatment when circumstances would permit of careful observation as well as treatment. It has also to be kept in mind that in most cases the vertigo has a tendency to subside under operative or other treatment or spontaneously. Concomitant signs and symptoms have also to be taken into consideration. The scheme makes no allowance for suppuration as such, as not necessarily diminishing the earning capacity apart from the loss of hearing-power, but every encouragement to undergo treat- ment is afforded and every facility provided. Another question is how to assess in case of pre-existing disease of the ear. This depends on the other question as to whether the disease w T as attributable to or aggravated by Military Service or not. Examination of the ear often reveals that there had been previous disease, as shown by cicatricial changes or perforations, and sometimes the man acknowledges having formerly been the subject of dulness of hearing, attacks of earache, running or fetor from the ear. More often, however, he does not, either because, like many in civil life, he has completely forgotten the circum- stances, or for some other reason known to himself. We consider the evidence and judge as exactly as we can, but we have to assume that if the man was passed for service, and retained under training and discipline, his hearing was good enough for Military Service. If, then, we find such a degree of deafness as is in- compatible with this, we have to give the invalid the benefit of the doubt, and find the disability attributable to or, at all events, greatly aggravated by Military Service in the absence of any other obvious cause. Our report as to the degree of disability is reviewed by the Award Officers in the light of our reports as to the causation and the other circumstances of the case. I think it will be agreed that the desire of the Ministry is, in the first place , to be generous to the damaged soldier or sailor ; and in the second, to consider the depth of the public purse. I venture to believe that in our limited sphere we are aiding in the arrival at just decisions. It must be realised that the present period is one of building up against the time of greater need when the war is ended, as the change in the labour market will throw out of employment the unfortunate deafened men who now find work at good wages in spite of their defective hearing. The machinery is now well-established and ready for those who are prepared to take advantage of 'it. 323 OFFICIAL REPORT ON THE AFTER-CARE OF THE DISABLED IN THE WAR (ULTRA- DISABLED). PROF. ETTOEE LEVI (Florence), Member of the Executive Com- mittee of the National Commission* for the Protection and Assistance of Invalids of War. The term ultra-disabled is applied to a special category of the disabled (Grands Blesses) whose wounds, whether single or com- pound (blindness, mutilated and crippled limbs, paralysis of the central nervous system), have caused such grave and complex disability as must be reckoned, in current actuarial phrase, at more than one hundred per cent. Such disabled are not only incapable of re-adaptation to any form of useful work, but must rely for their very existence upon the service of others. It is not an easy task to classify the different categories into which the ultra-disabled may be further sub-divided, since there is an infinite variety in the monstrous and complex mutilations of war. For brevity and clearness I shall here divide them into two main categories. First, those disabled by complex mutilation (blind, with double amputation of upper limbs) ; those patients with double amputation of the upper limbs, either with vision or with one normal eye ; those ampu- tated in three or four limbs ; and those crippled in the main joints with corresponding functional lesions. (With such cases, as far as I am aware, the Inter- Allied Conference at Paris, 1917, did not occupy itself.) The second category, unhappily much more numerous, is composed of those patients disabled by lesions of the central nervous system (tetraplegic, paraplegic, hemiplegic). Suffering from chronic illness , they require and have a right to special medical attendance and skilful moral supervision. Taking into consideration the inadvisability of sending these patients a great distance from their homes, I believe it would be unwise to create for them at the present time special institutions, but we ought rather to concentrate them in special hospitals or in special sec- tions of the general hospitals existing in each district of the country. I refer, of course, in this regard to Italy. (With this category the Conference of Paris has occupied itself, and I concur in their conclusions.) Having for the most part both senses and intelligence unimpaired, and in many cases possessing full control of their upper limbs, these patients are naturally capable of almost unlimited improvement, and of adaptation to useful and remunerative occupation. This is not the case with those ultra-disabled of the first category. For 16524 L 2 324 these the creation of special institutions would seem to be essential, for the following reasons : 1. The blind or mutilated patient adapts himself readily to an environment created to meet his special require- ments, and is less painfully conscious of his own incapacity than when he is associated with normal or semi-normal companions. 2. The presence of the gravely disabled is necessarily de- pressing to the less disabled men. 3. The material and moral help which the ultra-disabled will continually require is of so special and exacting a character that it will hardly be supplied by the per- sonnel either of the hospital or the training school. Such patients would inevitably constitute the minority in any general institution, and without a neglect of the majority could not receive the special care which is due to them. 4. The space required for the ultra-disabled in hospitals or schools of re-education would prevent such institu- tions from the accomplishment of the work for which they are intended. The ultra-disabled is neither ill nor capable of re-education, in the true sense of the word. 5. The ultra-disabled cannot receive in his own home, except when possessing ample financial means, the material and moral comforts which are supplied to him by a special institution. Present Development of Assistance in Italy, and Programme of Future Organization. In the course of repeated visits made since the beginning of the war to the various centres of concentration of the disabled in Italy, I have come to the conclusion that, for the reasons above-mentioned, it is essential to provide, without loss of time, for the first of the two categories of ultra-disabled, leaving to happier times the solution of the problems relating to the second and more numerous class of those suffering from permanent lesions of the central nervous system. In December, 1916,* I traced in broad lines the programme of a permanent home for the ultra-disabled. The Italian Bed Cross, acting in collaboration with Prof. Enrico Burci, Special Inspector, representative of the Minister of War, undertook, as an initial experiment, the execution of such a plan. The con- centration of ultra-disabled coming directly from the first recep- * Levi, Ettore. Of the Present and Future Treatment of our soldiers dis- charged for total incapacity for any form of Work. " Bollettino della Federazione Nazionale dei Comitati di Assistenza ai Mutilati, Storpi, e Ciechi." Anno II. Number 1, page 22. 325 tion hospitals of Mantua and Bari, was organised by the Florence section of the Italian Ked Cross, in a villa-hospital given for the purpose. This first period of experimental effort was so success- ful that I have felt it wise to undertake a second time the consideration of the same subject.* The Italian Parliament, by the law adopted in March, 1917, entrusted the protection of, and assistance to, disabled soldiers to the organisation, described by me in an official report to the Inter- Allied Conference, known as the National Commission for the Protection and Assistance of Disabled Soldiers and Sailors. Having had the honour to be elected a member of the Executive Committee of the National Commission, it has been my privilege to set before my colleagues various considerations upon this subject. The Council of the National Commission, whose purpose it is to provide for the ultra-disabled the most complete and generous assistance, is now establishing in Florence a model institution in their behalf, and intends also to organise two similar institu- tions, one in the north and another in the south of Italy, where patients may be received at not too great a distance from their own homes. The present report is largely the programme which the present writer will shortly present to the Council of the National Com- mission, for the organisation of the first Home in Florence. It is based upon the results of the experiments already carried out there, and upon an extensive experience of the concentration homes for disabled in Italy. Before entering into a discussion of the details of the organisa- tion of an ideal institution, I shall point out briefly some of the essential characteristics of its inmates. Mentality of the Ultra-Disabled. The ultra-disabled, by reason of their grave physical disability, generally undergo considerable change of character. They, as a rule, become extraordinarily sensitive; easily irritable, suscept- ible upon the slightest cause to profound depression and un- restrained exaltation; morbidly jealous of one another, and subject alternatively to happiness and despair. They present, therefore, the essential characteristics of a morbid infantile mentality, resulting in sudden and paradoxical reactions. These characteristics are relatively accentuated when the subject is of mediocre intelligence and culture, and correspondingly vary according to his general organic condition. But happily the same characteristics render the patients sus- ceptible to every good influence. Rarely, if ever, does suggestive persuasion fail. Patients who had been reluctant to enter the * New notes on the grave and serious problems of the Ultra-Invalids of War. Ibidem. Anno II. Number 10, October. 1917. 16524 L ;5 326 institution readily adapt themselves to their new environment. Even those whose sojourn has begun in a spirit of utter in- subordination yield in a surprisingly short time to the influence of their companions w T ho have already learned to appreciate the spirit of the house, and are transformed both in conduct and mental attitude. They attach themselves with grateful affection to their attendants, and are, if well treated, incredibly serene, allowing themselves to be calmed and distracted with remarkable docility in moments not infrequent of melancholy or excite- ment. The sense of isolation from social life is especially painful to them, and they are correspondingly happy under a regime which alternates wisely between diversion and occupation. The susceptibility of the patients to every form of influence, whether good or bad, makes it imperative that the rare cases of definite and irremediable insubordination should be eliminated, since the reaction upon their more amenable companions might otherwise inevitably follow. Recruiting of Patients. The utmost consideration must be given to the means by which the patients are to be induced to enter the institutions established for them. Experience has shown us one fact of capital import- ance, namely, the extreme difficulty with which the disabled can be persuaded to leave the environment where they have been received during the initial stages of their disability. This tend- ency on the part of the unhappy sufferers to attach themselves, with touching devotion, to those who have first ministered to them is entirely comprehensible. They are like the shipwrecked, w r ho throw themselves blindly upon the first means of succour. In the first agony of realising their position they are conscious only of their infinite misery ; they know nothing of the consolation and opportunity held out to them in the refuge prepared for them ; they dread lest the future may hold for them not solace, but only fresh pain. It is in view of such conditions that we in Italy have followed the plan, already described, of sending the disabled, as soon as their wounds allow, from Mantua and Bari (first concentration hospitals), to the Hospital -Home at Florence. This concentra- tion of all the ultra -disabled offers the double advantage of creating for them, with the least delay, the environment in which they are assured the maximum of comfort, and in which at the same time they may be persuaded of the advantages offered them of passing into the permanent home now in course of preparation. This plan is, however, only partially realised. There are many ultra-disabled already distributed throughout the territorial hospitals of Italy ; others who have returned to their own homes ; others still who refuse with desperate determination to be removed from the environment where they are now r established. In certain cases, where, with an unfortunate lack of tact, patients 327 have been forced against their will to submit to change, incidents of actual rebellion have occurred which must, at all costs, be avoided for the future. It follows, therefore, that wherever such conditions exist (and I believe them to be common to every belligerent country) there should be appointed representatives who, with true missionary spirit, should search out and identify such ultra-disabled, whether in the hospitals, throughout the country, or in their own homes. These missionaries for they are truly bearers of good tidings- will seek to convince the patients of the opportunity offered for their future by the State ; to persuade them that they are under no obligation either to enter or to remain in such institutions , but that it would be wise for them to consent to an experimental sojourn, which, in a successfully administered institution, is likely to have but a salutary result. Special care should be taken for the journey of the patients. They should be accompanied by an adequate number of atten- dants, in charge of a responsible officer, travelling with every comfort in a reserved compartment secluded from the curiosity of the public. If scrupulous attention be not paid to such details (humble, but essential !) the natural sensibility of the patients will be wounded, and the ends of the desired propaganda thus defeated. If the war is to continue for a long period, an ideal solution of this problem might be found by the establishment of a surgical hospital, preferably in the same city in which the first home- hospital is situated. To this surgical hospital every ultra-disabled man, without exception, might be sent, so that from the very first stages of his incapacity he may be surrounded by a maximum of comfort, and also be definitely at rest, without the necessity of that change of environment so painful to him, and fraught in a good many cases with such disastrous results. During the medical-surgical cure the patient should be so instructed as to look forward to his final reception into the special institution. Such instruction could be and should be carried out by the managing staff of the permanent institution, who will thus have an opportunity of making themselves both known and loved by their future pupils. Material and Moral Treatment. The first aim in the treatment of the ultra-disabled must always be to render his future life materially tolerable. But, by its very conditions, such life would tend to degenerate into the routine of a purely animal existence. The moral aspect of the problem is, therefore, no less vital. The foundation of a material and moral well-being for these unfortunate sufferers as, indeed, for every normal being should be an ordered life, a sane and wise distribution of time in accordance with their physical and psychical capacities. There must be developed in them the qualities of heart and mind, so that by every means by praise 16524 L 4 328 and rewards, by instruction, and, above all, by example, they could progress towards greater knowledge and a quickened moral instinct. The aim of the administration of such an institution should be to establish a discipline so perfect that the patients are conscious of no restrictive prohibitions, and that they may be content with a daily routine which wisely employs every hour of their day. Otherwise, from long hours of tedium or of idle- ness will result discontent, degenerating into the formation of vicious habits and disorderly conduct. Both work and play ought naturally to be adapted to individual capacity, according to degree of disablement and intellectual development. But for practical purposes the patients should be associated in groups based upon analogous physical conditions. Those patients who are blind, with double amputation of upper limbs, will naturally be brought together for study, diversion, and instruction at stated hours daily. Another class naturally associated are tfiose with double ampu- tation of the upper limbs, with vision; those amputated in three or four limbs ; and those with double amputation, deaf or blind ; or those amputated and also deaf and blind. The fundamental task then must be to secure for those who will for ever be dependent upon the service of others some small measure of independence in the recurring functions of physical life. Every effort must, accordingly, be made to enable each patient to eat, drink, wash and dress himself, and to attend to his bodily needs without the assistance of others. He should be provided with such individual prothetic apparatus as may best be suited to his disabilities. The household furniture and articles of daily life and work tables, chairs, desks, beds, small working machines, toilet articles, writing materials, table service, &c., must be exactly and correspondingly adapted to the prothetic apparatus used by the inmates of the institute. The present writer is not competent to describe the practical details of such prothesis and mechanical artifices, but he is convinced that every institution should secure for this purpose the permanent services of an intelligent orthopedic mechanic, who will be able, often with the advice of the ex-patients themselves, to perfect and adapt such artifices to greater practical efficiency. The present market of prothesis offers such facilities that every patient with double amputation of arm or fore-arm should be put into such a condition as to be enabled to feed himself all the more readily if such amputation be below the elbow. The same artifice can also serve the purpose of washing, at least the face, by means of individual sponges (attachable to the stump as glove or mitten) of rag or absorbent paper, renewable after use. The cleansing so important and painful of the genital organs and of the anal region should be carried out by means of special adaptations, either as those above-mentioned, or with the use of bide with continuous current with small ascending douche, or by means of movable metallic arms attached to the side of the water closet with paper sponges (individual) renewable after use. 329 Although the majority of patients will require assistance at such times, it may be limited to supervision and direction, without the humiliating necessity of actual manual help. The Institute should be furnished with baths and douches constructed for the special requirements of the patients with supports and seats. All such appliances should be adaptable, though with greater diffi- culty, to the bi-amputated blind. Indeed, for a zealous and intelligent head of an Institute, who will know how to inspire his charges with courage and goodwill, nothing should be impos- sible. The patients will themselves ask for nothing better than to become increasingly independent of the service of others, and such independence should form an essential part of their moral education. A fundamental modification must be made in the clothing adopted, substituting for the complicated type in general use a special pattern sufficiently loose and ample to be put on with ease ; in winter warm enough to reduce the underclothing to one garment in the form of combinations. The openings of outer garments should be large and adapted for the easy satisfaction of bodily needs ; buttons' lacings and hooks should be abolished and substituted by automatic fasteners larger than those in common use which the patients may manipulate independently or with the minimum of assistance. The same characteristics should apply to boots and shoes. Ingenious appliances of this character have been the subject of most successful research by Prof. Putti, Director of the Orthopedic Clinic of Bologna (Instituto Kizzoli), which it is to be hoped will be submitted to the Conference. It may wisely be considered whether, in view of the just and natural pride and patriotism of the patients, they ought not to be allowed to continue to wear the uniform in which they have served their country and made their supreme sacrifice. If the use of the uniform is adopted, it might be adapted in accordance with the special requirements of the patients, as mentioned above, retaining in all cases the stars and military distinctions of war and becoming also characteristic of the institution itself. For those with double amputations of the lower limbs, special low beds should be constructed, obviating the danger of a fall and easy of access. Those who are unable to walk should have at their disposal small carriages, to be propelled by the hands if these are not amputated. At least twice daily the patients should be taken into the country, where they may walk without danger and with a certain measure of liberty. For bad weather covered ways should be provided. For each group of patients, games, exercises and special occupations should be improvised according to their capacity. It seems to the present writer that various games at bowls or ball, to be played by groups or by individuals against a wall, could be made feasible, using balls and bowls alike larger and lighter than those in common use. Bowls and balls con- taining bells might be adapted for the blind, and could be pro- pelled by the feet, trunk, and even heads of those with double 330 amputations of tfie upper limbs. Precautions will naturally be needed to avoid accident Similarly, for indoor exercise, gymnastic apparatus of the Zander type may be used, especially those modelled on the move- ments of riding, bicycling, &c., which call into action the muscles of the entire trunk, as well as apparatus designed for the lower limbs or adaptable for the stumps of the upper limbs. Patients, even those gravely disabled, take great pleasure in dancing, and should be encouraged to improvise games and exercises according to their own ideas. Advantage will wisely be taken of the natural love of music, especially prevalent among the Latin races. Phonographs and gramophones give much pleasure, and, in particular, automatic piano and organ players (controllable by the feet) by which those amputated in the upper limbs are able to make music without assistance. Among the blind, or those with vision, we have known in Italy several patients who have taken up with enthu- siasm and success, the study of a violin made possible for them by the attachment of the bow to the stump of the forearm. Both stringed and wind instruments (not requiring the fingers) might similarly be adapted. With singing, both solo and in chorus, we have obtained excellent results. Great vigilance must be exer cised in order to prevent patients from street-singing, as a means of gaining the alms and commiseration of the public. Groups of patients and, in particular, the blind, should be assembled at stated hours daily, for reading aloud. Books should be chosen with special care, avoiding novels of a sentimental or passionate character, giving preference to books of travel, humour, adventure, legends, folk-lore, &c. The learning and recitation of good poetry is also suggested. Part of such reading should be instructive, so that the patients may become conscious of a steady advance towards a strengthened moral and intellectual development. Patients with double amputation of upper limbs, with vision, could read and study with little help (using pincers to be attached to the chin for turning and holding the pages). They also greatly enjoy and profit by the cinematograph, with which every institu- tion should be provided, both for diversion and instruction. In the institution established at Florence, many patients, blind and with partial double amputation of upper limbs, with only one remaining finger, have already learned with enthusiasm and facility both reading and writing in Braille by means of a special pointer attached by means of a ring. The typewriter has also proved a source of pleasure, both as diversion and occupation, even to patients with a single or part of a remaining finger. Although lacking the actual proof of personal experience, I am convinced that, provided the stump of hand or forearm be conical or pointed, with a bony and resistant subsratum and with well- preserved skin, even those patients who have lost all their fingers 331 may accomplish the study of Braille, using the stump in the place of fingers. It is unnecessary to emphasise the value to every patient of being adapted to the most elementary work, with the possibility of earning a wage, however small. The institute should establish laboratories or workshops where work may be carried out by the patients in collaboration. Elementary machines of various types (printing presses, etc.) may so be constructed as to be propelled by the feet of the amputated blind, while the more advanced processes could be supervised and completed by patients with vision or those still retaining a part of the forearm. The achievement of work by means of collaboration ensures a degree of moral satisfaction to the patients, who, thus following the natural law of an humbler order of life, become truly symbiotic in the realisation of a common existence. The encouragement and example of such trials and triumphs of will and persistence can hardly be over-estimated in its effect upon the moral advancement of the patient's mentality, or in regard to the contagious influence exercised upon the patience and perseverance of their less active companions. Each should be given an opportunity to use and develop every remaining faculty. I repeat that, for a director of intelligence and enthu- siasm , nothing should be impossible in the matter of advancement of the intellectual or physical life in his pupils. The patient who enters such an institution, worthily administered, need not abandon hope that he shall one day leave it so transformed as to be able to take up again a life of relative independence and self-reliance. Those patients possessed of moral energy and less painfully incapacitated for normal life may, with time and skill and devotion, become restored to such an extent that they need no longer be classed in the sad category of the ultra-disabled. They should, therefore, be continually encouraged by the stimulus of generous rewards and the fellowship of sympathetic emulation. Administration and Equipment of Institution. The selection of the site for such an institution is of funda mental importance for its administration and ultimate success. The choice of location between town and country may neces- sarily be pre-determined by the facilities offered in cities or regions where institutions are to be erected ; but, a priori, it will be well to set forth their relative advantages and disadvantages. The selection of a site in town would offer the following advantages : (1) Facility of contact with, and control by, those responsible for the supervision and direction of the Institute. (2) Facilities for the medical treatment, amusement, and instruction of patients offered by towns, where they may easily be transported to special clinics, theatres, 332 cinematographs , and to the various schools which they may attend to advantage. (3) Distraction for patients who are not blind and will find diversion in more frequented centres. A country site, on the other hand, presents the following advantages : (1) Better hygienic conditions and more favourable and normal environment for patients who may live almost continually in the open air, walking unaccompanied for comparatively long periods in the grounds of the institution (in the case of the blind upon paths indi- cated by carpets and low side cords) or, accompanied, in the surrounding country without arousing public curiosity and commiseration. (2) Facility for nature study and agricultural pursuits, which are familiar and congenial to patients taken for the most part from the peasant class. (3) The disadvantages of distance from supervisors or visit- ing teachers may be obviated if the institute be supplied with its own carriage or motor. These may offer also an additional source of distraction for the patients and eliminate the necessity of the use of public conveyances. A carriage or motor should, for the same reasons, be at the disposal of every institu- tion, whether in town or country. The sum of advantages are, I believe, in favour of a site in the country, provided only that it be at not too great a distance from centres where the above-mentioned town advantages are obtain- able. We must also reckon with the fact that, at the conclusion of the war, it will not be possible to count upon the continued services of those volunteers who during the period of critical need have displayed such admirable self-sacrifice. Nor in any case may such service be adequately systematised and controlled. It is, therefore, essential that the staff of the Institution shall be permanent, salaried, and, if possible, resident in the building itself or in its immediate vicinity. The Director of the Institute might be chosen with obvious advantage from among officers disabled in war. As such he would exert over the patients a special moral ascendancy. He should, however, be neither blind nor too gravely hampered in his physical independence to exercise the activity of so exacting a post. The ideal solution of a complex problem would be found if such a disabled officer were also a physician ; and failing a suitable personality among the disabled of war the military authorities might wisely be asked to indicate a medical officer from the active or retired list. But it is not imperative that the Director should be either a physician or an officer : it is highly imperative that he should be of irreproachable moral character, of serene energy, gifted with those special virtues of heart and mind which may 333 alone fit him for the difficult mission he has undertaken. If a director be chosen from civil life he may with advantage be either a physician or a teacher with special vocation for teaching. Since the institution should be of an undenominational character, it is not advisable to appoint a clergyman. Generally speaking, the appointment of a woman is also out of the question, since in exceptional circumstances only will a woman possess the force of authority essential for the control both of patients and staff who must necessarily live under a rigid discipline. The ques- tion of the relation of a patient with the other sex would also be likely to present difficulties to a directress. But, on the other hand, the administration of the institute will have absolute need of the co-operation of women. The sad inmates of such a home should feel themselves neither in a hospital nor an asylum, but members of a family for whose unfortunate children the self- forgetful and intuitive imagination of a woman may create the illusion of a life still relatively active, still holding something of opportunity and self -development. For a woman of such character the post of vice-directress may well be reserved ; and to women may also be given the supervision of the kitchen and linen-room, as also minor posts in the administration. The majority of the staff should be male, preferably composed of men of the Army Medical Corps, commanded by a non-com- missioned officer, who may be chosen from among the disabled of war, but must be possessed of sufficient moral and physical energy. The patients will require constant care, both in relation to the elementary functions of daily life as also because whenever and for whatever reason they may leave the institution they must be accompanied (and well accompanied!). The number of orderlies must therefore be calculated upon a basis of from one to two or one to three patients. Our experience has shown us that the employment of persons of low intelligence, relative good- will and indifferent morals may have most unfortunate results. Success may be looked for only if every member of the staff, from the director to the last orderly, from the teacher to the visitor, be chosen with the most judicious discrimination. The vice-directress (or director) will require several women assistants, chosen with scrupulous care, neither unduly young nor of obvious physical attractions, for reasons readily under- stood. The personal care required by the greater number of the patients makes it advisable that the nurses should not be women, except for special offices, such as the cleansing of the orbital cavity or of the artificial eyes. The staff should be divided into two categories : First, those who supervise the intellectual and moral activities of the patients, as well as their recreations and physical culture ; and second, those who are occupied with their material well-being. Both should, however, be endowed with the special qualifications essential to the successful performance of their tasks. Since the majority of the patients will be blind, requiring special moral and material treatment, a teacher or tutor, either 334 blind or with normal sight, but thoroughly experienced in Braile and in methods of instruction for the blind, should be a premanent member of the staff. For the successful administration of the institution and for the material and moral wellbeing of his patients, the director should be frankly convinced of the dominant importance of the sexual question. The majority of the patients are young and healthful, subject also to special sexual excitability by reason of a life of enforced repose, a generous diet, and of injury to the normal centres of sensorial satisfaction (sight, touch, sound). The diet must accordingly be studied, as indicated later on ; the patients must be physically fatigued by exercise in the open air or gymnastic apparatus ; their reading should be supervised with vigilance ; their relations with visitors, with members of their families and women members of the staff, should be rigorously controlled. The utmost care should be taken that they do not abandon them- selves to masturbation, either individual or associate, to prevent which they should remain in bed only when necessary with moderate coverings. The orderlies who accompany patients upon their outings must be of absolute moral trustworthiness. The possibility that patients may be persuaded into marriage with persons impelled by mercenary motives must be taken into consideration. Each case must be judged individually, and when undesirable the objections should be clearly stated. If the patient remains unconvinced by the advice of the institutional administration in Italy, the control of the. National Commission may be requested. This body will have the right to place under legal control those ultra-disabled who are incapable of safeguard- ing their own future. Marriage with persons of indubitable morality and self-sacrifice may in individual cases be sanctioned. Such will, however, be rare, especially among the more gravely disabled. In an institution open to every form of faith the principle of absolute religious tolerance must prevail. It is, therefore, un- desirable that a dominating religious element should be repre- sented either in the administration or staff. It is, however, just and natural that men so deeply afflicted should crave the comfort of religion. The service of a chaplain, with the special qualities essential for such a post, should be a member of the staff, and a chapel should be fitted up within the institution. To patients of every faith there should be given the possibility o'f following their individual religious inclinations, but the necessity of sending patients in groups to churches where they may excite the atten- tion of the public should be avoided whenever possible. If the staff of the institution has not the services of a resident physician (as may happen in those intended exclusively for the disabled not suffering from illness) the collaboration of a com- petent medical man in the vicinity should be secured. He should visit the institution daily for the supervision of general hygienic 335 conditions, and so as to attend the patients during passing maladies. An infirmary, for the isolation of contagious diseases or serious cases, should be equipped. This will obviate the necessity of the removal of patients to general hospitals, where they cannot receive the special care required. A room should be set aside for ordinary medical purposes, the treatment of accidental injuries, the cleansing of the orbital cavities of the blind, and for the dressings required exceptionally by the stumps of the wounded. A small orthopaedic workshop, which may receive from the large official workshops of the State the material necessary to be adapted to single cases, should be attached to the institute. The services of an orthopaedic mechanic, both competent and devoted, will be essential. His skill and ingenuity must provide for the prothedic appliances necessary for every patient, in accordance with the studies made by the great scientific institu- tions. The director of the workshop should also study and modify, by his daily experience, the objects of common use- knives and forks, toilet articles, writing materials, machines, &c. to the service of his patients and pupils. The diet of the patients must be studied with special care, bearing in mind two factors the development of a physical well- being without the stimulation of sexual excitability. It should consist principally of farinaceous foods (rice, semolina, maize, macaroni), of green vegetables, beans, potatoes, fats, &c. Meat should be given once a day in small quantities ; fish more fre- quently. Food should not be highly spiced ; little wine or coffee, and no spirits, should be given ; sweets and preserves generously. A diet adapted to their individual' tastes and local customs is a source of innocent pleasure to the patients which should be taken into just consideration. Indulgence and ingenuity should seek to gratify every legitimate preference, and the kitchen should be considered a laboratory of happiness. For patients condemned to an absolutely sedentary life, a diet composed largely of vegetables, and even the daily massage of the abdomen, will be found neces- sary to the regular functions of the intestinal tract. Patients of the institute should be at liberty to leave it to re-enter their homes within certain obviously necessary limita- tions. The staff of the institution will hardly be sufficient to permit patients to be often accompanied, as they must be accom- panied, upon journeys to and from home. Two to four leaves, of ten to fifteen days, should be allowed during the year, as a minimum, with special leave in cases of necessity for family or personal reasons. Carefully devised rules of discipline will be necessary to eliminate insubordination or disobedience. These may be : deprivation of exercise, of games or studies ; curtailment of leave or of wages ; isolation in a room which shall serve the purpose of imprisonment without its character or name. As a severe 336 measure, temporary banishment from the institute may be adopted or, in the last resource, permanent expulsion. If it is proposed to expel a patient permanently from the insti- tution, it will be necessary, in Italy, to report the case to the National Commission, who will have the sole right to sanction such a measure. Delegates of the Commission will supervise the well-being and conduct of the patient in his own home, and will safeguard him by every legal and material means. The same responsibilty will be assumed by the National Com- mission towards those disabled men who refuse definitely to enter a special institution and choose to remain either in their own households, or as pensionnaires. The charge of all such patients, who by their helplessness are exposed to every form of exploita- tion, will' be taken over by the National Commission. The necessary funds for the support of the institutes will be provided in Italy by the National Commission. The proportion to be contributed by the patients to the institute will be deter- mined by the State. For the disabled in their own homes, who are in need or have slender means, a supplementary pension, in addition to that until now assigned, will be necessary, in order that they may support those persons upon whose care they are dependent. The present law will necessarily be modified in this respect. The State, or those organisations to whom the State has entrusted the supervision of the relief of the disabled in war, must reckon without hesitation with the fact that such institutions as we have described will of necessity be extremely costly, both in initial installation and in upkeep. But no sacrifice, whether moral or material , will seem too great to those who are responsible for the welfare and happiness of these, our most unhappy brothers. It must, however, be borne in mind that in the interest both of successful administration and of economy the size of such institutions should be wisely considered. It seems to the present writer that the number of patients should average from fifty to one hundred, since, on the one hand, the initial equipment and installation for a smaller number would involve too great an expense ; upon the other, a larger institution would inevitably be too complex for successful management. Let us therefore Unite our forces on behalf of the Saddest Victims of the War. What I have thus far set forth is the expression of a limited experience. Our work would have been obviously simpler and more sure of success had we been- acquainted with the analogous efforts made by other nations towards a like end. But we are, unfortunately, wholly ignorant of what has been already accom- plished in the same field, either by Allies or enemies ; while, from the point of view of civilisation and of humanity, our Govern- ments should, without loss of time, cull all the knowledge they can from the experience of others. And I would therefore call 337 upon the newly-organised Revue Interalliee to meet this need, the gravest of our problems. A special rubric, designed for the study of the ultra-disabled, which should share the experience of every fortunate initiative and undertaking for their well-being, might yield a rich harvest. For it must be remembered that in such problems no features are insignificant, all are precious. The details of. organisation, of study, of games, of physical comfort, of clothing, of special pro thesis, may be of inestimable value to alleviate the sufferings of our cruelly stricken brothers. In the consideration of such questions there should be neither friends nor enemies, and for this reason I welcome the assurance that the President of the International Eed Cross of Geneva has accepted a proposal made by me* for the internationalisation of all work undertaken by every nation on behalf of the disabled in war, thus placing them au-dessus de la melee. Three proposals were advanced : (1) An international congress on behalf of the disabled; (2) an international exhibition, to be held by the Inter- national Eed Cross at Geneva, of. prothesis, &c. ; (3) an inter- national journal to be published by the International Red Cross. At the present time only the second proposal has been accepted, but the Red Cross is sending, accordingly, to every belligerent and neutral country a programme-circular relative to such an exhibition. We are as yet ignorant of the answers which have been received by the Red Cross. We trust, however, that they may have been favourable, and that the time is not far distant when, in a civilised Europe, the hearts and brains of every country may be united in a common effort to alleviate the miseries of the present strife. * Levi, Ettore. " Let us raise the disabled of every country ' au-dessus de la melee ! ' ' " Bollettino della Federazione Nazionale dei Comitati di assistanza ai Militari ciechi, storpi, e mutilati." Anno II. Number 9, September, 1917. 338 SECTION 3, B. Surgical Treatment. ON KINEMATIC AMPUTATION. DOTT. GINO FIERI, Army Surgeon, Yerona. The experience I have acquired up to the present in the appli- cation of the principles of kinematic amputation to war surgery can be summarised as follows : I. When a limb has been mutilated by a bullet or an explosion it is advisable to perform immediately a kinematic amputation (primary kinematisation) , because the tissues offer little power of resistance, and are very liable to infection or neurosis. II. After an upper limb has been severed by violence the stumps must be got into condition by removing only the injured or infected tissues. The skin should not be removed, and the bone ought to be sectioned at the normal level of the flesh or a little higher. In operations on the forearm two lateral incisions have to be made (radial and ulnar), so as to prepare the two motors, flexor and extensor. The resulting stumps may be treated successfully with elastic traction, so as to avoid retraction and muscular atrophy, and so as to increase the quantity of skin available, which is necessary to cover the motors. The preparatory or hypokinematic amputation will prepare the best conditions for a second operation aiming at the secondary kinematisation of the- stump. III. When stumps are obtained by the ordinary methods of amputation, it is possible to utilise the muscular element by operating a second time (tertiary kinematisation). The technique of this operation varies according to the position of the stump. (a) Upper limb. Kinematisation of the stump of the upper limb aims at obtaining the greatest possible motor energy of the stump. When the latter is the result of the disarticulation of the shoulder, it is possible to restore and utilise some of the muscles inserted in the humerus. In one instance I was able, with the tendon of the great pectoral muscle, to build a motor capable of lifting 5 kilos to the height of four centimetres. When disarticulating the scapular-humeral it is found ad- visable, if local conditions are favourable, to build two motors : 339 the first one with the pectoral muscle, and the other with the deltoid. In the case of short stumps resulting from the amputa- tion of the arm (upper third), the disarticulation of the humeral segment remaining allows the surgeon to utilise loopwise the muscles inserted in the humerus. This method has given good results in the one case in which I have applied it. In the stumps of arms (middle and lower third) it is possible to build two motors, the one flexor and the other extensory, in the shape of a double loop. I operated in such a case with good immediate results, but the bridge was demolished by the surgeons of the base hospitals. If the stump of the forearm is very short, it is advisable to build a motor with the biceps. In a case recently operated by myself I formed a loop by suturing the biceptal tendon, which had been cut at the point of its aponeurotic expansion, and covering it with a fragment of the skin removed from the anterior fasces of the elbow. When the stump is a little longer, but not extending beyond the half of the forearm, it is possible to build a very strong single motor with a flexe-extensor loop. In one case of this kind I cut off the distal portion of the bone of the forearm, and lined the resulting tunnel with two fragments of the skin. The results were satisfactory. When the stump is longer than the half forearm it is possible to build two motors in the shape of loops, utilising the flexor and extensor muscular fasces. This method also has good results in one case in which I applied it. So far I have made no attempt at tertiary kinematisation of the hand. (b) Lower limb. Kinematisation of the stump of the lower limb aims primarily at obtaining the greatest supporting power for the stump, so as to enable same better to bear the w r eight of the body. This is achieved by covering the bony extremity of the stump with a flap of flesh, capable of active movement, being endowed with movement in alternative directions. In the case of stumps resulting from very high amputation (para-articular) of the leg, I have in two instances obtained good results by the application of the Delia Vedova method : i.e., the osteoplastic condilic amputation of the femur, the building of a flexo-extensor loop, by suturing the rotular tendons to the flexor tendons. In the case of stumps resulting from amputation of the leg at the lower third, I have in two instances obtained satisfactory results by a method of kinematic amputation with the formation of a terminal flexo-extensory loop, and the building of a flexor motor for prothesis formed of a mass comprising the tendon of Achilles. In the case of man who had lost his foot (third degree of frost- bite), in which only the astragalus and the heel remained, partly 340 raw and gangrenous, after disarticulating and segmenting almost completely the malleous, I wrapped the stump in a flap containing the extensor tendons, which I sutured to the flexor tendons. By this means I obtained a flexo-extensory loop which played on the articular surface, and which was possessed of considerable moving power. It would prove most valuable if in the disarticulation of the hip-joint use could be made of the pelvic-femoral muscles to build motors which would allow of the active movement of the artificial limbs. In a case of disarticulation consequent on a serious septic wound which did not benefit by re-section, I preserved the gluteus muscles up to their insertion, and also the psoas tendon, together with their osseous insertion. With these I am in hopes of being able to build at a later stage two motors, one extensor and the other flexor. 341 CYNEMATIC AMPUTATIONS. PEOF. V. PUTTI, Director of the Rizzoli Institute, Bologna, Italy. Synopsis. The author having noted that the historical and theoretical side of cynematisation has been discussed by Dr. Vanghetti, confines himself to considering the method from the point of view of its practical application, resulting from the experience gained by him from numerous stumps from amputation of upper and lower limbs. Having indicated his limits and explained the groundwork and the results of cynematisation without loss of blood, the author proceeds to deal with the mode of operating in cynematisation and examines the methods tried by him and others up to now. He then studies plastic motors, both their morphology and their functions, pointing out the types which, in practice, have corresponded best. Then going on to consider results, he asserts that a decisive opinion on the value of the method cannot at this moment be given, sufficient experience not yet having been gained. More- over, there is still lacking that intimate collaboration between orthopaedy and mechanical skill which, on the one hand, will bring operating surgery to perfection, and, on the other, will improve the manufacture of artificial limbs. A NEW PROCESS FOR CYNEPLASTICS. BY PBOF. AUGUSTO PELLEGRINI, Territorial Hospital, Italian Eed Cross, Chiari, Italy. 1st Movement. Two transversal incisions are made, parallel to each other, and distant 3 to 4 centimetres, that penetrate the skin, the sub-cutaneous pores and the superficial aponeurosis : the two incisions are prolonged obliquely in a proximal direction for 2 to 3 centimetres, thus dilimitating a strip of skin that forms a bridge. 2nd Movement. This strip of skin is rolled back over a thin slip of gauze, and is held by 2 or 3 stitches. 3rd Movement. The lips of the operatory wound are pulled apart, the anatomical elements that are to serve for the formation of the plastic motor are found ; the motor itself is made by bring- ing a part of these elements in front of the cutaneous bridge and suturing them to those that have been left behind. 4th Movement. Cutaneous plastic by means of glides so as to cover up the plastic motor ; hemming of the orifices of the cutaneous tunnel that passes through the motor. By means of this process the writer has obtained satisfactory results, both clinical and experimental. I will describe briefly a system of cyneplastics with which I have experimented on animals, to start with, and later on, on human beings, with satisfactory results. This process is particularly adaptable to the formation of extraterminal plastic motors. I habitually prefer these for the cynematising of amputated stumps. For this operation local anaesthetics can be used, or the patient can be put under the influence of a general narcotic. Local anaesthesia might have the advantage of causing the patient to contract his muscles during the operation, thus allowing a better view of the anatomical parts affected. Instead, general anaesthesia would be preferable for the more extended plastics, and for sensitive or pusillanimous subjects. Having decided on the exact plan of operation, chosen the type of motor required and the variety of plastic motor to be con- structed, the technical side of the operation becomes both easy and simple ; but it must be done with the greatest care, down to the minutest detail. 1st Movement. Two direct transversal incisions must be made across the length of the limb : they must be parallel and about 3 to 4 centimetres distant from 343 each other. They must penetrate the skin, the sub- cutaneous pores and the superficial aponeurosis. The length of the two incisions will vary according to the parts that are being operated upon and the width of the plastic motor which must be covered over. The two incisions must then be continued at both extremities, for Ij- to 3 centimetres, in a proximal direction, and still remaining parallel with each other, or else slightly diverging, so that the tw T o peduncles are wider. 2nd Movement. The skin, dilimitated by these incisions, must then be detached, together with the superficial aponeurosis, and folded back on itself over a thin strip of gauze. By this means a cylinder of cuticle is formed which crosses the field of the operation like a bridge : 2 or 3 sutural stitches are taken with catgut so as to maintain this bridge of skin in position, with the result that the line of suture is proximal on account of the incisions being deviated at each end. The tend- ency of the cuticle is to roll over in a proximal direction . 3rd Movement. The edges of the cut are pulled apart by hooks, so as to place the field of operation in full view ; the anatomical elements, that are to serve for the construction of the motor, are found and noted. Having picked up the tendons or muscles that are to be used as the foundation of the motor, they are placed in evidence, and the motor itself is prepared. By bringing part of the motor elements in front of the bridge of skin, and suturing them to those behind, care must be taken that the sutures do not come in contact with said bridge, but are placed either nearer or further away. Should the motor be formed in a tendinous part, it would be well to leave the tendons in their sheath. The tendinous suture, or tendinous grafting, should be done with great accuracy, in order to be able to proceed quickly with the mobilisa- tion of the motor. 4th Movement. The motor having been formed, the cutaneous plastic is proceeded with by means of glides, so as to cover the motor up. exactly, and the orifices of the tunnel passing through the motor itself must be hemmed. A plastic of this kind succeeds easily, on account of the shape given to the incisions : the skin is displaced in a backward direction in such a way as to cause the line of suture not to touch the line of the tunnel, but to be slightly detached. The cutaneous suture may be done with stitches of very fine silk, or else partly with clasps and partly with silken stitches. 344 It would be well not to have the stitches too close together and to avoid drainage. If a few clasps are applied, it is well to take them off as soon as possible say after two or three days. Dry and abundant medication is indicated, so as to keep the stump warm. The bandaging must be very low : it will soon be replaced by a special stocking for stumps, that allows greater freedom of circulation and movement. The course of healing is normal, and the complete cicatrisation is likely to take place within ten or twelve days. At the end of about fifteen days an active and passive mobilisation of the motor may be begun. The process is subject to variations, either with regard to its technical formation of the plastic motor or to the treatment of the skin that is to cover the motor itself. I believe that this process may be used, not only for the formation of extra- terminal motors, but also in cases of cyneplastic amputations and re-amputations. The advantages of the process thus described are innumerable. The field of operation is fairly large, not only on account of the prolongation of the incisions, which allows for the pulling apart of the edges, but also because the skin that is rolled up on itself leaves a part of the field of operation uncovered. Should it become necessary to enlarge the field of operations, it will be sufficient to prolong one or both the incisions without having to make any others. The cutaneous covering-up of the motor is obtained completely and quickly, and much more safely than with the Von Wreden and Sauerbruch processes, because the skin of the tunnel retains more vitality, remaining attached at both ends and with a large base ; whilst the edges used by Von Wreden and Sauerbruch are detached for their entire length and have only one peduncle. The process upheld by Sauerbruch demands a greater quantity, of skin, because of the edge having but one peduncle, and the detachment being more extensive, the retraction is greater, and partial necrosis may set in at the extremity of the edge corre- sponding with the hem of the tunnel's orifice, where it would be most desirable that healing should occur rapidly. In both the orifices or mouths of the tunnel, according to my process, the cicatrix occupies only a part of the orifice itself, whilst in Sauerbruch 's process we have a complete circular cica- trix, which causes the tunnel to be less distendable and the skin to ulcerate more easily. The skin of the tunnel has a tendency to roll spontaneously and to remain rolled upwards, and for this reason the cicatrix of the skin of the tunnel is turned in a forward direction ; that is to say, on the side where no pressure is brought to bear on the prothesis from the inorganic attachment of the motor. Given its position, this cicatrix does not prevent the inroad of the motor, 345 and finds itself on a different level with the superficial cutaneous cicatrix, which is more distant. It is also better to see that the sutural stitches needed for the construction of the motor do not come in contact with the cutaneous suture. The plastic process is completed in a single sitting, and this constitutes an advantage over the systems that demand two sit- tings (Von Wreden and Sauerbruch). The operation is simple and easy, and all the movements are made in open sight, and not blindly, as is the case in the long canalisations of muscular motors according to the technics preferred by Sauerbruch. In applying the process recommended by Sauerbruch, it is often not easy to cover up the field of operation that has remained uncovered without having to resort to further incisions, or graft- ings, or an excessive stretching of the skin; whilst by using the process I have set forth the shape of the incision allows for the gliding of the skin in a backward direction ; hence the easy success of the plastic, with the certainty of its taking hold. As an illustration of my theory, I will here give a clinical case, on which I practised the above-described process : Emilo de Meo, private in the 217th Infantry, had his left hand blown away on a level with the wrist through the accidental explosion of a hand grenade. He was sent down to me directly from the front by order of the Director of Health of the 1st Army Corps, so that the cynema- tising of the stump should be seen to. I contented myself with cleaning and treating the wound, which was lacerated and contused , without proceeding to regulari- sation. I medicated with Dankin's liquid. The suppuration having ceased, elastic tractions were applied in order to accelerate the cicatrisation of the wound and to allow for the free articula- lations of the wrist. The wound being completely cicatrised, the cynematising was proceeded with. Plan of Operation. Besides the wrist, the little finger re- mained, but it was rigid and set in a defective position of adduc- tion, as may be seen by the photograph. The articulation of the wrist was pretty good. In deciding on the plan of operation with regard to the ultimate formation of the plastic motors, special account must be taken of the tendons and muscles, which, on being severed, have lost their power of movement, and the healthiest amongst these must be chosen. In this case it would be illogical to utilise the flexor and extensor muscles of the wrist that have retained their powers of utility. I intended making only one flexuous motor, and I decided to utilise the tendons of the superficial flexor muscle of the fingers, together with those of the deep flexor muscles, gathering them together so that they would form a loop. 346 In order to have greater freedom for the operation, and also to have a larger quantity of skin at my disposal, I consider it best to make only one motor, reserving the faculty of making others after recovery, should they prove to be needed. Operation 12, III., 1918. Preventive hgemostasis with elastic noose. The upper part of the wrist is brought to view and maintained extended. 1st Movement. I practise two transversal incisions, parallel to each other, in the flexuous region of the forearm. The first of these incisions is in line with the middle transversal fold of the wrist, and the second 3 centi- metres forward. At the extremities of the two in- cisions I continue, on each side, with an oblique cut in a downward and forward direction, about 2 to 3 centimetres in length. These incisions penetrate the skin, the sub-cutaneous pores and the superficial aponeurosis. 2nd Movement. The skin, dilimitated by said incisions, is partly detached and rolled over a strip of gauze : it is held in this position by 3 sutural stitches made with catgut. 3rd Movement. I enlarge with the aid of hooks the operative cut, and, probing for the tendons of the superficial flexor muscle of the fingers, I bring them out. I then, as far back as possible, detach the four tendons, which recede , and I draw them out , together with their sheath, towards me, causing them to pass under the bridge of the skin, and bringing them up front of it. I then suture them carefully to the tendons of the deep flexor muscle of the fingers with 8 to 10 stitches of very fine silk. 4th Movement. Having thus formed a flexuous motor with loop, I take away the enlargement hooks and proceed to cover up the field of operation completely with cutaneous plastic by means of glides. The forward edge of the skin is stretched to recover the cut where it is held in place by 2 stitches in silk and 2 clasps ; the orifices of the tunnel are carefully hemmed. Dry and abundant medication without drainage. The wrist is set in a cast, so as to avoid, during the first days,, the stretching of the tendinous and cutaneous sutures. Regular Course of Healing. On the third day I remove the two clasps ; on the seventh day I take away the silken stitches ; on the tenth day the cicatrisation is com- pleted, and the warm baths and active" and passive movements are begun ; on the fifteenth day I subject the motor gradually to the weight it will have to carry. 347 LE TRAITEMENT PRECOCE DES AMPUTES DU MEMBRE SUPERIEUR. By Dr. MAKTIX. Le traitement des ainputes comporte deux phases bien disiinc- tives : une phase chirurgicale, et une phase orthopedique. La phase chirurgicale comprend 1'operatioii proprement dite d' am- putation et les suites operatoires immediates. La phase ortho- pedique est celle du traitement orthopedique et de 1'appareillage. Jusqu'a oe jour, F operation seule a ete eiivisagee par les traites classiques. I/ experience de la guerre a montre d'ailleurs que pas mal de notions etablies a ce sujet doivent etre modifiees. Ni le tiaitement consecutif a 1' amputation, ni le traitmeiit ortho- pedique, n'ont ete serieusernent etudies par let auteurs. De cette partie du traitmeiit, cependant, depend pour une bonne part la valeur du resultat final. Depuis longtemps notre attention a ete attiree sur ce point. Nous avons pu observer frequemmeiit des amputes du membre superieur ou du membre inferieur porteurs d'um moignon cica- trise et gueri chirurgicalement, mais enraidi dans ses articula- tions, manquant de force et de puissance nmsculaire. Le resultat etait generalement d'autant plus defavorable que le traitement chirurgical avait dure plus longtemps (souvent a cause de 1' infection), ou que le blesse gueri avait ete abaiidonne a lui- meme. C'est pourquoi, a 1' Ambulance ocean, nous nous sommes efforces avec la collaboration des chirurgiens, d'instituer des le debut le traitement complet des amputes. Nous n'envisagerons j>as dans ce rapport, les notions qui reglent 1' intervention chirurgicale au cours de 1' operation elle-meme. Les suites operatoires interessent la plaie et le moignon. On peut dire, d'une fa9on generale, qu'il est toujours indique de hater la cicatrisation de la plaie d' amputation, soit par la suture primitive, soit par la suture secondaire precoce. Le chirurgien doit mettre tout en oeuvre pour faire la prophylaxie de 1' infection et pour reduire celle-ci quano! elle est etablie. Nous estimoiis, quant a nous, que toute plaie d' amputation du membre superieur peut etre guerie dans les trente jours. Ce delai est suffisant, dans la plupait des cas, pour amputer, aseptiser, refectionner et suturer un moignon. Le plus court est le meilleur : nous avons pu, dans certains cas, avec le concours de chirurgiens devoues et eclaires, reduire cette periode a huit jours. Le traitement du moignon lui-meme, pendant la periode des suites operatoires, est, a tort, selon nous, generalement neglige. Or ce traitement est de la plus haute importance et meriterait de retenir davantage P attention du chirurgien. 348 La valeur d ? un inoignon est determinee par la longueur et de ce dernier par sa mobilite active et passive. La longueur du moignon est fixee par P operation; so niobilite depend du traite- inent post-opera toire. L'atrophie musculaire et les raideurs articulaires sont les elements pathologiques contre lesquels il est necessaire de lutter ; on les evite par la mobilisation precoce et par le massage des muscles du membre ampute. A 1' Ambulance de P ocean, a la Panne, le traitemeiit est applique ainsi que Piiidique la note ci-jointe : NOTE SUB, LE TRAITEMENT IMMEDIAT DES AMPUTKS Priere aux chiiurgiens de Petablissement : 1. De faire un effort pour realiser la cicatrisation rapide des amputes, soit (a) par la suture primitive, soit (b) par la suture secondaire precoce. II faudrait intensifier le traitement de la plaie en vue de la sterilisation et suturer le plus tot possible. 2. D'iiistituter au lit meme, des le 2 ou le 3 jour, apres P operation, le traitement du moignon en faisant de la mobilisa- tion manuelle journaliere au lit, et en mstituant uii traitement par le massage leger, due segment superieur au segment ampute. Ex : masser la cuisse chez un ampute de jambe; les muscles pelvi- trochanteriens chez un empute de cuisse; le bras chez les amputes d'avant-bras; les muscles thoraco-brachiaux chez un ampute de bras. 3. Dans le cas d' amputation secondaire lie pas perdre de vue la possibilite de P amputation pendant le traitement conservateur ; done, faire subir aux membres susceptibles d'etre amputes, le meme traitement qu'aux membres amputes (ceci dans la mesure du possible). 4. De signaler immediatemeiit au service de prothese la presence d' amputes susceptibles d'etre traites par la prothese provisoire. Le traitement orthopedique proprement dit tend vers le meme but que le traitement immediat. On pent dire d'une fa con generale que cette partie du traite- ment etait inexistante avant la guerre. La therapeutique se limitait a quelques maiioauvres, qui, la plupart, manquaient leur but. On faisait la compression du moignon au moyen de bandes elastiques de Yelpeau dans le but de hater le travail d'atrophie. En fait, on contrariait ce dernier en entravant la circulation sanguine de retour c.-a-d. la nutrition des tissus et la travail de resorbtion qui accompagne necessairement toute atrophie. Cette manoeuvre aboutissait surtout a favoriser Petablissement des raideurs articulaires et de Patrophie musculaire. Les bandes de Velpeau, en genant les rnouvements, encourageaient le blesse a s'immobiliser ; or, ] 'immobilisation prolongee nuit considerable- 349 ment aux amputes des membres. Nous avons depuis plusieurs annees renonce a ce mode de traitement plus nuisible qu'utile. Le massage du moignon est fort conseille a ce moment encore. Nous estimons, quant a nous, qu'il constitue une manoeuvre inutile quand il s'adresse au moignon lui-meme, qui doit faire son atrophie. Par contre, il est de toute premiere utilite, lorsqu'il est applique aux muscles qui commandent le moignon. II sera d'autant plus efficace qu'on Pappliquera plus precocement. On peut en dire autant de la mobilisation manuelle. La mobilisation mecanique, c.-a-d. la mecanotherapie des moignons, est a nore avis, inutile et mauvaise : Inutile: parce qu'elle s'addresse a des moignons faits, que Ton peut traiter par des methodes plus simples, plus rationnelles, plus efficaces. Mauvaise : parce qu'elle est brutale et toujours realisee d'une maniere def ectueuse, dans la meoonnaissance des axes articulaires et squelettiques. L'electrotherapie ne s'adresse qu'a des moignons anormaux atteints de nevrite ou de nevrome. Les lotions sont des soins utiles de proprete. L' element le plus nuisible aux amputes du membre supe- rieur est 1' immobilisation du membre ampute dans une echarpe ou dans le vetement. II n'est d'ailleurs que la consequence d'une habitude consacree ; le bras de parade aboutit parfois au meme resultat. On ne saurait trop s'elever contre de semblables pratiques. Le traitement orthopedique bien compris du moignon s'adresse au moignon, a Petat general, et au psychisme du blesse. L'ele- ment tnerapeutique essentiel est la prothese dite provisoire, mieux denommee la prothese therapeutique. Celle-ci mobilise activement et passivement le segment du membre ampute, rem- pla^ant avantageusement la mecanotherapie et la mobilisation manuelle. L' agent therapeutique principal de ce traitement est le travail volontaire, organise, mesuree, dose, en qualite et en quantite ; c'est un exercice naturel commode et agreable. Contrairement a ce qu'ecrivent MM. les Profs. Rieffel et Gourdon, dans leur rapport au Congres de Mai 1917, a savoir : " Pour le membre superieur, il y a interet a n'appliquer precoce- ment aucun appareil," nous estimons que la prothese therapeu- tique sera avantageusement appliquee le plus tot possible apres 1' amputation, 8 js, 15 js, rarement davantage, et cela pour des ^aisons bien definies, qut interessent le moignon lui-meme et le segment superieur a 1' amputation. On sait depuis longtemps qu'un moignon d' amputation ne peut rester bien adapte dans son premier appareil de prothese pendant plus de deux a trois mois. C'est une notion classique en Amerique, ou les fabricants de membres artificiels tres perfeo iionnes et tres etudies, ne conseillent 1'appareillage que plusieurs mois apres Pamputation. Nous avons pu constater d'autre part 350 que la sensibilite effective du moignon est en rapport avec Fetendue de contact de la peau a la paroi interne de la gaine de 1'appareil de prothese, c.a.d. qu'elle est fonction de Fadapta- tion du membre artificiel au moignon. Pour ces raisons, il est done necessaire de former les moignons en vue de la prothese definitive. II faut pour cela confectionner des appareils 'a adaptation precise, exacte, et changeante, afin de suivre les evolutions successives des moignons au cours de leur consolida- tion. On a pu observer en outre qu'une amputation d'un avaiit-bras provoque un processus d'atrophie qui envahit le bras et Fhemi- thorax en reduisant parfois considerablement la musculature. II est done necessaire de lutter immediatement centre ce pro- cessusu; il faut chercher a en limiter les effets. Nous avons conseille a cette fin le massage et la mobilisation des la deuxieme jour apres F amputation. Mais cela n'est pas suffisant, et il est indispensable de faire travailler le blesse tres precocement au moyen d'une prothese therapeutique bien congue et bien realisee. Nous n'avons jusqu'a present rencontre aucun obstacle a Fappli- cation tres precoce de cette prothese, si ce n'est celui de contrarier parfois des habitudes d'oisivete, heureusement peu repandues. La prothese therapeutique contribue pour une large part a la formation du moignon ; sa qualite essentielle est son adaptation : celle-ci doit etre rigoureusement precise au cours de revolution de la forme due moignon. On ne saurait trop deconseiller Futilisation d'une prothese mal adaptee, usagee, faite en serie. Une telle prothese ne couvre jamais le pourtour du moignon. C'est dans le but d'obtenir la plus grande exactitude possible dans F adaptation que nous avons eu recours au platre pour la confection de nos appareils provi- soires. Nous n'avons d'ailleurs qu'a nous louer de son emploi. La prothese evolue comme le moignon. L'appareil doit etre renouvele assez frequemment, du moins Femboiture. Pour cela, il sera peu couteux, facile a confectionner utilisable du jour au lendemain. II nous faut 5 a 10 minutes pour confectionner Femboiture j'un appareil d'ampute de bras et son prix de revient n'atteint pas deux frcs. Nous estimons pour ces raisons que ces apparelis constituent une bonne prothese de travail, simple, solide, remarquablement bien adaptee, et d'un prix de revient presque nul. C'est le vrai membre de Fouvrier; celui qu'on remplace sans retard et sans frais. Le but de la prothese therapeutique est de mettre en action les groupements musculaires et de mobiliser les articulations. Le jeu articulaire devra etre libre de toute entrave et Faction musculaire devra se faire normalement. Nous recommandons particulierement de monter les appareils de fagon a respecter F orientation normale des axes articulaires et des axes longitu- dinaux du membre. Les moyens d' attache de F appareil an corps ne contraieront pas la mobilisation des membres. La plupart des appareils existants ne tiennent aucun compte de ces donnees. Nous estimons que c'est la une lacune profoiide sur- tout en ce qui concerne le bras de travail. Chez un ampute 351 d'avant-bras par exemple, le rendement sera meilleur si le coude est bien axe sur le coude naturel et si les muscles flechisseurs et extenseurs de 1'avant-bras sur le bras produisent leur action en direction normale. La fatigue surviendra moins vite chez un ampute muni d'un bon appareil que chez un ampute muni d'un bras artificiel commercial. Le travail manuel est un element therapeutique de tout premier ordre. Par la diversite des mouvements V qui le composent, on peut varier a Pinfini 1' action therapeutique sur les .groupes musculaires ou les articulations, que Ton desire tiaiter particulierement. Nous avons coutunie de dresser, a lusage de nos amputes de bras et d'avant-bras, un programme d'exercices simples et gradues, variables en qualite et en quantite. Chacun de ces exercices tend a diriger une action localisee sur certaines articulations et des groupes musculaires bien definis. Nous cherchons en outre a obtenir un effet propre sur le moignon lui- meme. Un moignon recent est sensible, surtout au voisinage de la cicatrice de la plaie d'amputation. L'appareil menagera cette susceptibilite ; il ne dbnnera aucun contact, il ne prendra aucun appui sur cette region terminale. Parfois les mouvements ou les contractions musculaires sont douloureuses, surtout si le membre ampute a ete immobilise pendant longtemps. Les premiers exercices seront moderes, limites dans leur etendue et dans leur puissance. L' ampute est appareille aussi tot que possible de 8 a 30 js apres son amputation. L'appareil est forme d'une emboiture en bandes platrees, au seiii desquels sont fixees deux lames de feuillards. Celles-ci, rapprochees a leur extremite inferieure, retiennent la pince terminale, porte-outil rudimentaire. Cette terminaison se deplace dans un plan frontal et un plan sagittal. On cale dans la position desiree. On possede ainsi assez de mobilite pour suppleer a 1' absence des mouvements du coude et du poignet. Les exercices sont bien determines de fagon a oe que 1' action therapeutique soit bien localisee. Ce n'est pas un travail quel- conque, visant a une production ou a une reeducation. C'est une serie de gestes et de mouvements coordonnes, exigeant de la pre- cision et de la mesure. Ce traitement reclame de la part du medecin une surveillance constants : il faut rectifier les attitudes des blesses, afin de creer le geste desire, avec la direction et P amplitude recherchees. Le travail a la lime constitue une serie d'exercices destines a mobiliser les articulations du coude et de 1'epaule. Chez un ampute' de bras 1' action est limitee aux flechisseurs et aux extenseurs du bras. Chez un ampute d'avant-bras, on obtient une action sur les muscle flechisseurs du bras et de 1'avant-bras. Ces exercices simples et faciles doivent etre bien conduits. Le 352 inouvernent s6 fera autant que possible dans un plan parallele au plan median du corps. La longueur de la lime determine Pet-endue du mouvement; son poids et son mordant commandent la puissance de 1' effort a produire. On augmente ou 011 diminue P amplitude du mouvement de flexion du coude en faisant varier la hauteur de 1'etau qui retient la piece a limer, par rapport au limeur Nous analysons le tyavail produit au moyen de la lime dynamographique de Amar; elle nous permet die inesiirer et de decomposer 1' effort. L'ampute debute par le travail a la lime douce et courte, qui est rapidement remplacee par la lime longue, lourde et dure. Le mouvement de la scie est sensiblement le meme que celui de la lime, inais P amplitude du mouvement est plus grande. II s'y ajoute en outre 1' intervention des pronateurs et des supin- ateurs ou de leurs suppleants, quand le sujet cherche a coiiduire le trait de scie marque. Le travail a la scie constitue un exercice de mobilisation semi-passive, quand Poutil est manipule par deux blesses qui se regardent; Pun et Pautre tire alternativemeiit sur la lame realisant ainsi Pextension passive de Pavant-bras et du bras de son assistant. II est necessaire que le mouvement se fasse dans le meme plan, sensiblement parallele au plan median du corps. Nous conseillons a nos blesses de tenir la face interne du bras contre le thorax. On peut faire varier P amplitude du mouvement avec la longueur de la lame de scie. On augmente Peffort a fournir avec le poids de Poutil, la durete et la grosseur du bloc a debiter. De meme, il est aise d'obtenir une flexion ou uiie extension plus complete selon que le sujet se rapproche ou s'eloigne du morceau a couper. On peut ainsi mesurer Peffort demande et P adapter aux sujets a traiter selon la tolerance des raideurs articulaires. La scie peut etre maniee par un seul sujet et animee de mouvements diriges verticalement ou horizontale- ment. Dans le premier cas, on provoque le travail des adduc- teurs et des abducteurs du bras, c.a.d. le deltoide et les muscles thoraco-brachiaux anterieurs et posterieurs. En meme temps nous obtenons la mobilisation de Pepaule. Dans le second cas on obtient une action sur les flechisseurs et les extenseurs du bras et die Pavant-bras. Le travail au maillet (par exemple debiter une piece de bois a la gouge et au maillet) a une action marquee sur les adducteurs et les abducteurs de Phumerus. (Le maillet est toujours tenu par le membre ampute). II en est autrement chez les blesses du carpe et du metacarpe et chez les amputes des doigts. On peut chez ces derniers, localiser Peffet therapeutique au poignet. Nous avons en effet etendu P application de la methode aux multiples blesses des membres. M le D Delrez traitera cette question. Le travail au maillet est tres utile chez amputes du membre superieur : il forme remarquablement les moignons. Pendant les premieres heures les blesses supportent difficile- ment les contre-coups des chocs repetes du maillet sur le manche de la goxige, mais Paccoutumance est rapide et entiere. C'est 353 un des exercices les plus interessants a suivre. Au debut, 1'ouvrier est gauche, maladroit et craintif ; au bout de deux a trois jours, il acquiert une grande confiance et une surete parfaite dans la direction et la puissance de 1' effort. On obtient surtout un bon resultat s'il existe un peu d'emulation entre les blesses. Ce traitement par le travail du maillet developpe la seiisibilite. II rafPermit les parties sensibles et avive au coiitraire la seiisibilite de la peau en contact avec la paroi interne de Temboiture. On con$oit par quel mecanisme la sensibilite depend de ^adaptation de 1'appareil au moignon. L'ampute niesure 1' effort donne a la sensation ressentie dans le moignon, il peut identifier la nature de 1'objet qui frappe. Nous pensons qu'une seiisibilite nouvelle nait par 1'exercice au cours de revolution du moignon. Nous avons d'ailleurs observe le meme phenomene cliez les amputes du membre inferieur. Nous avons vu de& amputes de cuisse qui localisaient et mesuraient un choc sur leur pied de bois et nous avons eu des amputes de jambe qui sentaient parfaitement le sol sous leur pied artificiel. Chez eux aussi, la sensibilite acquise etait en fonction de I'adaptation de Temboiture du moignon. Les exercice sont varies de faon a traiter alternativernent les different^ groupes musculaires. Les result ats obtenus sont remarquables, infiniment superieurs a ceux obtenus par les moyens habit uels. Le moignon subit une evolution rapide et favorable, il acquiert une souplesse et une puissance egale a la normale. Un moignon datant de 4 jours est fort, mobile et d'une sensibilite complete. L'atrophie des muscles, qui existe quelque peu anatoiniquement malgre ce traitement precoce et intensif, est fonctionnellement nulle. L J amelioration a ete etonnante chez un sujet qui avait ete tres infecte; 1'amputation f aite dans le foyer de fracture avait donne une plaie prof ondement infectee par le streptocoque : En 15 jrs, revolution du moignon fut tellement avancee que le sujet mit en usage trois appareils. Le materiel necessaire est tres rudimentaire : quelques banes de menuisier, quelques outils et un peu de materiel, bois ou fer. On peut d'ailleurs, dans une certaine mesure mettre, a profit le travail fourni. Toutefois, oe traitement exige du medecin une presence constante au milieu de ses blesses au travail. Les exercioes varient en qualite, en intensite et en duree. Le premier jour Line heure de travail suffit; lo deuxieme jour, on peut pousser jusqu'a deux heures, jusqu'a trois heures le troisieme jour. Les jours suivants, les amputes sont occupes 4 ou 5 heures. Nous estimons que ces heures de travail sont necessaires; ilfaut de la persistance et de la continuite dans Peffort fourni. C'est la, a notre avis, un facteur important de succes. 16.-.24 M 354 L'adaptation du membre artificiel doit rester parfaite; il est necessaire de renouveler les appareils devenus trop larges : c'est d'ailleurs facilement et rapidement fait. Pendant combien de temps est-il utile de maintenir ce traite- nient? Nous ne pourrions repondre categoriquement a cette question. Tout depend de la volonte et des intentions du mutile. Au point de vue du moignon, nous pensons qu'apres deux ou trois mois, suivant les cas, le traitement peut etre termine. Au point de vue du mutile, il devrait se prolonger, selon nous, jusqu'a Fappareillage au moyen du membre articule, chez les amputes exercant un metier manuel. La reodi.cn lion professionnelle devrait se faire en continuite directe avec la restauration fonc- tionnelle. Chez les desarticules du poignet, les mouvements de pronation et de supination sont conserves, si le carre pronateur a ete integ- ralement respecte, et si les articulations radio-cubitales inferieure et superieure ont ete menagees et entretenues au cours du traite- ment chirugical, 011 peut dans ce cas, esperer une recuperation fonctionnelle complete de ces mouvements. Le travail recom- mande a ces amputes consiste a forer des trous au moyen d'une meche munie d'un manche special, ou a visser des vis a Paide d'un tourne-vis monte a cet effet. Toutefois, 1'emboiture de 1'appareil n'engainera que la moitie inferieure de 1'avant-bras, afin de ne pas s'opposer au deplacement du radius sur le cubitus. Depuis pres d'un an nous appliquoiis le traitement par la travail a tous nos amputes du rnembre superieur. Ceux qui ont con- senti a ecouter nos conseils n'ont connu ni les raideurs articu- laires, ni les atrophies musculaires. Leur moignon n'a ete le siege d'aucune douleur, fistule ou abces ; son evolution fut simple et rapide. Les moyens que nous precoiiisoiis sont rudiment aires, peu couteux et a la portee de tous le monde. Le traitement orthopedique precoce des amputes influe notable- ment sur Petat general et le psychisme du mutile. En stimulant les organes de la vie vegetative, on ameliore 1'etat general du blesse : rien n'est plus salutaire en effet, qu'un travail leger dans un atelier bien eclaire et bien aere. Le travail therapeutique ameliore le psychisme du mutile. II reconforte les amputes recents non appareilles. Aussi doit-on -conseiller le groupement des amputes dans les formations sani- taires. Ce traitement influe aussi sur le moral de 1'ampute appareille. En occupant ce dernier par un travail interessant, on ramene la confiance en son esprit. En ce moment, on a trop la tendance, selon nous, de chercher a faire naitre des suppleances du cote du membre sain. Le bras ampute conserve une reelle valeur d' usage. II faut eduquer le blesse vers son utilisation immediate et complete; de la mise en 355 valeiir des fonctions subsistantes dependra la capacite produe- trice du inutile. Le moignon, plus que la prothese, determine le reiidement du travail du mutile. Le traitemeiit orthopedique forme les moig- nons en les ameliorant : il constitue done un f acteur essentiel de bonne reeducation professionnelle. II devrait etre generalise, et nous regrettons qu'une chose aussi simple, aussi peu couteuse, aussi rationnelle, aussi efficace et aussi bienfaisante, tarde a se repandre. 16524 M '> 356 PAPER ON FITTING AND ADJUSTMENT OF ARTIFICIAL LIMBS. BY T. H. OPENSHAW, C.B., C.M.G., F.K.C.S., Col. A.M.S. ; Surgeon , London Hospital ; Senior Surgeon , Eoehampton ; Consulting Surgeon, Eastern Command. I have been honoured with the request to lay before you some points in connection with the subject of the Fitting and Adjust- ment of Artificial Limbs. Before an artificial limb can be fitted care must be taken to see that the stump is free from any morbid condition. There must be no painful bulbous enlargement of its divided nerves. There must be no pain due to a neuritis. The end of the bone must not be painful, owing either to an enlargement, to a conical condition, or to the presence on its edge of sharp spicules of new bone. There must be no sinus, leading either to necrosed bone or to an unremoved foreign body. The skin over the stump must be healthy, movable and not inflamed. There must be no abscess. The scar should be thin, movable, and neither eczematous nor ulcerated. The nearest joint should be healthy and movable, not fixed by fibrous or bony ankylosis, or by contraction of muscles , or owing to the presence of contract- ing scar tissue on its flexor surface. A long, loose, flabby stump, or one too fat, is difficult to fit. There are situations in the body where a stump may be too long or too short. The stump should not be puffy or oedematous. Any of the above morbid conditions, if present, must be suit- ably treated by operation or otherwise, before the patient can be properly fitted with an artificial limb. Accurate fitting of the thigh or leg socket of the artificial limb is of vital importance. Successful fitting depends largely upon the experience and intelligence of the fitter, as amputations, although similar in appearance, vary indefinitely in the manner in which they can bear pressure. Each limb should be specially constructed for the individua 1 project. This makes it exceedingly difficult to fit, so as to pre- vent the stump coming out of the backet when the patient sits down or stands up ; nor is it easy to fit a tilting table to such a projecting short portion of the femur. In certain of these cases it is imperative to remove another two inches of bone. Mid- femoral amputation. When the amputation is at or above the middle of the femur, it is imperative, in my opinion, that every case should be fitted with a pelvic band. Experience proves that wherever this is fitted, the weight of the braces on fhe shoulders is reduced considerably, and the patient finds that the centre of gravity of the limb is brought much nearer the body by this attachment. The pelvic band should fit most accurately, and not reach higher than the level of the anterior iliac spines. The centre of the hip joint should be in advance of the centre of the knee joint, so as to ensure the proper lock when the weight of the patient is borne on the limb. The proper adjustment of the bucket of the artificial limb in every thigh amputation is essential for the comfort of the patient. In every case a model of the stump should be taken. Limb- makers differ in the way in which they take a model of the thigh stump. Some makers take a model of the stump in plaster of Paris ; others in wax. It should always be remembered that the patient has to walk upon the limb, and therefore the plaster model should be taken with the patient in the upright (standing) position, and if possible it should be moulded by pressure, so as to represent the shape of the stump when the pressure of the body weight is exerted upon it. Messrs. Eowley used to obtain a model of the stump by filling the inside of the upper third of a- wooden bucket with mouldable material , which first takes the exact shape of the stump when the patient is standing upon the upper end of the artificial limb, and then hardens. It should be remembered that the upper end of every thigh bucket should fit accurately, should not press on the rami of the pubes, should take a firm hold below the tuber ischii, and should fit accurately round the outer surface of the femur. The upper edge of the inner surface should be thin, and moulded over the adductor muscles, which, whilst the plaster cast is being taken, should be made tense by the patient. The bucket of an artificial limb for mid- thigh amputation is usually made of wood. The wood should be willow, seasoned slowly for five years. The supply of such willow in this country is almost exhausted, and most of the wood now in use has been kiln dried. This method of drying willow increases the prone- ness to one of the defects which are inherent in a wooden bucket, viz., the liability to crack. This tendency of the bucket to crack should be obviated by the insertion of screws transversely around its upper part, as is done by Messrs. Hanger. Further, it must be remembered that all stumps have a tend- ency to shrink, and that every wooden bucket applied to an amputation stump must inevitably in time become too large, and. 361 allow the stump to move about freely within it, thus causing dis- comfort by friction of the skin, necessitating renewal at an early date. Lower third thigh amputation. Should the amputation be in the lower third of the leg, or be supra-con dylar , the bucket, in my opinion, should always be made of Jeather. A plaster cast should be taken of the stump, a plaster model of the stump obtained, and the leather should be moulded in a wet state on the exterior of the plaster model. When dry, the leather retains its shape accurately, and fits the stump like a glove. The leather should be bark-tanned sole leather, covered with vellum, open up the centre of the thigh anteriorly, and made to lace. A thigh bucket thus made will fit accurately below the tuber ischii, will not press unduly at any one spot, and can be laced up from time to time so as to counteract the shrinking of the stump. More- over, in consequence of the close fitting of the thigh bucket, these patients are enabled to dispense with safety with the necessity of wearing a pelvic band. An artificial limb made with a leather thigh bucket fits per- fectly and is exceedingly comfortable, and as it can be adjusted it continues to fit the limb, and thus movement and friction between the thigh stump and the bucket are prevented. Amputation at or just above the knee. For a Stephen Smith, a trans-condylar, or a Stokes-Gritti amputation, an accurately fitting model of the stump should be obtained whilst moderate pressure is being borne upon the lower surface, and a tightly fitting case of thick sole leather should be made, enclosing the whole stump. Tt should be opened up and made to lace along the centre. For a trans-condylar amputation, it is wise to pad the edge of the cut femur before the model is taken. Pain from pressure is often experienced in this amputation stump if this precaution is not adopted. The sharp edges of the femur are apt to cause irritation of the skin from pressure, and in some cases the bone ulcerates through the skin. Of the above three amputations, incomparably the best is a Stephen Smith. The condyles are broader, they are smooth, and they are accustomed to carry weight. It is essential that the femoral condyles should be well covered with loose movable integument. It is preferable that the patella should have been removed. The artificial limb is made with lateral steels, attached ex- ternally to the leather thigh case, and jointed at the level of the knee joint. Amputation at the site of election. Should the amputation be below the knee joint, the best stump is that where the tibia is cut transversely, with its anterior edge sloped off. The fibula should have been divided three quarters of an inch shorter than the tibia, because it grows after division. The skin should be 362 movable, well nourished, and devoid of scar. The best point at which to cut the bone is four to seven inches from the upper edge of the tibia. A longer stump loses in vitality at its lower end, and a shorter one loses in power over the leg bucket. The weight in such an amputation is occasionally borne on the actual end of the stump, more frequently on the lateral surfaces below the knee joint (viz., on the internal tuberosity of the tibia and upon the head of the fibula), and partly by the friction of the thigh bucket on the thigh. Occasionally it has to be borne by the tuber ischii resting upon the upper end of the thigh bucket. The best gait is obtained where the weight is carried below the knee, and preferably on the end of the stump. In any case, it is imperative to adjust the weight bearing and the form of the artificial limb to the amount of pressure which the end of the stump or the lateral surfaces of the tibia can bear. In every case an accurate plaster model of the stump should be obtained, and the bucket should be accurately moulded so as- to fit accurately the inner tuberosity of the tibia, the head of the fibula, and the patellar tubercle. The leg case may be made of wood or leather. The stump- should fit accurately into the leg case, or it may be en- closed in a leather slip socket or cap, which fits into the wooden or leather leg case, or this leather socket may be slung by straps from, or be continuous with, the lower edge of the thigh bucket. For very short tibial stumps this latter arrangement gives the more perfect and quite satisfactory results. Of the many makers who are adepts at fitting this artificial limb, the writer has come to the conclusion that for strong serviceable legs which have to stand hard wear* none can excel those made by Messrs. Masters for fit, durability and efficiency. There are other makers who run Messrs. Masters very closely, viz., Gillingham, of Chard, Grossmith, and the Essential Limb Company. The writer has on many occasions marched two patients, each with double amputation at the site of election, one man fitted by Masters, the -other fitted elsewhere, and the walk of the patient with Masters' legs has nearly always been slightly more natural than those made by any other maker. The artificial leg made by Messrs. Masters for this amputation is fitted with an adjusting screw, whereby in a few moments the length of the tendon can be regulated. This enables any stretching of the tendon to be taken up. The tendon is attached to a steel prolongation backwards of the lower end of the thigh steel. Thus more leverage is obtained, and the heel is elevated as the knee is straightened. Syme's amputation. In Syme's amputation the stump should be able to stand pressure upon its extremity. It should have no tender nerve in it. Should there be one, it should be re- moved. It is preferable to encase the stump wholly in leather, as is done for a Stephen Smith amputation. A stump so encased is in no danger of being ulcerated from friction, and carries the 363 weight of the body more safely. A leather case should carry lateral steels jointed in the foot. The stump rests on a cushion within the socket. An anterior elastic strap is attached below to the top of the instep, and above to each side of the front of the leg. These stumps, when healthy and able to bear pressure, do not require thigh bearing or shoulder straps. If, however, the end of the stump remains sensitive, the artificial leg will have to be provided with a bucket whose upper end fits accurately the tuberosities of the tibia and head of the fibula. In rare cases there must also be provided a leather thigh bucket, laced in front, and supported by strong lateral steels jointed at the knee. Where the amputation has been performed as recommended by Syme, there is room in the foot for the joint to be placed at the level of the normal ankle. When, however, the malleoli have been left, the stump is too long to enable this to be done. The artificial foot is then too short vertically, and the joints have to be placed in the lateral steels external to the foot. This produces increased lateral diameter. This is especially the case after Pirogoff's amputation. Chopart's amputation. Care must be taken to see that the heel is not drawn upwards, and that the sole rests flat upon the ground. A leather casing should be moulded accurately to the foot and ankle, and should then be attached to the instep of the anterior half of the foot. Lateral steels are usually neces- sary, and there should be an articulation opposite the ankle joint, so that free flexion of the foot at the ankle joint is permitted. Artificial Limbs Upper Extremity. With regard to the fitting of artificial limbs for the upper ex- tremity, there are two considerations which militate against finality : (1) that it is slowly becoming an honour to have lost an arm and to show it, and (2) the opposite arm slowly and con- tinuously develops in usefulness, so as in many cases entirely .to replace the lost arm. At the beginning of the war there were practically only two regions in the arm and forearm which could be fitted with artificial arms, viz., at the centre of the arm and centre of the forearm. Now any amputation can be dealt with. In every case a plaster model of the stump should be made, and the artificial arm fitted thereon. We have at the present time some twenty different types of artificial upper extremity. In advising what particular arm shall be fitted, it is imperative that the fullest consideration should be paid to the work of the patient. For officers and for men engaged in clerical work, and who 'have lost their arm at the middle of the humerus, there is no .arm to compare with Games' artificial arm. 364 The Games' arm is made on a plaster model and according to measurements. With this appliance a patient is enabled to bend his elbow and carry anything directly to the mouth. He can write, strike a match and light a pipe, raise his hat, shake hands, carry parcels and bags, and perform many other acts. It takes 3 months to make, is American, and costs 40, but for suitable cases it is worth the money. Upper arm. For amputation of the upper arm. Anderson's Worker's arm has been designed with the object of taking advan- tage of the principle that the shorter the arm bucket the greater the control of the patient over any appliance attached thereto. The essential point is that the arm bucket is made of leather, closely moulded to, and the exact length of the stump. There are arm and forearm adjustable buckets, each strengthened at each quadrant by means of a steel frame. Each bucket can be tightened by means of straps and buckles. The forearm is attached at the level of the opposite elbow to a steel prolonga- tion from the end of the arm bucket. This arm can have a detachable mechanically-operated fore- arm. With such a forearm the patient has mechanical control over the elbow and thumb. The mechanism is enclosed in the forearm, and is operated by attaching a Bowden cable to a lever projecting through the forearm, which cable, when pulled, dis- engages the ratchet, and elevates the forearm as required, which will again automatically lock in the new position. The forearm is lowered by putting a tension on the cable, which disengages the ratchet. By the action of a small lever suitably placed, the locking ratchet may be put out of action, giving a forearm which may be moved freely at the elbow by the Bowden cable. In this arm. movements of the opposite shoulder and arm are utilised for the purpose of moving volitionally the artificial elbow and thumb. Short upper arm. For short upper arm amputations, a special leather cap should be fitted. To this cap is attached a steel pla,te, which covers the acromion process, projects downwards, and is jointed to a similar steel plate which is firmly attached to and embraces the upper part of the arm bucket. This special form of attachment not only relieves the stump of the weight of the artificial limb, but controls inward and outward rotation of the arm. For shoulder joint amputations. For a workman who has lost his arm at the shoulder joint, the arm first made by Blatchford, at my suggestion, fulfils many requirements. An exact plaster of Paris model is taken of the shoulder region, and a leather cap accurately fitted on the model. This shoulder cap gives a very firm attachment to the trunk, and prevents friction upon the bony points. With this leather cap the artificial limb is subse- quently incorporated. In this arm also movement of the elbow and thumb is volitionally performed by means of Bowden bands , as in the above-mentioned Anderson's Mechanical Worker's 365 Upper arm amputation. An artificial arm for above elbow amputation has recently been made by Mr. Adams. It has certain advantages. It is light and strong, and the locking of the elbow joint is stronger than in some other makes, and is so arranged as to prevent wear. The forearm is detached without screwing. Any appliance attached to the wrist plate is quickly detached. At the elbow it has an eccentrically placed spindle'. Less force is thus required to bend the elbow. Trie weight of the limb is 2 Ib. Amputation at elbow. Should the amputation be at the elbow joint or through the forearm within two inches of the elbow, the whole of the stump should be enclosed in a closely-fitting leather case, made to lace up the centre. This case carries lateral steels continued into the artificial forearm, and jointed at the elbow. Forearm amputation. The best site of amputation of the fore- arm is at the lower end of the middle third. A forearm so ampu- tated gives the movements of pronation and supination, and the stump is not too long. For such an amputation the artificial arm should have a bucket carrying a metal end plate, to which can be attached various appliances. The most secure method of attaching this forearm leather bucket to the arm is by soft leather prolonged upwards, enclosing the lower third of the arm and made to lace up in front, as is done in Williams' arm. Should the forearm have been amputated at a point between two and three and a half inches from the tip of the olecranon, it will be found that this stump is too short to move a forearm bucket. In this case it is well to remove by postero-lateral incisions the supinators, extensors and flexors of the forearm just below the elbow joint. This operation gives a flattened anterior surface to the stump, on which the upper part of the forearm bucket can rest securely. Wrist joint amputation. Although the, pronation and supina- tion movements are retained in this amputation, the stump is- too long for practical purposes. A new wrist joint may be made by removal of one and a half inches of the radius and ulna at a point two inches above the end of the stump. Thirty degrees of flexion extension movement can be obtained in this new wrist, and this movement can easily be transformed into closure of the thumb and fingers. Mr. Ferris has made for me several forearms and hands to effect this. Thus, a man who has had this operation done can voluntarily close the artificial fingers on to the thumb. In my opinion, this operation gives a nearer approach to natural movement in the hand than anything yet seen in an artificial upper extremity. Amputation at the wrist. For this amputation the artificial forearm made by Hobbs, which fits accurately to the forearm and carries within it an automatic wrist twisting device, supinating the hand when the elbow is flexed, is an excellent one. Extension of the fingers is obtained by means of a band whiv?h passes up the centre of the forearm, and from thence to 366 a webbing passing round the patient's chest. Closure of the fingers is effected by a spring movement. Appliances. Various methods are adopted for attachment of the various appliances : (1) by a screw movement ; (2) by a bayonet thrust and locking (a very rapid method, and very efficient for light implements, such as a razor, brush, &c.) ; (3) by a hexagonal bolt passed into a hexagonal aperture in the centre of the forearm end plate and locked there (very rapid and very strong) ; (4) by a bolt, cogwheel shaped with eight cogs, which fit into similar depressions .on the inner surface of the above aperture (this is very rapid and very strong. It has been invented by a New Zealander named McKay, who has worked as a joiner for years and done any kind of carpenter's work with tools so fixed), or (5) by a special facing plate dropped into a slot at the end of the artificial forearm and locked by means of a cogwheel shaped bolt passing into corresponding slots on the inner surface of the end piece of the artificial forearm. The latter method of fixing has been invented by Messrs. Eooney, of Belfast, and is designed to prevent the attachment becoming loose, a condition which is apt gradually to supervene, and also to obviate the corresponding liability to fracture of the lower end of the forearm bucket. Of all these methods, fixation by screw is the more usual. This can be securely locked by a winged nut. The thread is a fths inch Whitworth screw, which is in universal use in the engineering world. 367 " ON THE LIMBLESS." BY SIB WILLIAM MACEWEN, F.R.S., LL.D., Eegius Professor of Surgery in University of Glasgow. In considering the limbless, the subject is so large and has so many sides that it is impossible to deal efficiently with all of them within the quarter of an hour to which all papers of the Allies' Conference have very properly been limited. One has, therefore, to select a few salient points for discussion. A few remarks on the Surgical Aspects of Amputations relatively to the Utility of the Stumps. The difficulties encountered by the surgeon in ships during engagements and the surgeons in the primary or even the Army base hospitals are so great that one wonders that the results are as good as they are, and many times they are so good that they leave nothing further to be desired. Examining thousands of amputations it is found that where it has been possible to secure the opposing muscles of the limb (flexors, extensors, abductors and adductors) either by fixation to the bone, which is best, or to cicatricial tissue well covered by mobile skin at the end of the stump that the utility of the remaining part of the limb is greatly enhanced and the economic value of the individual is increased. It is also obvious that where this has been obtained, the padding of the stump covering the osseous extremity has usually been secured and the shrinkage of the soft tissues has been prevented. When asepsis prevails, the closing of the cut nerve end, within its own sheath, aids in preventing neuritis and lessens the exuberant production of the fibrous tissue which forms the bulbous extremity of the nerve, which latter is so often trouble- some in amputation. Neuritis in a distal nerve is not always due to a distal peripheral lesion , but sometimes to one in the main trunk much higher up. It is obvious that removal of distal portions of nerves will not relieve such patients of pain. Inves- tigation of the main trunks by screen or photo sometimes reveals the lesion. In one such case, a pain in a distal nerve of forearm was found to be due to a piece of shrapnel in one of the trunks of the brachial plexus of which the patient was unaware. In another case, pain at a peripheral spot, in a below knee amputation, was due to a splinter of bone, the point of which penetrated the sciatic nerve between trochanter and pelvis. 368 Rigid cicatrices and flaps of skin adherent to the bone are productive of much discomfort to the wearer of artificial limbs. These may, of course, be prevented at the time of amputation by providing ample flaps especially in the thigh and by treat- ing them when they do tend to occur by extension and careful massage during the healing process. The aid of button sutures the buttons being made of block tin is of service in such cases , as it does away with the necessity of using adhesive plaster and weight and pulley. The buttons ought to be double threaded in order to allow for increasing or relaxing the tension as required. The attempt to make use of the living tendon covered with cutis to move fingers of an artificial arm may be of service in exceptional cases. Causes of Retardation of Healing of Stumps. Many men come into the preparatory hospitals with sinuses of many months' duration sometimes of years from which con- stant suppuration ensues, and which produce frequent recurrent inflammatory conflagrations ending usually in abscess, which upset the patient and greatly retard his recovery. The longer those suppurating foci exist, the greater the forma- tion of cicatricial tissue and the more adherent the soft tissues become to the bone. It is a pity to allow these suppurating foci to exist for such a long period, as a small operation suffices to cure them. Osteomyelitis, a frequent cause of painful stumps and long- standing suppuration, ensues when the exposed marrow of bone becomes germ infected. The infection spreads up the shaft, necessitating operation and sometimes even re-amputation. The causes of retardation of the healing of stumps in sailors and soldiers apart from the occasional occurrence of tubercu- losis, which requires special treatment are to be found in the presence of germ-laden substances which have been carried into the tissues in a vehicle, usually of a porous nature, such as articles of clothing, splinters of wood, sloughs of tissue and such substances as are non-absorbable and yet afford cover for germs to propagate, being kept at a proper temperature and supplied with abundant pabulum. Pieces of shrapnel or shell with irregular ragged edges, sometimes containing in crevices, soft germ- irnpregnated tissue. Pieces of necrosed bone which have been infected form a very suitable home for germs and retain them for long periods, maintaining persistent suppuration until removed. Any of the pyogenic organisms may be found in these cases, but the common streptococci and staphylococci are most prevalent. Though not a cause of retardation in healing, the mode in which new bone is sometimes thrown out into the soft tissues at the end of stumps, in irregular pointed masses, may give great dis- 369 comfort to the wearer of artificial limbs. The osteoblasts, meant for the closing of the bone marrow, here find themselves sub- jected to strange environment, and possibly to frequent and irregular movement, which disperses them among the lacerated tissues where they wander, no longer having purposive action, and form detached or irregular masses among the muscles. This may be greatly modified or prevented by periosteal flaps over ends of bone or by careful moulding of the stump during its early progress after amputation and by keeping it free from excessive movement. X-rays shows the formation of new bone, and often guide the surgeon to propose modification of artificial limbs or to relieve the necessity for this by removing the irregular mass of bone. The methodical use of X-ray for examining the condition of stumps is of service. It 'shows shrapnel, bullets, necrosed bone, osteomyelitis when marked, as well as new formation of bone sometimes enclosing foreign bodies. The Length of Time which should be Allowed to Elapse after Amputation before an Artificial Limb should be Applied. Hitherto the practice has been to allow six months as a minimum to elapse before putting on an artificial limb. This is much too long both for the stump and for the man. As soon as firm healing of a stump has been secured, a provisional limb ought to be supplied, and the patient ought to wear it without resorting to crutches. The nerve energy is thus early directed to the newer problems of muscular control and development of new movements in the stump, and thereby increases the func- tional activity of the part and prevents disuse atrophy. The brain and the heart are thus benefited. The former by the stimulation of the cortical cerebral centres controlling movement of the stump, the latter by securing and retaining the increased cardiac energy resulting from amputation of the limb and turning it to account for rejuvenating the health and strength of the body. This is apt to be lost were the patient allowed to remain inactive for long periods after amputation, when fatty degeneration of the muscles generally, and the heart in particular, is apt to ensue. Local benefit results from hardening of the stump and adjacent parts whenever pressure requires to be borne , and by the hasten- ing of the shrinkage and remodelling of the limb to nearer normal dimensions. The practice thus obtained enables the patient to adapt his muscles to the new problems of equilibration and generally fits him for his new mode of life. Provisional Limbs, their Forms and Uses. The .term " provisional limb " has been applied to those forms of apparatus which have been used for temporary and preparatory purposes. It has been customary for those who had amputation 370 of the lower limb to use crutches for ambulatory purposes, in doing so the stump is left hanging as a useless appendage, not participating in the movement, and, if sufficient time elapsed r disuse atrophy resulted. Instead of crutches a provisional limb is applied, so that the stump can come quickly as possible to participate in the action of walking and thereby develop its muscles and nerves under the control of the spinal and cerebral centres. The parts of the limb are thereby energised and their new function developed. The balance of the body is adjusted to the new conditions and the equilibrium established. The parts of the body through which its weight is transmitted to the provisional limb becomes hardened by use and ready to bear the pressure of the body on the permanent limb when it is ready to be worn. The necessity for massage and electricity is lessened by wearing provisional limbs, though both may be required in special cases. Though the cause of a sinus ought to be sought for and removed, yet the presence of a .sinus does not generally preclude the wearing of a provisional limb. On the contrary, the latter often aids in the healing of a sinus by its local stimulation, the movement favouring the loosening of the foreign body and aiding its discharge , and it further aids by restoration of health. Dressings can also be applied to *the extremity of the stump through the open backet of the Erskine provisional limb. The shrinkage of the circumference of the stump to its per- manent dimensions is rapidly secured by the wearing of pro- visional limbs, so that from all points of view the application of the provisional limb is desirable. It ought to be applied as soon as the wound of the stump is firmly healed. The patient at the beginning is weak and cannot stand prolonged use of the limb, and this in one sense is an advantage, as time is afforded for the stump to get gradually accustomed to the use of the pro- visional limb and excoriations and pressure points are thus avoided. The mental effect is likewise of service as the patient attains progression by an apparatus more closely applied to his body and less obtrusive than crutches and the folded empty trousers. The forms of provisional limbs are very various. Among others may be mentioned : bandages soaked in plaster of paris, paraffin wax, starch, glue, &c., making a stiff mould of the limb w r hich may be strengthened by strips of wood or metal. All these may be easily and quickly applied. Rolls of fibre, millboard or wood made in conical shape and fitted with straps have their advocates and serve a useful purpose. As applied to the thigh, there are certain disadvantages with most of these appliances. The first is that owing to the shrinkage of .the stump the plaster bucket requires frequent renewal. The second is that the top of the plaster or fibre bucket is not easily 371 made to fit the pelvis with comfort to the patient while bearing the weight of the body. The jErskine Provisional Limb and Pin Leg. The experience obtained at Erskine Hospital with numerous forms of provisional limbs, especially for thigh amputations, made it apparent that there was still much to be done in this direction, and investigations were begun toward that end in the Erskine Kesearch Laboratory. These have so far resulted in introducing a new form of provisional limb which has been extensively tried at Erskine and has been found efficient and agreeable to the patient. It is light and can be quickly applied. It is in the form of an adjustable peg-leg, with adjustable bucket to accommodate the shrinkage of the stump, and an elliptical ring made to suit the anatomical configuration of the pelvis. It is simple in construction and all the parts are standardised. The pelvic elliptical rings are made in eight sizes according to their circumference and these govern the width of the corresponding buckets. Besides this, to each width of ring there are various lengths of buckets to suit the levels of different amputations of the thigh. When a patient is to be fitted with a provisional limb a set of pelvic numbered rings are given him, and he is asked to select the ring which fits him best. This he does by threading his leg on the ring and getting it to fit at the pelvis. It ought to be made to fit accurately. When this has been done, the size of the ring selected is ascertained, the length of the stump taken ; when the attendant selects the corresponding size of provisional limb from stock one is fitted to his limb, the straps adjusted, and he is able to walk. DESCRIPTION OF THE ERSKINE PROVISIONAL LIMB AND PEG-LEG. A. The Pelvic Elliptical Ring, i.e., the ring which fits the pelvis at a point where the thigh joins the trunk. This is an elliptical ring constructed to fit the anatomical lines of the pelvis at parts where the weight of the body should fall- principally the ischium. The ring may be constructed of various materials, but English elm is one of the best woods for strength lightness. It is cut from a solid piece of wood 1J inches lick. The rings are made in eight sizes to fit the various sizes )f limbs. The ring must be very specially shaped to fit the mtour of the pelvis so as to carry the weight of the body where it normally ought to be placed. The final shaping of the ring mst be done by hand. The ring is checked round the under inside edge for J inch in depth and 3/16 inch in breadth to receive the three-ply wood moveable bucket and is also checked underneath to receive the supporting lathes. The ring must be fixed to the apparatus at a special angle. The outer part (tro- chanteric) must be 3 inches above the level of the inner part 372 (public). The upper side of the ring must be carefully rounded off and finished smooth with fine sandpaper, while the under side is left flat. 13. The Compressible Bucket is made of a single piece of three- ply wood J inch thick and each ply of equal thickness. This must be first quality birch. The outline of the top must be so shaped as to conform with the proper angle of the ring, while the lower part is straight and when put into position should form a cylinder. The upper end of the overlap of the movable bucket is fastened with a rivet, while the lower is left free and made so as to be able to be contracted by means of straps. The inner edge of the bucket is thinned and the two surfaces slide one within the other so as to present a smooth surface internally. For stability of construction the central knee block ought not to be more than 3 inches from bottom of bucket. The upper part of the bucket is fixed by screw 7 nails screwed into the check on the under 'side of the ring, and the overlap is fixed in front with a copper rivet about an inch from the ring. Immediately above the rivet, the top of the bucket for about an inch and a half on either side of overlap is lowered about quarter of an inch so as to allow of free movement of overlap. The buckets are made in three lengths, measuring from perineum 6 inches, 8 inches and 10 inches, and one out size for amputations through knee joint in tall persons 12 inches. C. The Supporting Lathes 4 or 5 in number are for carry- ing the weight of the body from the pelvic ring to the centre block. These lathes are, in breadth, If inch and J inch in thickness, aad made of birch three-ply, first quality and Govern- ment tested. They may also be made of elm, properly seasoned. If inches by 5/16 inch. These supporting lathes are let into checks in pelvic ring or ri vetted to bucket about an inch from outline of top and fitted tight under ring. Below T they are firmly glued and screwed to the central block w r hile resting on the projecting ledge. Instead of wood, strips of hoop iron may be used as supports. They may be made stronger and do not add much to the weight. D. The Central Block (above level of knee) is tapered from above, downwards and is made of willow or elm about 2J inches in thickness and 4 inches in diameter. A circular hole is bored in the centre of this block 1J inches in diameter to allow the pin leg to pass through and be adjusted to length. Two holes are bored, one toward the top and one toward the Bottom of the block, to receive screws for fixing pin. These screw r holes should' not be opoosite each other. By a slight variation of the central block the compressible bucket of the provisional limb can be adapted to the lower portion of the permanent limb. A special shaped central block with a diameter of not less than four inches is turned, and the inside 373 of same is hollowed oat to allow the knee block of the permanent limb to fit accurately into the cavity. This central block may be turned in varying lengths to suit amputations at different levels. The provisional compressible bucket may be thus interchanged with that of the permanent limb. E. The Adjustable Pin I^eg is made of home-grown ash. It fits the hole in the block and there is space between the bucket and the block for the adjustment of the pin which, when adjusted to height, is fixed by two screws, not placed opposite to each other. F. A Turned Saucer-shaped Support for the end of the stump may be fitted at the top of the pin, which gives stability in movement. The stump when quite healed is allowed to rest lightly upon this support. The amount of pressure to be borne upon the end of the stump can be regulated by increasing proximally or withdrawing the pin. G. The Foot Block is made of a turned piece of wood about 3 inches long and 3 inches in diameter, of conical or ogee shape, and the sole is covered with thick india rubber. A hole is bored in the block to receive the pin and fixed by means of two small screws at the top. If it be desired, a spring can be inserted into the foot block which would break the impact and modify the shock of walking. . The movement of the spring is about three-eighths. The foot block can also be formed with an under convexity to give more natural movement in walking. The Supply of Artificial Limbs: A New Industry. Eegarding the supply of artificial limbs for the thousands of men who have lost limbs in a great war, it was at once apparent that a peace loving country, estranged from war-practices and their consequences, which finds itself suddenly drawn into the vortex of a maelstrom of clashing nations, without proper pre- paration even for the prosecution of the war, would be without adequate resources to meet the requirements of the limbless.' When we opened a Hospital for Limbless at Erskine, we were frankly told that it would be impossible for us in Scotland to get artificial limbs unless we employed alien limb-makers who were already at work in this country. Having unbounded con- fidence in the potentially of our citizens and in the capacity, youth and vigour of our sons, I had no hesitancy in saying that even were we left without professional limb-makers, we should get in such a cause those who would make artificial limbs sufficient for the demand. We have men amongst us whose creative genius has made the Dreadnoughts possible and others who calT into existence the lightest, fastest ships afloat and whose works are as dreams realised of what physics may create. To men such as these, the making of artificial limbs would prove a recreative diversion after days spent in the solution of recondite problems. 374 Such skilled men we called to our assistance, and they have given freely the most practical and valuable advice. A Limbs Committee was appointed for the making, standardisation and improvement of artificial limbs. It is .comprised of expert physicists, engineers and surgeons who have together considered the various problems set before them the one from the mechani- cal, the other from the anatomical and physiological, point of view a happy combination which has already yielded excellent results, and which has been followed by the Government in the composition of the Advisory Committee for the Standardisation and Improvement of Artificial Limbs. The Erskine Limbs Com- mittee has directed the production of limbs by wood carvers, pattern makers and skilled mechanics, in shipbuilding yards and engineer shops, and have been able to supply artificial limbs in sufficient quantity and quality to satisfy requirements. Thus, by employing home industry alone, a new industry was created and the knowledge of limb-making and the problems involved therein have been and are being diffused over an ever widening area. Standardization of Artificial Limbs. The special limbs supplied by our Committee have been stan- dardised, the component parts being kept in stock with the exception of the bucket, which requires to be specially fitted. When the bucket is fitted, the other parts are assembled and quickly put together, and the limb is completed in a very short time. The standardisation ensures that any part which gets damaged can be quickly replaced and accurately fitted. Artificial Arms. Just a w r ord about artificial arms. There is great difference in the utility between appliances for amputation below the elbow and for those above. With the former much good useful work can be done ; so much so, that many men after some years' work at certain occupations are able to compete and hold their own by their use of their artificial arms with their more fortunate two-armed neighbours. (The Williams type of arm or the TJ.V.F. arm are practical and useful arms.) This cannot be said for artificial arms and appliances for amputation above the elbow, which diminish in utility the further up the arm the amputation is performed. The Advisory Committee on Artificial Limbs, of the Pensions Ministry, is at present collecting infor- mation as to how far the artificial limbs and appliances which have been already supplied from the various limbless hospitals have been of service to the men. The problem of the utility of the limbless is not solved by supplying artificial limbs alone. They require to be taught the use of the artificial appliances provided, and they must be re- educated so that they may be able to employ their future to the utmost, not only for their own good but also for the good of the 375 community. To this end workshops must be provided both for curative and vocational purposes. It is contended that preparatory cases and fitting cases ought to be treated in the same hospital at the same time. When this is done, it has the double advantage of getting the men ready sooner for their artificial limbs and giving the men more time for re-education under one system. For the few who have suffered amputations of several members t two legs or two arms or one of both, or three amputations some places of residence near to workshops fitted with special appliances to aid them in their work is advocated. 376 LA STATIQUE DBS MEMBRES INFERIEURS ARTIFICIELS DETERINE LEUR VALEUR REELLE. PAR DR. MARTIN. La prothese des membres s'efforce de restituer la fonctioii perdue du fait de 1' amputation. Les membres inferieurs ont uiie fonction de statique et de dynamique, c.a.d. qu'ils perinettent la station et la marche. Celles-ci sont essentielles a la vie. II est done indispensable de les recuperer au maximum. Les elements d' appreciation de la valeur des membres artificiels inferieurs generalement admis jusque maiiitenant sont: le poids, la mobilite, et 1' adaptation des appareils. Ces elements, a notre sens,, n'ont d' importance que pour autant qu'ils servent la foiiction du membre artificial; ils sont d'ordre secondaire. La conformation statique et la dynamique des appareils de prothese de la cuisse et de la jainbe constituent, selon nous, les points les plus importants pour juger de la valeur fonctionnelle de ces derniers. Pour denioiitrer cette affirmation, nous aurons recours a 1' observation directe et a 1' experimentation . Nous pouvons declarer que la statique et la dynamique humaines ne sont pas identiques chez tons les indimdus; les appareils dnstatique et d dynamique uniformes et constantes sont done, en principe, defectueux. L' observation nous a demontre les points suivaiits : 1. deux hommes ne possedent jamais la meme conformation anatomique des membres inferieurs. Le femur, oblique en bas et en dedans dans la position debout iiormale, forme avec le tibia vertical un angle obtus ouvert en deliors : c'est V angle de declinaison du femur. L'ouverture de cette angle varie avec chaque sujet; elle oscille entre 174 et 164, d'apres nos observations. Les deux os de la jambe ne constituent pas un axe vertical absolu, c.a.d. que la verticale passant par le milieu du genou (espace intercoiidylien), ne coupe pas la milieu de la ligiie bi- malleollaire. Cette verticale tombe tou jours en deliors du milieu de 1'axe bi-malleollaire, ea cela, d'une quantite variable avec chaque sujet. L'axe longitudinal du tibia, c.a.d. la ligne unissant le milieu de 1'axe du genou au milieu de 1'axe bi- malleolaire, fait, avec la verticale passant par le milieu du genou, 1111 angle, que nous avoiis denomme " angle de cambrure de jambe. 1 ' L' amplitude de cet angle varie avec chaque sujet. Elle oscille entre 2 et 8, d'apres nos observation. L' amplitude ;les angles de declinaison et de cambrure varie d'une facon 377 generate avec la taille clu sujet, son ampleur, son sexe, ses caracteres ancestraux, &c. L' angle de deviation externe du pied, c.a.d. Tangle que fait Taxe longitudinal dn pied avec le plan median du corps, varie avec chaque individu; ce fait est d' observation courante. 2. la marche depend dela conformation anatomique des membres inferieurs. 'Deux hommes ne possedent done janiais la meme marche. L' allure generate de cette derniere, son rytlime, sa cadence, sont des elements fort variables. On ne pent pas comparer par T analyse la marche decomposee cinemato- graphiquement de deux individus differ ents. Ce fait -est d' observation courante: il nous est arrive a tous d' identifier un ami en entendant son pas naarteler un terrain diur et sonore. Nous observons aussi frequement des analogies de la marche chez des personnes composaiit la meme famille. Le pere legue a ses enfants des analogies de structure anatomique des membres inferieurs, et du fait meme, des ressemblances dans la marche, Enfin, la marche de Thomme differ e taut de celle de la femme, parce que la statique du premier est totalement differente de celle de la seconde. Celle-ci, en vue de la maternite, a un bassin large et evase. L 5 angle de declinaison du femur et Tangle de cambrure de jambe sont tres marques. De ce fait, la statique est tres speciale, ce qui influe sur la cadence et le rytbme de la marche. L' anatomic particuliere des membres inferieurs cree cette statique et cette allure generate de la marche. 3. L'angle de declinaison du femur et 1'angle de cambrure de la jambe sont, des necessites statiques et dynamiques de la marche d'un bipede. Dans la station debout normale, le centre de gravite du corps passe par le milieu de la base d'appui, c.a.d. genera lement la plan median du corps. Mais au cours de la marche, il n'en est plus de meme. On peut dire, que la marche de Thonime est une marche unipede inter- mittente. Lors de la phase du simple appui, dans Taccomplisse- ment d j un pas, le centre de gravite doit passer par le pied portant. C'est pour faciliter cet appui unipede que la ligne de gravite du corps a ce moment, c.a.d. la verticale passant par le milieu de Taxe du genou, est situe en dehors du milieu de la ligne bi- malleolaire de la jambe portante. Nos observations a ce sujet ne font que confirmer celles de Destot (de Lyon), qui par des recherches radiographiques et T interpretation de la forme de Tastragale, est arrive a cette conclusion : Vaxe du pilon de jambe pa$se en dehors du centre de figure de la face inferieure du tibia.. Nous reviendrons plus loin sur ce point. 4. La statique des membres inferieurs est normalement con>- stituee de telle facon que la station debout se maintient avec tie minimum de contractions musculaires, c.a.d. de fatigue. A cet effet plusieurs elements interviennent. (a) La ligne de gravite du corps, en station verticale, passe derriere Taxe qui unit les centres des deux articulations coxo- femorales. (Poiries.) 378 Ainsi, sous la pesee du corps 1'extension de ce dernier a une tendance a s' accent uer. L' attitude as maintient passivement, ce mouvement etant bloque par les puissants ligaments de Bertin. (b) La disposition du genou en hyper extension, c.a.d. en genu recurvatum, fait tomber la ligne de gravite du corps devant Tone obturateurs, les jumeaux et le carre crural, sont fortement rotateurs en dehors. Les extenseurs, c'est-a-dire surtout le grand fessier, sont tres rotateurs en dehors. Recherchons comment au cours de la marche se manifesto Faction de ces muscles. Xormalement, en attitude de depart, la periods du double appui, le femur est en direction oblique en bas et en dedans. Cette direction est due a la forme du femur, on dispositif articulaire et a Faction du toiius musculaire. Des que s'execute une phase du simple appui, le femur de la jambe oscillante se flechit. Le psoas-iliaque entre en jeu; il flechit la cuisse et il la porte en legere rotation externe. Gette attitude s'accentue au fur et a mesure que F oscillation du membre se deroule jusqu'au moment de la flexion maximale de la cuisse. En ce moment la jambe oscillante est anterieure et elle ya com- mencer son extension. Le flechisseur se relache progressivement et nous assistons au deroulenient en sens inverse de la cuisse; elle 382 s'etunde, se porte en legere rotation interne. Cette evolution, que Fon peut observer sur un film cineinatographique, est normale ; elle resulte de Faction des muscles, qui eux sont sous da dependance du sens deleur traction, c.a.d. de leurs insertions au squelette. Lors lu deroulement de la cuisse en avant au moment ou le pied anterieur retombe vers le sol, aucun muscle ne parait entrer en jeu. La pesanteur nous semble etre le seul element actif ; cette interven- tion est rendue possible grace au relachement des flechisseurs. S'il en est ainsi, il serait preferable de pas faire des appareils de prothese trop legers, car Faction de la pesanteur en serait amoindrie. II y am ait lieu de rechercher experimentalement le poids optimum des membres artificiels. Au moment ou le femur fait sa rotation externe, la tete femorale se deroule dans la cavite cotyloide, decouvrant ainsi la face interne de la cuisse qui devient quelque peu anterieure. La forme meme de Fepiphyse femorale superieure fait que ce mouvement de rotation externe s'accom- pagne d'un leger mouvement d'abduction; celle-ci est consi- derablement augmentee par la longueur du femur : c'est pourquoi 1' abduction est surtout marquee au genou. Dans la phase suivante, celle de la rotation interne, ce meme mouvement se produit en sens inverse : le genou se reporte en adduction. Done shematiquement et nornialement, au cours de F execution d'un pas, le femur du cote du membre oscillant decrrit un mouvement de flexion, rotation externe et abduction, suivi d'un mouvement inverse et egal, c.a.d. extension, rotation interne et adduction. On peut observer que revolution d'un membre artificiel physiologique est identique : la statique normale cree une dyiiamique normale. II n'eiL est plus de meme quand I'ampute est muni d'un membre commercial : la statique vicieuse cree une dynamique anormale. Nous savons que les membres conimerciaux out une statique anormale. Le docteur Hendrix, dans sa monographie " Les principes fondamentaux de la prothese orthopedique du membre inferieur," en a bien decrit les caracteres essentiels. Nous retiendrons settlement ceci : Taxe longitudinal de la cuisse est dans le prolongement de Faxe longitudinal de la jambe : les angles de declinaisoii et de cambrure de janibe n'existent pas. Le cuissard est vertical. Le moignon engaine dans ce dernier est necessairement dans la verticalite. Or nous savons que la direction normale du femur au repos est oblique en bas et en dedans, c.a.d. en adduction legere. Pour en gainer le cuissard, le moignon se porte en abduction legere; a cet effet les abducteurs se contractent, avant la marche et procurent ainsi la position exigee. Or les abducteurs, nous Favoiis dit, sont fortement rotateurs en dehors; d'autre part la rotation externe, comme Favons vu, s'accompagne d'une abduction tres marquee au genou. Au repos le moignon est en abduction forcee et en rotation externe. Cette anomalie fonctionnelle des actions musculaires modifiera entierement F evolution du membre artificiel. 383 Reprenons 1'evolution de la jambe oscillaiite lors de la phase du simple appui. La cuisse se flechit : le psoas-iliaque entre en contraction; les abducteurs, qui sont legerement extenseurs, se relachent. Des lors le femur est porte en haut ; le niembre attire par le psoas, se met en adduction ; ce dernier mouvement s'accom- pagne d'une rotation interne. Ces mouvement s s'accentuent progressivement jusque la flexion maximale : la jambe oscillante est anterieure. Alors s'executent son deroulement et 1'abaisse- xnent du pied vers le sol. Le psoas se relache, les abducteurs se 'Contractent, le moignon redevient vertical : le membre se met en extension, abduction, et rotation externe. Dans cette phase les abducteurs entrent en jeu parce qeu le cuissard est vertical, quand le pied prend appui au sol. Done schematiquemeiit, 1'evolution du membre artificiel com- mercial est inverse de celle du membre naturel la flexion de la cuisse s'accompagne de rotation interne et d' adduction; son extension, de rotation externe et d' abduction. Cette anomalie est due uniquement au trouble provoque par le jeu musculaire resultant d'une statique defectueuse. Des contractions muscu- laires interviennent mal a propos et en exces : c'est la une cause de fatigue et de mauvais rendement de la prothese. La simple observation d'un film cinematographique decomposant la niarche d'un ampute demontre ce que nous ;afiirmons ci dessus. On poiirrait s'etendre davantage et envisager Faction des ant-res anomalies statiques sur la dynamique du membre artificiel. Mais nous devons nous limiter dans ce rapport. Nous pensons d'ailleurs en avoir dit assez pour avoir fait la preuve de 1' affirmation suivante: la statique des membres inferieurs artificiels determine leur valeur reelle. Les notions reprises dans ce rapport sont d'ordre scientifique. On peut dire que le probleme tout entier de la prothese des membres est d'ordre scientifique : seule 1' etude scientifique, basee sur F observation rigour euse des faits et sur 1' experimentation objective en donnera la solution. A 1' ambulance de T Ocean c'est dans cet esprit que nous avons aborde et que nous continuons Tetude de cette question. 384 LES NOTIONS NOUVELLES SUR LE TRAITEMENT POST-OPERATOIRE ET L'APPAREILLAGE PRECOCE DBS AMPUTES. PAE le DR. MARCEL STASSEN, Directeur Medical de 1'Institut Militaire Beige des Mutiles et Invalides de la Guerre, a Port-Villez. Jusqu'en ces derniers temps, 1'art chirurgical et 1'art de la prothese etaient deux entites nettement definies, et bien eloignes etaient les rapports qui existaient entre eux. II n'y avait pas entre le chirurgien et le prothesiste de collaboration intime. Tout au plus, le chirurgien estimait-il , interessant de connaitre 1'art de la prothese, en vue de la place a assignor a la cicatrice lors de 1' intervention opera toire. Ce n' etait que quand son role etait termine, que quand la cicatrisation anatomique etait obtenu, qu'il adressait son patient au prothesiste. La reeducation fonc- tionnelle des moignons en vue de 1' utilisation de la prothese ne retenait nullement son attention, c'etait affaire au prothesiste de tirer parti de ce que le chirurgien avait bien voulu laisser, or, comme nous a lions le voir, c'etait une erreur. La therapeutique des amputes exige la collaboration du chirurgien et du medecin-prothesiste et pour etre bon medecin prothesiste, il faut etre un clinicien averti. La reeducation fonctionnelle, ou mieux 1'utilisation fonctionnelle du moignon doit commencer le plus tot possible, apres 1' amputation. Au meme titre que le traitement des fractures et de& trau- matismes articulaires , la therapeutique des amputes est au premier chef, un probleme anatomophysiologique. Tout en visant a la cicatrisation de la plaie opera toire, il faut des le principe, c-a-d., des le moment de 1' intervention opera toire, s'efforcer de conserver aux segments du membre, un maximum de mobilite et de tonicite mnsculaire. L' amputation n'est pas une lesion a effet local, elle exerce au contraire, une action nefaste sur la physiologic de tout le membre restant. La section des groupes musculaires et le desequilibre qui s'en suit, la section des nerfs et des vaisseaux determinent des troubles circulatoires tant arteriels que veineux ou lympha- tiques, troubles circulatoires qui ont un retentissement grave sur la bonne nutrition du memb.re entier et par consequent sur se, rnoyens de defense. Utilisation fonctionnelle et cicatrisation sont inseparables Tune de 1'autre. La chirurgie traumatique doit en finir avec cette notion du repos favorisant la cicatrisation et prevenant r infection. Les resultats obtenus par la mobilisation immediate dans le traitement 385 des fractures ; les resultats inesperes de la methode Willems dans la therapeutique des infections articulaires , la cicatrisation rapide des plaies torpides par la methode " biokynetique," font bonne justice de cet aphorisme considere jusqu'aujourd'hui comme une verite intangible. C'est la formule lapidaire de Lucas Championniere. ' Le inouvement c'est la vie, qui doit dominer toute 1'activite thera- peutique de la chirurgie traumatique." Le principe directeur de la consolidation anatomique prealable avec retablissement ulterieur de la fonction, devrait etre raye des traites de therapeutique chirurgicale traumatique pour etre remplace par celui bien plus logique de " 1' utilisation fonctionnelle amenant par surcroit la consolidation anatomique . ' ' Aussi bien, chez les amputes, il faut mobiliser leg segments du moignon des les premieres heures qui suivent 1' amputation. Bien plus les amputes doivent etre appareilles le plus tot possible apres 1'acte operatoire, et le plus tot possible signifie dans les premiers jours, sans meme attendre la cicatrisation complete de la plaie operatoire. 11 faut aux amputes une prothese therapeutique, precoce, voire meme, hative, permettant I' utilisation fonctionnelle du moignon. Le Medecin-prothesiste doit intervenir immediatement apres 1'acte chirurgical, pour prendre, avec le chirurgien, la direction du traitement post-opera toire du moignon. Attendre la cicatri- sation pour appareiller un moignon, c'est attendre le desequilibre et 1'atrophie musculaire, 1'endolorissement et la raideur des irticulations, c'est meme retarder la cicatrisation de la plaie >peratoire. Celle-ci sur un moignon muni d'une prothese therapeutique evolue au contraire vers la guerison, avec une ipidite extraordinaire. L'atrophie musculaire et les raideurs irticulaires n'ont pas le temps de s 1 installer et la circulation se fait dans d'excellentes conditions. Les differents segments du lembre restant s'assouplissent vite, leur volume diminue de plus jn plus et bientot le moignon tout entier atteint un etat definitif , pent alors recevoir une prothese definitive. Un autre bienfait de 1'appareillage immediat est le reconfort loral qu'il anr>orte aux amputes. II leur rend la confiance dans ['avenir en diminuant, des le principe, les inconvenients de leur infirmite : il previent surtout chez les amputes du membre snperieur, cette resignation, ce scepticisme decevant centre lequel les prothesistes doivent souvent lutter, lorsqu'ils sont appeles a ppareiller des manchots, amputes de longue date. En realite, entre le moment de 1' amputation et celui de 1'appareillage definitif, il s'ecoule une periode plus ou moins ongue, au cours de laquelle 1'ampute doit utiliser une prothese imple, commode, facile a construire. Cette prothese thera- peutique, a fournir des les premiers jours qui suivent 1'amputa- tion, permet 1'utilisation fonctionnelle du moignon, element de premiere importance pour la cicatrisation de la plaie operatoire et revolution favorable du moignon vers son etat definitif. 16524 N 386 A cote de 1' influence qu'il exerce sur le moral de 1'ampute, 1'appareillage imraediat, en conservant aux segments du moignon, une tonicite et une souplesse normales, assurera pour 1'avenir, le rneilleur rendement de la pro these definitive. En prenant ces principes pour base , nous etudierons succinctement dans les pages vont suivre : Lies types de prothese therapeutique : (a) pour amputes du Membre Inferieur ; (b) pour amputes du Membre Superieur. A. La Prothese Therapeutique des Membres Inferieurs. F. Martin, adjoint au Pr. Depage et Chef du service du centre beige d'appareillage de 1' ambulance de 1' Ocean a La Panne, fut un des promoteurs de cette prothese. Rejetant les conceptions qui avaient cours avant la guerre, au sujet des appareils pro- visotres ou d'attente qui, dans 1' esprit des orthopedistes, etaient destines a des moignons cicatrises et permettaient aux amputes d'attendre un appareillage plus perfectionne F. Martin- estime que la prothese therapeutique doit etre con^ue d'une fagon plus complete. Elle doit, ecrit-il, achever le traitement chirurgical. Elle con- stitue au meme titre que le massage et la mobilisation mecanique ou manuelle, un adjuvant primordial de 1'evolution des moignons. L'emploi judicieux de la prothese therapeutique abolit presque completement 1'usage nefaste des bequilles. Ces instruments, devraient 6tre bannis de 1' arsenal chirurgical; car, independam- ment des accidents qu'ils peuvent causer (paralysie du plexus brachial, nevrite, etc.) leur usage prolonge determine dans la statique de l'homme des modifications profondes et presque irremediables. Dalla Vedova, dans un interessant article paru en aout 1916, faisait prevoir tout le parti que Ton pouvait tirer d'un emploi plus etendu de la prothese dite provisoire. II signalait notam- ment les avantages que 1' emploi precoce d'une prothese simple, economique exergait sur revolution des moignons d' amputation. Nous devons, disait-il, trouver line prothese simple et aussi economique que possible, que 1'ampute portera des que le moignon sera cicatrise et qu'il faudra meme parfois appliquer avant que la cicatrisation soit obtenue. D'apres Putti, aucun traitement physio-therapique ne peut rendre au moignon autant de nutrition, autant de souplesse que 1' utilisation fonctionnelle native, et dans le traitement des moignons 1'appareillage precoce represente la physiotherapie la plus utile et la plus complete. Mais pour etre d'un bon rendement, un membre artificial de traitement doit reunir quelques qualites essentielles que F. Martin fixe comme suit : 38T L'appareil s'applique sur un moignon recent, c.-a-d. toujours sensible, il devra done donner un appui judicieusement reparti pour menager la susceptibilite du moignon. Celui-ci, au debut, change rapidement de forme et de volume. L'appareil suivra ses evolutions successives, il faudra le remplacer, afin qu'il s'adapte constamment aux modifications de forme et de volume du moignon. Le poids de 1'appareil sera peu eleve, il ne depassera pas deux kilos pour un pilon d'ampute de cuisse ou de jambe. II faut donner la preference aux appareils en platre qui sont superieurs aux appareils construits en carton ou en toute autre matiere. Un des points essentiels du bon fonctionnement de ces appa- reils, est d'enlever le bout inferieur de I'emboiture, afin de degager de toute pression, d'eviter tout frottement a I'extremite et aux bords inferieurs du moignon. Dans 1' album que 1'Institut de Port-Villez a depose a 1' Exposi- tion, on peut voir plusieurs photographies de ces appareils de traitement en platre pour arnputes du membre inferieur. B. La Prothese Therapeutique des Membres Superieurs. A la suite d'une enquete que nous avons faite aupres de 147 amputes du Membre Superieur, le Dr. Hendrix et moi, avons acquis la conviction que ces mutiles pouvaient aussi retirer le plus grand benifice d'un appareillage precoce. Plusieurs de ces amputes nous ont meme declare qu'ils regrettaient de n' avoir pas ete appareilles aussitot que possible apres 1' amputation. Sans doute, les traitements physiotherapiques que leur moignon avait subi avant d'arriver a son etat definitif, avaient eu une certaine efificacite au point de vue de leur reeducation fonction- nelle ; mais celle-ci aurait ete plus complete encore si, au traite- ment physique, etait venu s'adjoindre un appareillage precoce. Celui-ci les aurait empeche de faire abstraction du membre perdu. 11 ne les aurait pas ensuite reduits, lors de 1' appareillage definitif, a une grande depense d'energie morale, pour vaincre 1'habitude prise, de se trouver assez complets dans la vie avec un bras de moins. Le moral, le manque de confiance en 1'avenir des amputes du Membre Superieur, appareilles longtemps apres 1' amputation. est, en effet, un des plus grands obstacles, contre lesquels doivent lutter la bonne volonte des reeducateurs. L'homme qui a perdu un bras se resigne, avec un certain senti- ment de fatalisme, a sa mutilation. Quand il a reeduque sa main valide, pour suppleer au membre perdu, 1'ampute, plus parti- culierement 1'ouvrier ampute, ne cherche pas a ameliorer sa situation. Une vague conscience d'etre desormais une moindre valeur professionnelle fait naitre chez lui un etat d' esprit special. Convaincu que les metiers mariuels lui seront desormais fermes, il accepte avec scepticisme les conseils de ceux qui veulent 16524 N 2 388 1'aiguiller vers 1' atelier. Si on lui propose une prothese de travail, qui lui rendra possible 1' execution de certains travaux, il est bien rare qu'il ne reponde pas par un refus. II est ebloui par le mirage de la petite place ' ' (gardien de musee , gardien de square, garde-barriere, etc.) qu'il attend de 1'Etat ! Bien plus, souvent il refuse meme d'utiliser le bras automatique. II pretexte que cet appareil est plus encombrant qu'utile. S'il 1'accepte, c'est pour le releguer au fond d'une armoire, apres quelques jours d'essai. La prothese therapeutique, 1'appareillage precoce et la reeduca- tion fonctionnelle par le travail, sont les meilleurs moyens de prevenir chez ces amputes le developpement de ces sentiments de resignation et de desesperance en 1'avenir. Le Dr. Martin de 1' Ambulance de 1' Ocean, a La Panne est arrive, lui aussi, aux memes conclusions que nous. Les amputes du Membre Superieur sont, dit-il, comme les amputes du Membre Inferieur, susceptibles de retirer le plus grand profit de la prothese therapeutique rapidement appliquee. Aussi bien, la Commission d' Etude de la prothese du Membre Superieur qui fut institute par le Gouvernement Beige par depeche ministerielle en date du 13-1-18 et qui, sous la Presidence du Medecin Principal de I e classe Maistriau, etait composee de Mr. le Prof. Turner, de Paris, Mr. Le Dr. Ducroquet, de Paris, de Mr. Breton, orthopediste a Paris, du Medecin de regiment de 2 classe Waffelaert, des Medecins de bataillon de reserve Stassen et Hendrix, des Medecins-adjoints Martin et Delrez, a-t-elle admis, a I'unanimite, les principes suivants relatifs a 1'appa- reillage precoce de ses amputes du Membre Superieur. 1. II est indispensable d'appareiller les amputes du membre superieur, des les premiers jours apres 1' amputation. 2. L' appareil provisoire (prothese therapeutique) doit etre aussi simple, aussi leger que possible et facilement renouvelable. J7 se composera : (1) d'une emboiture.rigoureusement adaptee au moignon ; (2) de moyens d' attaches simples. Emboiture et moyens d' attaches doivent etre realises : (a) en vue du maintien de 1' orientation normale des axes longitudinaux et articulaires du membre ; (b) du maintien de 1'integrite normale du jeu articu- laire et du fonctionnement des groupes musculaires ; (3) d'une terminaison sur laquelle pourront s' adapter une serie d'instruments pour- la vie de relation et d'outils pour le travail therapeutique. 3. Programme des exercices a executer. 389 Outre les mouvements necessaires a la vie de relation, 1'ampute devra executer avec le prothese provisoire, sous la surveillance du medecin-prothesiste , un programme de mouvements ou de gestes ouvriers, simples, gradues, ayant pour but de mettre en oeuvre le jeu des muscles et des articulations des segments du membre restant. Ce programme pourrait, p. ex. : se resumer dans la serie des gestes ouvriers suivants : l cr exercice : limer avec une lime demi-douce et courte pendant une demi-beure environ le premier jour. 2 C exercice: limer avec une lime dure, lourde et longue, pendant une heure environ, le second jour. 3 6 exercice : scier un bloc de bo'is ou un morceau de fer pendant une heure environ, les jours suivants. 4 C exercice: a partir des 5 e ou 6* jour, exercices varies des jours precedents et, en plus, debiter a la gouge et au maillet des blocs de bois, pendant 3, 4 ou 5 heures environ. 4. L'ampute devra etre dirige sur le centre d'appareillage, immediatement apres la cicatrisation de ses blessures. 5. La prothese therapeutique qui suit les evolutions du moignon est la seule prothese provisoire qu'il y ait lieu de fournir aux amputes du M.S. avant de leur donner une prothese definitive. II y a lieu de laisser au chirurgien et au Medecin-prothesiste le choix de la matiere a employer pour la confection des divers rnodeles de la prothese provisoire. Les appareils en platre que le Dr. Martin, a 1' Ambulance de V Ocean a La Panne, le Dr. Hendrix, au Centre d'appareillage de 1'Armee Beige, a Bonsecours, ont fait construire, sont con- formes a ces principes. Dans 1' album qui est depose a 1' Exposition, nous donnons egalement des photographies d' appareils " de traitement " en platre, pour amputes du Membre Superieur. Ces appareils ont ete fabriques a Port-Villez e% leurs constructeurs se sont, eux aussi, efforces de repondre aux desideratas exprimes par la Com- mission d'etude de la Prothese du Membre Superieur, institute par le Gouvernment Beige. 16524 390 SUMMARY OF THE REPORT " ON THE PRESENT CONDITIONS OF PROTHESIS IN ITALY" TO THE INTER- ALLIED CONFER- ENCE IN LONDON ON ASSISTANCE TO DISABLED SOLDIERS AND SAILORS. For PROFESSOE EICCAEDO DALLA VEDOVA, Director of the Orthopsedical Traumatical Clinique of the Eoyal University at Home. The intensification of the construction of prothesis that has manifested itself in Italy as a result of the war, can be thoroughly examined only by means of a detailed, analytical study. This is not possible so far as this brief summary is in question, by reason of the limited amount of space. I will therefore content myself by setting forth the extra- ordinary unexpected need for providing with artificial limbs (anatomical and functional) a great number of youths who have sacrificed their limbs in the defence of Eight against Might, which has increased the importance of this study for the perfecting of prothesis and has caused it to be recognised as the means for giving back to the disabled man his social autonomy. The efficacious initiative of Her Majesty the Queen has blended with the generous co-operation of the citizens of all classes, under the moderating protection of the Government, to assist this good work. And side by side with the workshops for artificial limbs that already existed before the war in the two centres for univer- sity or higher orthopaedic studies (of Bologna and of Milan), orthopaedic workshops have arisen in nearly all the principal pro- fessional training schools for disabled soldiers and sailors (Milan. Florence, Eome, Turin, Palermo, Pescia, Naples, Venice, Genoa). The efforts of all of them have been united to those of the workshops belonging to private firms, for the more rapid perfecting of the production of artificial limbs. The first national competitive exhibition of artificial limbs, held at Bologna in March, 1917, brought the results of this activity to the attention of the public and offered a foundation for the laws and regulations that have been enacted for its guidance. The general idea that has characterised this movement has been the democratising of artificial limbs. We shall not be able to differentiate in our war prothesis, a prothesis of luxury, or the rich* man's prothesis, from the poor man's prothesis, for the one pre-occupation that has dominated oar choice has been that of providing our brave disabled men with means that would assure 391 them the most complete and perfect functional and morphological compensation for their disablement. As the principal condition of success consists in the artificial lirnb fitting exactly the disabled stump, the morphological indi- vidualisation of prothesis was accepted as being the fundamental rule for its construction, and this not only from the point of view of the cosmesis, but especially with regard to the success in the research of the most opportune and adequate support. Both the shape and the size of the disabled limb are subject for a long period to modifications, even after the anatomical lesions have healed, and this is caused by trauma or its conse- quences. These morphological modifications are the result of the anatomical condition of the limb, and, more especially, of the organs remaining in it ; but, for a cause that can certainly not be set aside, they are the result of the functional stimuli that are practised, adequate to the new conditions of the limb. And for this reason the evolutions of these transformations are notably influenced, both as to duration and modality, by the precocious use of the stump and artificial limb. This precocious use reacts again on the general physical condition and on the psychic adaptment of the disabled men. The problem of the precocious application of artificial limbs to stumps still undergoing the phenomena of settling down could have been solved in two ways : either by the construction of apparatus in such a way as would allow for the progressive adapta- tion to the morphological modifications of the limb, or by the construction of provisional apparatus to be used during the period of settling down, and their substitution by definitive apparatus, once the complete consolidation of the limb had taken place. The first solution, although simpler and less expensive, was justly considered as being less useful in its general application ; it was accepted only for a few functional protheses and for a few anatomical protheses of the superior limbs. But it was judged to be less adapted to the prothesis of the lower limb, as being the one that uses apparatus of a complicated construction the result of components of multiple and heterogeneous ingre- dients, that do not offer a morphological individualisation that is sufficiently stable and proportionate to the very grave static and dynamic exigencies. So the other solution was chosen instead : that is, to provide each disabled man with a provisional prothesis and a definite prothesis. At the same time, it was decided 'that for the disablement having to undergo a longer period of settling down the provisional apparatus shall be of two types : one a provisional hospital prothesis, and one a transitory prothesis for temporary use, but which will represent, for the disabled man, the apparatus in reserve, even when he has been provided with the definite prothesis. The requirement that the prothesis shall be of as light a weight as possible has been appreciated to the full as much for the pro- thesis of the superior members as for the lower limbs. But it 16524 N 4 392 has been considered as an essential requirement only for func- tional prothesis and for anatomical prothesis of the thoracic member; this, because they bring their weight to bear constantly on the member or on the body of the disabled man. Whilst, for the anatomical prothesis of the pelvis member, which leans its weight periodically on the ground and having the function of offering an unshapable support to the burden of the weight of the body, the requirement of lightness was not considered as a principal coefficient in the question of choice. All the more so that cinematic dispositions can lighten the weight carried by the stump during the period of oscillation, and that the greater the distance of the individual's centre of gravity from the ground, the more it inclines towards the healthy side, so the greater the difference between the weight of he prothesis and that of the amputated limb, the higher will be the centre of gravity of the prothesis. For the amputation of the lower limb, the type of prothesis which has been used the most, and enjoys the more unanimous approval, has been the mechanical limb, a rigid funnel with a basic support, as offering the best guarantee regarding static results and assuring the most surrender to dynamic effects. The definite wooden prothesis has, up to now, enjoyed the absolute preference for hip amputations. At present, however, the wooden prothesis for amputations above the knee is giving way to the metallic funnel of more recent innovation. This type has been especially studied in the workshops of Turin, Florence and Palermo; it has been chosen because it unites to the rigid support at the base of the limb the lateral and soft support of a leathern pad, adaptable to the stump, thus utilising the lateral movement more efficaciously than could be done by the continuously rigid prothesis : they also allow for the simultaneous providing of transitory and definite apparatus. Definite prothesis in wood are exclusively provided for leg amputations, and, being morphologically individualisable because of their simplicity and robustness (on a stump that has com- pletely settled down), they have given excellent results. The workshops at Bologna have furthered most appreciably these constructions, not only on account of the great number of apparatus supplied by them, but also because of the interesting experimental studies that have been made there on this subject ; the workshops of Borne, also, as well as several less important ones, have most efficaciously increased this construction. The characteristics of the wooden prothesis have caused it to become more acceptable in comparison to the lighter fibrous ones ; the construction of the latter in a few workshops (Milan) has been perfected in a manner worthy of all consideration. For amputations of thoracic limbs, the type that has been chosen is the prothesis of an adaptable funnel in leather, provided with metallic guards. 393 The greatest care has been taken to create for the prothesis of the superior member supports that were specially arranged for their morphological individualisation to the stump : by studying the tools that would give the best workable results (working member) and finally by studying the cinematising (mechanical or surgical) of the apparatus and of the stump. These invesiga- tions have revealed the joint importance of the morphological individualisation of the funnel and of the functional individualisa- tion of the prothesis. This, however, pre-supposes the mor- phological and energetic valuation of the stump, and yet it cannot make any deductions from the intellectual attitude of the patient. Others will report to the Conference on the subject of the working prothesis and of the cinematic prothesis. I cannot, however, neglect to mention the new orientation that is being given to the construction of prothesis for the superior member, with the results of reducing to a minimum or even doing away with the awkward appliances for support and for anchorage (waistcoasts, shoulder straps, bandoliers, &c.), using instead the properties of the muscular centres as a means of support. The elasticity and the contraction of the muscles have been, used as a support for the prothesis of the ingenious " estetizzabile " working member that has been created in the national workshops at Milan. The muscular hypertrophy, brought about by the opportune strengthening with a rigid bracelet, thus transforming in so many digastrics the stump's residual muscles, has found an anchorage for the prothesis of the superior member in the furrow between the two enlarged muscular lines. I am unable to express a definite opinion as to the possibility of there being a greater use made of such a system of morpho- logical adaptation of the stump with its own structure obtained through the functional activation of the muscular components of the stump. But I hold that this system ought to be called to the attention of this Assembly as much because, by activating the energetic residua of the stump to the point of hypertrophy, it prepares it for possible secondary cinematic valorisations ; as also, and especially, because it illustrates the reciprocity of the morphological relations between the stump and the prothesis (the prothesis must be morphologically individualised to the stump, but the stump can individualise itself to the shape of the prothesis by means of the function). This principle may allow for the perfecting of the actual morphological individualisation of the prothesis to the stump in the most: complex, but equally complete, functional individualisa- tion of the prothesis to the holder. I believe that this functional individualisation is destined to represent the most important factor of his social autonomy. 394 THEORY ON THE VITALISING OF THE PROTHESIS. BY PKOF. GIULIANO VANGHETTI. Orthopaedic surgery is the static, dynamic and cinematic study of the actions of standing, of locomotion and of grasping ; but in actual practice, cinematic surgery consists in all kinds of cinematic plasticity for cinematic prothesis. Cinematic prothesis or cineprothesis consists in utilising all the remaining or restored articulations in whatever part of the body they may be situated, whatever their attachments may be, and at whatever distance they may be from the mutilated parts, in order to reproduce other articulations that are lacking, and that are held to be of greater utility than those actually remaining. Plastic cinematic or cineplastic is that branch of orthopaedic surgery that undertakes the treatment, with or without the let- ting of blood, of muscular masses anatomically mutilated, or the artificial utilisation of others that anatomically are intact, always with the aim of conferring voluntary and direct articulation to- the prothesis (vitalising of the prothesis). Each moving entity so obtained is called plastic motor, and naturally it must be provided with an organic or somatic attach- ment that unites it to another inorganic or prothetic attachment that is destined to communicate the movement to the prothesis. The fundamental types that can be utilised for the more or less easy attachment of the numerous varieties of motors are,, according to the shape, the loop, the club and the loop-club. The club motor consists in a thickening of any kind, and ob- tained in whatever manner, of the extremities of muscles and tendons, above which (at the neck of the club, the somatic attach- ment) can be applied a noose, a ring, &c. (prothetic attachment),, so as to bring traction to bear on the prothesis. The loop motor consists in the natural or artificial gathering together of the muscular or aponeurotic tendons , allowing a space (opening of the loop, tunnel, channel, somatic attachment) through which either a noose, a hook, a button, &c., can be- passed (prothetic attachment). The somatic attachment can also serve as the sole support of the prothesis. 395 Whenever the stump has a plastic stump only, we then have the cinematic mechanico-surgical prothesis (surgical cinepro- thesis). Should there be only some mechanical transformation of the residuum of natural movements, we have the purely physio- mechanical prothesis (mechanical cineprothesis) . If on the same prothetic mechanism there is a plastic motor .and a mechanical transformation, we have the mixed cinematic prothesis (mixed cineprothesis). In all that regards the mechanical workers, the surgical, mechanical or mixed cineprothesis ought to be considered separately (laboratory cineprothesis). The term cinematisation was originally used for all bloody or bloodless cineplastic (surgical cinematisation) : it was then also used for the simple application of the cinematic prothesis (pro- thetic cinematisation) ; and again_ for the active and precocious mobilising of the muscles connected with a cinematic plastic (postoperative cinematisation) . If the somatic attachment is made in the first instance that is to say, contemporaneously with the primitive surgical trauma, or in continuation of the latter, it is primary (or firstly). If the best conditions for the construction of a somatic attach- ment in the second instance, at no matter what lapse of months and years from the first one, can only be prepared during the said surgical trauma, it is secondary. When the somatic attachment is moulded on to any kind of stump that has not been cineplastically prepared, but is the result of an ordinary amputation already advanced, it is tertiary. Consequently, we must admit three different kinds of amputa- tions with regard to cineprothesis : (1) Cinematic amputation, equivalent to a primary cinemati- sation. (2) Hypo-cinematic amputation, or transitory to a secondary cinematisation. (3) A cinematic amputation, or ordinary, capable only of tertiary cinematisation. The principle of cinematisation is the following : In an actual or progressive amputation or disarticulation, the tendon or muscle for which the necessary physiological protection is provided (spare cuticle, vessels, nerves, &c.) can generally be utilised for the cinematic prothesis, pro- vided that an attachment can be formed with it under the same conditions of protection. Plastic motors are unimotors and plurimotors, according to function. 396 The unimotor, or simple motor (unique, double, triple, &c.), is the one that by itself alone that is to say, without any mechanical or other aid is capable of giving contraction in an only direction, and therefore one single prothetic movement automatically antagonistic. The plurimotor (bi-motor, tri-motor, &c.) is the one that is capable of two or more contractions in different directions, as, for example, the bi-niotor or alternator, which, with only one somatic and prothetic attachment, gives two contrary movements to the prothesis. The respective principle of oscillation may be formulated as follows : In the case of two muscles that could have reciprocal antagonistic action, which are connected by a running loop or any other support, a double oscillating motion can be given to the prothesis by means of only one attachment. In accordance with the position, the motors, can be terminal, lateral, super-segmental , &c., bearing in mind that these last- named must be those that are constructe'd apart from the muti- lated segment, and are definitely residuary. In accordance with the fitness, the motors are firstly r secondary, or tertiary, similar to the cinematisation from which they spring. For the treatment of the secondary, or post-operative, muscular retraction, there are various methods : (1) The free method, which does not take it into considera- tion in the least ; (2) the internal method, which counteracts the retraction by supporting the motor on a support inside the stump ; (3) the laqueal method (the laqueum-noose) , that practises the tieing of the motors, afterwards providing an ex- ternal support for the nooses by attachment to the ferule, pulley, &c. ; (4) the adhesive method, based on the employment of adhesive materials placed on the outside of the stump so as to cause either ordinary or elastic traction ; (5) the mechanical method, which seizes the motor stump on the outside, pressing upon it without endangering its recovery ; (6) the mixed methods, which can be obtained through a combination of those mentioned above. What has been said up to this point suffices to make it clear that it is not one system alone, as many have believed, and still believe ; but an unlimited series of systems that vary according to the member, the segment, the conditions, the individual, the surroundings and many other circumstances ; ana 1 it may also be understood how, on the w r hole, the surgical views on this question form a real doctrine apart, called the theory of plastic motors. 39T It will be noted that, for the sake of brevity, we have not mentioned the principle of joining together, which follows that of oscillation, but that has not yet been favoured by clinical elements. Clinical data are not lacking for giving ample proof of the justice of the theory, and to try for the solution of other important problems, such as the single loop oscillating amongst muscular paunches, the single club oscillating in either a bloody or bloodless manner, the systematic cinematising of conical stumps, the formation of pseudo-wrists with motive functions, the construction of directly prensible motors, the phalanxing of the second and fifth metacarpius, and others similar. Both cineplastic and cineprothesis aim at obtaining the maxi- mum self -aid from the mutilated patient, compatible with the degree of mutilation. The mechanical cineprothesis, that is equivalent to automatic prothesis, indeed is pseudo-automatic, is of the greatest utility in many cases, but it also has many drawbacks ; therefore, as far as is possible, it is best to avoid using it in conjunction with the plastic motor. The ideal cineprothetic may be summarised in the following principle of surgical cineprothesis : The co-operation of the plastic and of the prothesis, both cinematic without the mechanical usurpation of residual functions is both useful and necessary for the maximum approximation of the prothetic members to the natural ones, both superior and lower with the maximum of simplicity and the minimum of expense. In the laboratory cineprothesis, in order to obtain the maxi- mum autarchia, every effort must be made to get rid of all anthropomorphical maxims that unconsciously lead to continual errors, and to follow instead other mechanical ones that harmonise better with the theories of Taylor's School. The fundamental mistakes of the ordinary systems for the clutch and release of implements can be avoided by keeping to the following principle of laboratory prothesis : Given the case of a serious mutilation, an automatic and elastic clutch to be eventually strengthened by subsidiary closing with screws, dc., without the intervention of any hand will bring about the maximum utilisation of the patient, with the maximum approach to the normal, com- patible with the existence of the mutilation. By getting rid of anthropomorphical maxims, also with regard to the so-called ultra-mutilated, it would appear possible to make a man who has lost his four limbs independent of the meal feeder, leaving in complete liberty the movements of the head. A last problem that deals exclusively with the laboratory cine- prothesis, besides the various mutilated, is that of the work of the wounded and broken in practice and of the cripples, also not because of the war. 398 During the past twenty years, and more especially during the last two years, there has appeared, on the subject of cinematic plastic, a vast amount of literature that can serve as a fairly good guide. Anatomy has added a valuable contribution for the superior member, dividing it no longer in thirds and fourths, but in unequal portions called zones of capacity that is to say, of capacity of cinematising. Even physiology has busied itself with the plastic motor. The strength of the latter has been calculated as oscillating between 10 and 80 kg/cm, for the superior member alone. As a rule, practice has shown that, over and above the diffi- culties connected with the sepsis, the teguments, the cinepro- thesis, with the psychology of the patient, there are others that cannot be easily described. Thus, in a big centre, it may be impossible to construct even one plastic motor ; and in another much smaller centre one may come upon an over-abundance of spontaneous offers. Every- where, however, a first success is necessary and sufficient to create the demand. We already have a few sections of cineplastic surgery ; but , from a logical and practical view-point, there ought to be insti- tuted special sections for selection, and others reserved for the real surgical treatment, absolutely complete on the surgical side, both mechanically and scientifically, and in no way exposed to the danger of evacuation. The evacuation of patients who have been prepared for cine- matising, so as to send them to ordinary sections, is always equivalent to the loss of all the trouble and labour, and often re- amputation has to follow. Possibly it would be expedient to issue instructions with regard to this to all the orthopaedical military surgeons. 399 RESTAURATION FONCTIONNELLE PAR LE TRAVAIL PRECOCE DES BLESSES. Par Dr. Louis DEBREZ. Sous Tinfluence de causes diverses, notamment de la legislation sociale rendant obligatoire la reparation des dommages causes par les accidents du travail, nous avons assiste, pendant les annees qui ont precede la guerre, aux efforts tentes dans le but de recuperer rapidement la valeun fonctionnelle totale des blesses. Les principes de Lucas Championniere sur la mobilisa- tion precoce trouvaient des adherents chaque jour plus nombreux ; la doctrine de la reparation physiologique, fonctionnelle, prenait une place de plus en plus importante a ete cote de la reparation anatomique qui avait ete trop longtemps 1' unique souci du chirurgien. Nous connaissions deja les beaux resultats dela mobilisation precoce des fractures de clavicule, des fractures du poignet, des contusions musculaires, des epanchements et des fractures intra- articulaires. Par ailleur on ne voyait plus guere de fractures des os longs vouees a une immobilisation complete et severe jusqu'au dela de la consolidation plus que certaine ; on commengait a se soucier des fonctios des muscles et des articula- tions. Pendant toute la premiere periode de la guerre, ces principes resterent lettre morte ; non pas quils f ussent tombes complete- ment dans Foubli, mais la nature et surtout 1'evolution des plaies de guerre ne permettait pas de les appliquer. Toutes ou presque toutes les plaies de guerre, du moins les plaies par projectile d'artillerie, se compliquaiten d' infection souvent grave, si bien que le premier et presque Tunique souci legitime du chirurgien etait de combattre les complications septiques. Au mal terrible des gangrenes, des infections septiques graves, on ne tarda pas a trouver des remedes therapeutiques d'abord, preventifs ensuite ; progressivement la prophylaxie de T infection des plaies passa au premier plan des preoccupations du chirurgien. C'est la periode des vastes debridements qui succede a celle de I'msumsance du debridement. Mais la seule vue des grands delabrements fait naitre naturelle- ment le desir de les reparer. De la naissent ou plutet renaissent d'abord la pratique de la suture secondaire et ensuite les differentes methodes de sterilisation des plaies par les moyens chimiques. Jusque la pont de place pour la restauration fonctionnelle precoce ; toujours pour des raisons vitales, elle reste inapliquee et presque inapliquable. Seule la restauration tnrdive est possible, mais souvent precaire, parfois inefficace. 400 Cependant le traitement des plaies de guerre continue son evolution et affirme ses progres iiicessants : la suture immediate des plaies articulaires, pratiquee couraniment deja en 1916, se generalise rapidement, puis bientot apres la suture primitive retardee et la suture immediate des plaies des parties molles et meme des fractures des os longs. Le traitement prophylactique methodique a elimine dans une large mesure les complications infectieuses ; grace aux progres gigantesques realises dans le traitement chirurgical, grace a la fermeture des plaies, le terrain est redevenu propice a 1'applica- tion des methodes de restauration fonctionnelle precoce. La restauration fonctionnelle est le complement indispensable du traitement des blessures; elle fait partie des soins au meme titre que la reparation anatomique ou anatomo-chirurgicale. Mais elle ne doit pas s'en tenir aux pratiques un peu trop classiques du massage ou de la mecanotherapie et surtout elle ne doit pas succeder au traitement ehirurgical proprement-dit, mais elle doit accompagner ceu-lui-ci. Parfois en temps de paix, souvent pendant la guerre, nous avons vu des plaies superficielles, insignifiantes de la main ou des doigts occasionner des troubles fonctionnels de 1'avant-bras, du bras et meme de 1'epaule, tout-a-fait disproportionnes a la gravite de la lesion anatomique ; des blesses atteints de contusion banals ou de simple egratignure de la main presentent, a 1'arrivee a I'hopital, de la contracture des muscles flechisseurs des doigt et de la main; 1'extremite est froide, cyanosee, la sensibilite est exageree, la motilite active partiellement abolie. L'etat de contracture ne persiste souvent que deux ou trois jours; il est suivi bien tot d'une hypotoiiie tres marquee et d'atrophie musculaire a evolution rapide, qui frappe tous les muscles de 1'extremite, y compris ceux du bras et de Tepaule. Abandonnes a leur evolution naturelle, ces troubles peuvent persister long- temps et s'accentuer. Si au contraire on s'attaclie de bonne heure a les combattre, on parvient a les enrayer assez f acilement ; le facteur decisif est Pintervention des mouvements volontaires; par la persuasion la medecin arrive a faire executer a ces blesses des mouvements actifs, tres simples d'abord, puis de plus en plus compliques; ces mouvements doiventetre actifs, repetes frequemment, on pourrait dire constamment, sans repos. Alors Phypotoiiie musculaire disparait et Patrophie s'arrete et regresse bientot. Que se passe-t-il, au point de vue physiologique, chez ces blesses? Pourquoi une blessure minime a-t-elle sur le tonus musculaire une repercussion aussi profonde, meme sur des seg- mente du membre tres eloignes ? II n'existe pas encore a 1' heure actuelle de conception bien etable de la physiologic du tonus musculaire. Dans des travaux datant de quelques annees avant la guerre, Yan Gehuchten coii- sideiait le tonus musculaire comme 1'expression du " tonus nerveux " des cellules motrices de la corne anterieure de la 401 moelle; ce tonus nerveux lui-meme est la resultant d' influx de sens divers, venus de difierentes directions, qui se combattent ou se contrarient. Ces influx sonf, les uns excitateurs, les auties inhibiteurs : parmi les premiers figurent les excitations peri- pheriques amenees par les voies centripetes, les influx nerveux volontaires (voies motrices des cordons lateraux) ; parmi les facteurs d Inhibition figure entre autres la voie cortico-ponto- cerebelleuse (independaiite de la voie motrice). II est tres probable que le systeme nerveux sympathique (extra et intra medullaire) joue egalement un role important, mais il n'est pas determine. (Voir a ce sujet, Pieron: Mecanisme physiologique du tonus musculaire, etc., Presse meidicale, 18/2/18.) Quoi qu'il en soit, la theorie de Yan Gehtichten nous permet de saisir partiellement du moins, le mecanisms physiologique du tonus musculaire. Une lesion peripherique determine, par la voie ceiitripete, des modifications du tonus nerveux de la cellule motrice tantot dans un sens (contracture), tantot dans Pautre (hypotonie), ou successivement dans Tun et Pautre sens, ou du moins ces modifications nous apparaissent comme telles. II est probable, en effet, qu'elles se produisent toujours ,dans le meme sens, mais que les details et la modalite nous en echappent partiellement. Ces modifications primitives sont d'ordre reflexe; elles echap- pent completement a la volonte du sujet; mais nous pouvons intervenir pour retablir Pequilibre rompu, entr' autres par la voie de Pinnervation volontaire; il n'est pas demontre que les mouvements volontaires aient sur le tonus nervenx et musculaire line influence permanente, c.a.d. une influence qui persiste en dehors des periodes de contraction volontaire. Mais leur inflence sur Patrophie musculaire est certaine, soit qu'ils Pempechent completement ou qu'ils la combattent. Empecher ou combattre Patrophie musculaire n'e^t d'ailleurs, a noire avis, qu'un avantage d'ordre eloigne, que vient par surcroit; Pavantage essentiel, piimordial de la mobilisation active precoce est le retablissement de Pequilibre du tonus nerveux. Reprenons Pexemple cite plus du blesse qui, pour une lesion minime des parties molles de la main, a des troubles profonds des organes moteurs de tout le membre superieur; lorsqu'on P invite a executer des mouvements actifs, il en est presque totalement incapable, bienque ses muscles n' aient encore subi nul dommage reel. Ce qui Pempeche de mouvoir les doigts, la main, c'est son impuissance a "lancer P influx nerveux" volontaire dans ses muscles ; comme si les actions inhibitrices (peripheriques) soustrayaient ses cellules motrices a Paction de la volonte. C'est a vaincre cet obstacle que le medecin doit s'appliquer assitot que possible; car il parait bien que les chances de reussir sont d'autant plus grandes que la blessuie est plus receiite. Des que les premiers mouvements volontaires out pu etre executes une fois, le blesse les repetera plus facilement et aussi souvent qu'il le pourra. Sans doute les troubles du tonus neuro-musculaire lie seroiit pas siipprimes du coup, les excitations peripheriques patholo- 402 giques 'continuant a agir, mais leur action sera compensee. partielleinent du morns, par 1' intervention de 1' influence antago- niste des mouvements voloritaires. L'exeniple dont il vient d'etre question doit etre considers comme pathologique ; dans ce cas les troubles eiigendres par le traumatisme depassent notablement en intensite ce que 1'on observe couiainment; mais cet exemple met en relief la nature de ces troubles qui existent apres tout les traumatismes a un degre variable. Prenons un autre exemple, celui d'une plaie penetrante articu- laire du genou ou meme une hernarthrose simple. L' experience demontre que ces traumatismes entrainent tres rapidement de 1'hypotonie et de 1'atrophie musculaires de la cuisse si on les abandonne a leur evolution, au repos; ainsi une plaie articulaire operee dans les delais voulus, que guerit sans reaction inflamma- toire, est suivie d' impotence fonctionnelle tres accusee; au contraire qu'on pratique la mobilisation active precoce, que le blesse execute des les premieres heures des mouvements actifs et frequents, et ces troubles fonctionnels se reduisent a un minimum, 1'hypotonie musculaire est toute passagere et 1'atrophie presque nulle. Comment expliquer la repercussion qu'exerce la lesion articu- lairs sur la musculature qui commande r articulation ? Des recherches experimentales ont demontre que les troubles neuro- musculaires consecutifs a un traumatisme articulaire peuvent etre evites si on sectionne prealablement les racines posterieures dont les fibres desservent le segment de membre interesse. II en resulterait que les excitations nerveuses peripheriques, parties de la region traumatisee et conduites vers les centres medullaires par les voies centripetes, jouent un role preponderant sur le torius nerveux; si on exclut ces excitations par la section des racines posterieures, on exclut du meme coup les troubles du tonus neuro-musculaire. Chez Thomme il est impossible de soustraire completement les centres medullaires a ces excitations periphe- riques; mais on peut tenter de retablir 1'equilibre du tonus neuro-musculaire par 1' intervention de la voie motrice, c.a.d. par T influx nerveux volontaire. Et c'est ce que realise, en partie du morns la mobilisation active precoce; des mouvements actifs du genou, apres une plaie articulaire, executes immediate- ment apres 1' operation chirurgicale, et repetes d'une fa^on continue, reduisent a un minimum les troubles d'hypotonie et d'atrophie musculaires. L'experience clinique nous le demontre journellement. Sans doute la mobilisation active n'empeche pas ces troubles d'une maniere certaine, il faudrait pour cela que la lesion flit supprimee entierement; aussi longtemps qu'elle existe, si bien traitee soit-elle, elle exerce une action certaine. La mobilisation active precoce n'a ^d' autre but que de reduire cette influence a un minimum. J'ai cite ci-dessus deux exemples de troubles du tonus neuro- musculaire consecutifs a des traumatismes de gravite differ ente : dans le premier cas ces troubles atteigrient uri degre anormal, pathologique ; dans le second, il s'agit de troubles constants 403 norrnaux. Dans 1'un et 1'autre cas, ils peuvent etre combattus efticacement par lee mouvements actifs precoces. On pouvait supposer que ces troubles ne sont pas speciaux a telle ou telle lesion particuliere mais qu'il s'agit la d'un phenomene general, inherent a tous les traumatism.es. II etait par consequent logique d'etendre les indications de la mobilisa- tion active precoce a la plupart des traumatismes. C'est oe que nous avons fait a 1' Ambulance du Dr. Depage. Le service chirurgical qui nous est confie re^oit specialement les plaies des articulations, des mains et des pieds; nous avons done eu 1' occasion de faire de nombreuses observations dans le domaine qui nous interesse pour le moment. Quelques mots d'abord sur le sens que nous accordons a 1' expression {t mobilisation active immediate." D'apres les considerations theoriques que nous venons d'exposer, il va de soi que seuls les mouvements actifs les mouvements volontaire.s du sujet peuvent exercer une influence utile; ce qui importe avant tout, au debut du moins, ce n'est pas tant de combattre 1'hypotonie, encore moins 1'atrophie, que de retablir entre les centres volontaires et Porgane peripherique du mouvement, les relations qui existaient a 1'etat normal avant la blessure. C'est peut-etre la periode la plus difficile, celle ou 1' intervention du medecin est le plus necessaire ; il f ant initier le blesse aux mouve- ments qu'on exige de lui. Si, lors de la visite, le medecin lui ordonne distraitement et, brievement, de faire des mouvements sans lui donner d'autres explications, il n'obtiendra rien de son malade, et pour cause. Presque regulierement, meme s'il y met sa bonne volonte, le blesse reste incapable de fournir le travail demande parce que, en general, il a la tendance d'executer d'emblee des mouvements compliques, tels que deux qu'il etait habitue d'executer presqu'automatiquement avant sa blessure. II faut au contraire 1' initier a F execution de mouvements aussi simples que possible, decomposer ces mouvements ; ainsi pour une blessure de la main, il serait illusoire de 1'obliger d'emblee a saisir un objet, a ecrire, etc. II n'y reussirait pas; mais il reussira facilement a ebaucher d'abord a accomplir ensuite le mouvement de flexion et d'extension d'un doigt, puis de deux doigts et ainsi de suite pour les differents groupes musculaires sur lesquels on se propose d'agir. C'est done par la decomposition des mouvements, par 1' initia- tion methodique qu'il importe de commencer. Cette initiation est parfois laborieuse, elle exige du medecin du temps, de la patience, et cet ascendant qui donne au blesse la confiance, la volonte. La mobilisation active doit etre precoce ; 1' experience demontre que les mouvements volontaires se retablissent d'autant plus facilement que le traumatisme est plus recent; c'est comme si 1' influx volontaire rencontrait a ce moment moins d' obstacle et retrouvait plus aisement sa voie; il semble qu'alors Fequilibre du tonus nerveux puisse etre plus facilement retabli. L' ideal serait de pouvoir, dans chaque cas, commencer immediatement 404 apres la premier traiteinent chirurgical, apres 1'operation ; mais frequemment des raisons d'ordre primordial s'y opposent; ainsi dans les fractures diaphysaires des os longs des membres, la contention en bonne position exige 1' immobilisation; il en est de memepour certaines plaies articulaires avec lesion osseuse ; bref , partout ou la consolidation anatomique, la cicatrisation, exigent 1' immobilite, il faut renoncer a la mobilisation ou plutot la retarder on la reduire. Partout au contraire ou 1'etat anatomique le permet, il y a un avantage considerable a retablir immediate- men t les mouvements volontaires, qu'il s'agisse de traumatisme ferme ou de plaie. En ce qui concerne las plaies de guerre, la pratique de plus en plus repandue de la suture primitive immediate ou retardee elargit beaucoup le champ d' action de la restauration fonctionnelle precoce. Le dogme de 1' immobilisa- tion des membres blesses, des traumatisrnes articulaires surtout, tend de plus en plus a disparaitre, et il est possible que ce lie soit qu'un debut. On pourrait croire a priori que les mouvements actifs executes immediateraent ou tres tot par les membres atteints de plaies recentes doivent etre particulierement douloureux. I/experience demontre qu'il n'en est rien ; il existe a ce point de vue un con- traste frappant entre les mouvements passifs et les mouvements actifs; autant les premiers sont penibles, douloureux, autant les derniers sont indolores. Et ceci est vrai non seulement pour les traumatismes, mais aussi pour certains foyers inflaramatoires : nous avons eu 1'occasion d'experimenter dans un certain nombre de cas d'arthrite purulente du genou le traitement inaugure par le Dr Willems (arthrotomie et mobilisation) ; ilest etonnant de constater que les mouvements actifs executes par la malade lui meme sont laborieux mais nullement douloureux. Nous n'avons jusqu ici evisage la mobilisation precoce que comme moyen de retablir Tequilibre du tonus neuro-musculaire et par la oombattre 1'liypotonie et Fa trophic musculaires. A cet avantage immediat s'en ajoute un autre, eloigne; empecher les raideurs articulairrs, les positions et attitudes vicieuses. Sans doute celles-ci relevent parfois de processus cicatriciels que la mobilisation precoce ne pourra ton jours enrayer, mais qu'elle combattra et dont elle pourra reduire la gravite. Technique de la restauration fonctionnelle par le travail precoce. Je n'envisagerai pas ici le traitement des moignons d'amputa- tion par le travail precoce ; ce sujet se trouve traite dans le rapport du docteur Martin. II ne sera question que de certaines blessurrs ou mutilations partielles desmembres, des mains, des pieds. L'orsque nous entreprenons la mobilisatio active d'un membre, ce n'est pas seulement dans le but d'obtenir du blesse des mouve- ments habituele de la vie courante ; ainsi pour le mernbre inf erieur ce que nous recherchons c'est la marqhe, c.a.d. la fonction de soutien et de translation du poids du corps; au membre superieur 405 le but est de rendre an blesse 1* usage utile du membre, par exemple, la prehension de la main, etc. La recuperation effective des mouvements utiles n'est possible que par le travail. MEMBRE SUPERIEUR. Main. La plupart des plaies de guerre dela main sont suturees irninediatement et guerissent generalement par premiere intention. Afin de perrnettre la mobilisation immediate des doigts, nous reduisons le pansement a un strict minimum ; pas de volumineux pansement sur toute la main quand un seul ou deux doigts sont blesses. Des le lendemain commence la mobilisation active rnethodique, non seulenient des doigts intacts, mais aussi des doigts blesses, a moins qu'il ne s'agisse d'uue fracture de la premiere phalange ou d'une suture d'un tendon flechisseur. Les mouvements commencent par la flexion et 1'extension des phalanges les unes sur les autres, puis des doigts sur la main, f adduction et ^opposition du pouce ; viennent ensuite les mouve- ments combines du pouce avec les differents doigts et enfin les mouvements utiles de prehension; le blesse s'exerce a saisir un couteau, une cuilltr, un crayon, et la plupart des objets qui lui servent dans la vie de relation ; dans bien des c#s, ces exercices ne suffiraient pas a maitenir ou a retablir 1'activite musculaire, surtout parce qu'ils ne sont pas continues methodiquement ; c'est le travail a 1'atelier qui suppleera a leur insuffisance. Pour les mutilations partielles de la main, nous procedons de nienie ; une des plus frequentes est la mutilation du segment radial : perte des deux phalanges du pouce, de 1'index et du medius avec une partie de leurs metacarpiens ; dans ce cas nous pratiquons 1'ablation totale des deuxieme et troisieme meta- carpiens, de telle sorte que le I er metacarpien se presente comme un pouce nouveau par rapport aux doigts restants. Ces mutiles sont, cornme les autres blesses des mains, soumis au meme traitement de restauration fonctionnelle et diriges sur Tatelier des les premiers jours ; tres rapidement ils adaptent les organes restants aux fonctions nouvelles qui leur incombent; il est surprenant de voir combien la fonction de prehension se retablit rapidement ; nous avons vu de ces mutiles executer apres peu de temps des travaux tres delicats. A 1'atelier, la restauration fonctionnelle de la main consiste essentillement dans la recuperation de la fonction de prehension ; a cet effet les blessee sont mis au travail du bois ; ils debitent du bois a la gouge et au maillet ; le docteur Martin a construit un jeu de maillets moiites sur manches en 7 gross eurs differentes ; le travail commence avec le maillet a gros manche et se tremine par le maillet a manche fin et a tete lourde. Si, a 1'arrivee a 1'atelier, la prehension est pratiquemeiit nulle, il est indispensable de fixer le manche de 1'outil dans la main du blesse par des tours de bande ; en tres peu de jours la prehension peut se retablir. Poignet. Le travail a pour but de rendre au poignet le mouve- ment dans les deux plans : flexion et extension d'une part, mouve- ments de lateralite d'autre part. Pour localiser la mobilisation 406 active dans ces deux directions, on immobilise Favant-bras centre le thorax au moyen d'une ceinture ; seuls le poignet et la main reste libres; suivant que Favant-bras est fixe en pronation on en supination, le blesse pent, Foutil a la main, executer les inouve- ments de flexion et d' extension on bien les mouvements de lateralite. Les exercices de pronation et de supination sont exe- cutes par le vissage ou le forage dans la bois. La fracture de Fepiphyse inferieure du radius est egalement susceptible de la mobilisation tres precoce ; nous procedons de la faon suivante : la fracture est d'abord reduite, ce que Fon obtient facilement. D'une main le chirurgien saisit Favant- bras du blesse et Fimmobilise solidement, de Fautre il saisit la racine de la main ; par un mouvement brusque, accornpagne de traction, il reporte la main du blesse en flexion et en abduction cubitale ; cette manoeuvre tres rapide permet tou jours la reduc- tion. La position de la main en flexion et abduction cubitale forcee est maintenue par une attelle dorsale et des tours de bande qui laissent les doigts libres ; la periode d' immobilisation dure de quatre a sept jours pendant lesquels le travail des doigts est deja possible. Le pansement immobilisant est definitivement ecarte et le travail actif commence, travail fhi maillet etc. La recuperation fonctionnelle est extraordinairement rapide, sans que la reduction soit compromise. Coude-epaule. Les blesses que nous avons eu Foccasion de traiter par le travail precoce etaient atteints de plaies articulaires simples ou de plaies osteo-articulaires avec lesion osseuse parfois assez importante (destruction d'un condyle humeral par exemple). Les exercices et travaux executes a F atelier sont les memes que ceux que le Dr Martin decrit dans son rapport sur le traitement precoce des amputes du membre superieur : pour le coude, travail a la lime, a la scie; pour Fepaule, travail au maillet a bras libre, travail a la scie, a Fenclume. (Pour les details voir le rapport du Dr Martin.) La fracture fermee de la clavicule beneficie aussi largement du traitement par le travail ; depuis longtemps, comme beaucoup d'autres d'ailleurs, nous avons renonce aux appareils et panse- ments immobilisants qui, en realite n'immobilisent que les muscles et articulations et nullem.ent les fragments de Fos frac- ture. Des le premier examen, nous faisons executer des mouve- ments actif s de plus en plus etendus du membre blesse : pro- jection en avant, elevation en abduction; a la premiere seance, on peut obtenir presque regulierement que le blesse porte le bras en elevation verticale, la main a la nuque ou au moins au sommet de la tete. Bien conduits, sous la surveillance patiente du mede- cin, ces exercices ne sont nullement douloureux ; ils sont laborieux au debut mais deviennent de plus en plus aises au fur et a mesure que le blesse les multiplie. Comme nous F avons dit au debut de cette communication, IE restauration fonctionnelle des blesses est une necessite absolue elle doit etre conduite simultanement avec le traitement medica dont elle fait partie. Pour le membre superieur, il nous parai que le travail precoce est la methode de choix. Les resultats qu( 40T nous avons observes ont depasse nos esperances. Pour que cette methode produise tous ses effets utiles, il faut que le travail soit guide par le medecin qui prescrit les exercices au moment voulu, decompose le travail, le gradue dans le temps et dans Fintensite, localise les mouvements sur les segments de membre qu'il se propose d'atteindre. La methode est d' application simple : a F Ambulance du Dr Depage, elle est reglee de la facon suivante : les premiers mouvements, mouvements elementaires, sont executes au lit meme du blesse; des que la restauration exige F intervention du travail, le blesse passe chaque jour un certain nombre d'heures a Fatelier du Dr Martin, qui a menage a cet effet Foutillage necessaire. Chaque matin dix, quinze, vingt blesses de notre pavilion se rendent au travail, et parmi eux bon nombre d'operes- recents. MEMBRE INFERIEUR. Les principes sont les memes qu'au membre superieur mais F application en est plus aisee du fait que le travail est moins delicat. Le travail du membre inferieur consiste dans le soutien et la translation du poids du corps ; il se resume a la marche correcte du blesse. Pied. La mobilisation active a un double but : recuperer la marche et si celle-ci est impossible, empecher les attitudes vicieuses. S'il s'agit de plaie de Favant-pied, ou de fracture d'un metatarsien, nous faisons lever les blesses tres precocement, des les premiers jours, en interdisant formellemeiit Fusage des bequilles. Eventuellement le soulier est garni d'une semelle metallique plantaire qui soutient la voute. Pour les fractures du tarse, nous sommes restes tres prudents jusqu'a Fheure actuelle. Lorsque les points d'appui de la voute sont interesses par le traumatisme, nous redoutons Feffondrement, toujours tres pre- judiciable; la marche en ce cas n'est permise que tardivement mais les mouvements reguliers et methodiques au lit sont prescrits. C'est dans les plaies articulaires que la mobilisation active pre- coce rend les plus grands services. Cette methode a ete inau- guree par le Dr Willems (de Gand). C'est actuellement le complement necessaire du traitement chirurgical par la suture immediate de la jointure. Les plaies penetrantes simples ou avee lesion osseuse peu importante ne doivent plus etre immobilisees pendant de nombreux jours ; au contraire dans la plupart des cas il y a avantage a pratiquer des mouvements actifs de F articu- lation blessee des le lendemain ou le jour meme de Foperation. Grace a la mobilisation et a la marche precoce, on n'assiste plus a la fonte des muscles, on ne voit plus Fatrophie et la raideur du membre, parfois si longues et si difficiles a guerir. 408 FUNCTIONAL RE-EDUCATION; PRELIMINARY CONSIDERATIONS. BY MAJOR W. G. TURNER, M.C., C.A.M.C., AND MAJOR G. W. F. BOYER, C.A.M.C., Granville Canadian Special Hospital. Professor Amar has classified the organization of the work of the wounded in three periods after the orthopedic and restorative work has been completed : " In a first period, called functional re-education, the point " in question is to analyse the movements of man in order to establish his functional state , to revise as much as possible his " motive power, and finally to assure oneself that a continued and " prolonged exercise does not compromise his organic resistance. ' In a second period, one will strive to fill up the deficit caused ' ' by impotence by means of an orthopaedic system ; suitable " apparatus will be adapted to the mutilated limb, and then will " start the professional re-education, which is the third and last "period." The subject of re-education is such a wide one that it appears wise to call your attention to certain factors which may be remedied, and which manifest themselves during the orthopaedic period or during the first period referred to above. These occur in the class of cases such as are seen at a special hospital like the Granville Canadian Special Hospital. Some preliminary measures might be adopted in such cases before they enter the classes for regular vocational re-education. One of us (W. G. T.) has been much impressed by certain facts ever since working in the orthopedic clinic in Munich some years ago. There it was .essential that the patient know how to read and write, and the hours of working be adapted to the physical condition of the patient. The cripple institute was associated with the clinic. The allocation of work and training was made and graded to the functional efficiency and organic power of the individual. It was striking how, very shortly after the ambition of the patient was aroused, his working hours became longer with- out any physical detriment. At regular intervals the patients were inspected physically, to see if the advance of surgery w r ould enable any cases to have the disability reduced. Since working in a special hospital of war disabilities these facts have been accentuated. We are going to carry on a vigorous national propaganda. Are we carrying on a propaganda among our dis- abled soldiers? There is a varying long interval of time, in months, during which these soldiers are having treatment for reducing joint disabilities, waiting for amputated stumps to be healed, stretching contractures , and, in extensive hand and wrist 409 lesions, carrying on the necessary treatment to increase f unction r or in putting off the dire necessity of removing a useless hand. In the Granville Hospital such time is necessarily shortened as we clear the cases to Canada as soon as possible, but in orthopsedic centres in this country and other home centres a certain amount could be accomplished. Could not deficient education be taken up in such cases when it can be applied? In all single hand or arm disabilities might not a reprint of that excellent article on Count Zichy " Lancet," 5th August, 1916 be given to the soldier? At least, until we have teachers for the same, such as at Montpelier, where Dr. Emile Jeanbreau rules, and where M. Tammenne teaches the re-education of the left hand, the pamphlet would in many cases bring some results. It is our custom to advise such cases to work regularly at waiting, to prac- tice the co-ordination of the hand by picking up small pills or )ins and putting them in a box, &c. In a proportion of cases there is an eagerness to follow the suggestion. One officer went at once and bought a school copy book and worked very keenly. But a few illustrated pamphlets of the above article and that of ;-' Lancet," 7th April, 1917, would help a great deal in stimulating ambition. In the leg amputation cases there has been keen co-operation with Colonel Clarke. He has now arranged that as many cases as possible will be fitted with peg legs. The results have been very gratifying. The patient almost at once becomes more in- dependent, educates himself as to balance and gait, and incident- ally, when fitted with an artificial leg, wears it comfortably, and is prepared to start in at once for vocational training or resuming civil occupation where such is suitable. A large percentage of our soldiers are farmers, and in our Western country particularly distances are long and " leg work " is very great. These men are asked to think seriously about carrying on in such work, and think seriously what they would like to take up. The number o have stated they wanted some time in business college is mggestive. Could not some propaganda be used at this stage r mch as authoritative and periodic information about the trades which there is demand for skilled labour and jobs are to be had the demand for typists, &c. ? As far as possible these men are assured that they will receive the regular pension for permanent Usability, no matter how efficient they become. The suspicion that efficiency will be followed by reduction of pension, as you know, is present in a certain number of the more ignorant. As to future training of amputation cases, more competent judges than myself will organize that, but one fact needs to be recorded there is no more cheerful ward anywhere than that of limbless )ldiers. Would it not be wise to have them segregated in their training until fully efficient or until the time when greater efficiency is brought out by competition, before they are thrust into general competition with their more fortunate fellow beings ? The question of the disabled farmer taking up subsidiary rural occupation is a very important one. I mention this here as the tradition of a man's occupation and his natural leaning to a job of choice are factors which cannot be overlooked, and still more 410 to the soldier after hospitalisation and the campaign life, in which two thoughts are paramount the enemy and his rations. In wrist, elbow and shoulder disabilities the full education of a- good right arm must be improved. Where the right arm has been disabled or partially disabled, the active re-education of the left hand and arm to act for the right must be emphasised, also the use of the disabled right in subsidiary function to the other. In the treatment department of the G-ranville Hospital, besides massage and hydrotherapy, the greatest importance is attached to the gymnasium and curative workshops. Here the re- education has been made a great factor. In the former, the results obtained by Capt. Patterson, C.A.M.C., have been very stimulating. The system demands an enormous amount of time and patience. By individual attention and small group instruc- tion this officer and his faithful sub-staff have been a decided example. The re-education of the intrinsic muscles of the hand and foot have been specialised, so that the patients realise it and co-operate more and more keenly. The appreciation of so-called " pain block/' which causes such active resistance in opposed muscles , is highly important , and we have many examples of pretty extensive fixation of the fingers, wrist, elbow and knee, worked out to a satisfactory result under the " active-passive " work of the patient and instructor where massage and passive movement have failed. The complete mental concentration and co-operation of the patient are the primary essentials, and it is only when special gymnasium treat- ment has reached a finality that such special cases are drilled in larger groups. The ground work here is very thorough, and we are optimistic as regards progressive advance. The curative workshops, as you all know, have become a great factor. In these the work is regularly prescribed, and the patients have to report just as for treatment. You will be interested to know that it is rare to have a soldier reported as absentee. In fact, working overtime is very frequent. The mental incentive of doing a job more or less " on his own " brings about, by the exercise, a decided functional result. In these shops the various requirements of hospital apparatus, splints, surgical boots, peg legs, hospital furniture and all kinds of repairs are carried out under the instruction and advice of skilled in- structors. The relations between the two are highly satisfactory. Gardening in the summer has been much encouraged. The success of these departments is due to the interest of Colonel Clarke and active work of the sub-staff. We hope to still further specialise certain " work treatment " for special cases, and ro have certain special shop work to co-ordinate and further the results of special gymnastics. As a variation, the M.O. in charge has the privilege of organising baseball, handball, and other games for the different classes of patients. This brings in the competitive spirit, which is also encouraged in the shop work. Among other cases, last year, the catcher of the baseball team obtained a striking improvement in his knee condition. This 411 system of correction and re-education has spread out great fields for future results in cases both of organic and functional dis- ability. May I again draw the comparisons : months or years of cam- paign conditions, these thoughts the enemy, rations, a dry sleep; then a grave wound, months of hospitalisation, and then the above as an applied system. It may be asked, Do you use massage, mechanotherapy and hydrotherapy ? Yes, indeed, and find them of the greatest value ; but in all these cases passive treatment must be supplemented as soon as possible by the active voluntary effort of the patient. Emphasis must be laid on the more careful re-education and supervision of a frequent cause of disability i.e., that of nerve lesions. The most frequent nerves affected are ulnar, musculo spiral, median and sciatic. Under the present arrangement of collecting such cases in special hospitals an advance has been made. Our anxiety is the fate of these cases three months or more after the nerve suture has been done. An ulnar nerve lesion carefully attended to, i.e., contractures cleared up and suppleness fully established, gives a small percentage of disability even when the nerve suture has failed. That is to say, when the partially disabled hand is made subsidiary to the sound one. In a right arm lesion, full re-education of the left arm and hand is imperative, the right becoming subsidiary. In musculo-spiral 'nerve lesions it is very satisfactory to note the excellent com- pensation accomplished by tendon transplantation. All special clinics concur in this. The re-education of the transplanted muscles to the opposite function, i.e., from flexion to extension, takes place within 3 to 4 months after the operation ; after that muscular development is necessary. One reason for this is that the extensor function of hand and fingers is fairly gross, especially in the common extensor group ; but the thumb results are equally satisfactory, since the important factor of steadying the ossis metacarpi pollicis has been recognised. The re-education is simple. Daily, or twice daily, after the third or fourth week, the hand is taken off the splint, and the patient is shown how to slowly carry on the actions and to fix his mind constantly on the same. In a short time the dissociated function becomes estab- lished. After this, regular hand extension exercises and wrist class in the gymnasium will complete the result. The disability of the median nerve lesion is great. The loss of function to the thumb, index and middle fingers disables the hand to a marked extent. Yet much thought is being expended, and it is hoped some compensation can be worked out in cases where the nerve damage is irreparable. Can a satisfactory trans- plantation be done utilising the supinator longus and extensor carpi radialis muscles? We must encourage such optimism. As was mentioned above, the present anxiety is the care and supervision of these cases for a long period, yet the daily treat- ment is for only a short time. Can this extra wasted time be utilised in education of some kind? 412 The problem of the duration of time peripheral nerve lesions of varying severity should be kept in hospital in England before being returned to duty, or to Canada for continued treatment, involves a consideration of each case largely on its own individual characteristics ; but perhaps a few general remarks will not be amiss as a guide in the disposal of these usually protracted cases. After a patient is admitted to hospital, he is at once examined in detail with Faradism, Galvanism and the Lewis Jones' Con- denser, and the reaction of each muscle or group of muscles is carefully recorded. At the same time, a careful chart is made of epicritic, protopathic and deep nerve changes, if there are sensory fibres in the injured nerve. The case is then put upon treatment consisting usually of galvanism (or f aradism) , massage , passive movements of joints and tendons and an apparatus to prevent elongation of the paralysed muscle. This is carried on for a period of two weeks, when re-examina- tion is made and the results charted, after which another period of two weeks is given to continue treatment. Depending upon the degree of change, it is easy in this way to follow improvement or retrogressive changes. Those cases of severe lesion with marked changes soon are assorted, and operation for suture or freeing from callous or scar is recommended, and they pass on to the hands of the surgeon. But our present concern is only with the non-operative, or post-operative recovering cases. It is necessary to consider these cases under different headings : Voluntary power, reaction to Faradism, condenser reactions, and sensory reactions. The return of voluntary power after the injury of peripheral nerves always ushers in a new era of hope and progress. The question of the length of time which must elapse after a serious injury to a peripheral nerve before good useful motor function can return is the one that concerns us chiefly here. It is, of course, understood that the muscle fibres have been kept in a good state of nutrition as outlined in the preceding paragraph. The diffi- culty in arriving at an answer to this is at once apparent when we remember that it is frequently impossible to keep a patient under observation for longer than from 3 to 4 months. There are many factors to be considered in estimating the time when voluntary power may be expected, such as the hearty co-operation of the patient, the active exercise he will give a recovering muscle, the freedom of joint and tendon movement, and the degree of fibrosis in the nerve ; but it has been our experience here that a period of from 3 to 6 months is required in the average recovering case before there is satisfactory use of the once paralysed muscles. There is nothing to add to the accepted view of the prognostic value of f aradism. By the time irritability has returned to moderate currents of faradism the patient has regained voluntary power, providing he has given his whole-souled effort to co- operation and his muscle tissue has not suffered from disease, 413 stretching or pressure from splints. It has been oar experience that in from 3 to 5 months after the return of faradic irritability, useful voluntary function has usually returned. The condenser reaction is one of the most useful methods we have of graphically recording the progress made during regenera- tion. From our experience, we conclude that if the muscle requires 1 microfarad or more after some weeks' treatment (the cases have usually been wounded 3 or 4 months previously), and providing the muscle tissue is in good condition, we are deal- ing with a very serious nerve lesion. If the reaction record shows a slight month to month increase in irritability, we are encouraged to continue along the same lines of treatment. Condenser re- actions of under 1 microfarad and over 0'5 microfarads at 100 volts will require as long as six or eight months before the muscular power will have returned sufficiently to give a low re- action point (e.g., '025 M.F. 'at 100 v.). Then an additional 3 or 4 months are required before the result is complete. At the same time, let us remember that the condenser reaction does not solely indicate the prognosis. As complete return of -function is approached, the improvement as shown by the condenser re- actions becomes slower. The most disabling sensory lesions are the median injury close to the wrist and sciatic injury producing hyper algesia of the foot sole. In the median cases, if the right hand is involved it is a severe disabling condition, even when the long flexors of the fingers are quite free from adhesion. Then we are very ready to recommend early operation for the preservation of all the sensory functions of the index and middle fingers and the tip of the thumb. The motor disturbance may be negligible, but the lesion is very prone to incapacitate the man materially for all but rough work ; and in view of the prevalence of cigarette smoking and resulting burns and then indolent ulcers, one realises the seriousness of this disability in returning this type of case to duty. The. majority of serious median nerve lesions appear with slowly healing abrasions on the index or middle fingers. It is, therefore, best to dispose of such a man by placing him in un- exposed employment for several months after the operation for section, and a shorter period if only freeing from scar has been done. In closing, should be mentioned the hyperalgesia , especially to pressure, in the front half of the sole in sciatic nerve lesions. Operation has relieved some of these, especially where fibrosis is dense and annular, but in others the progress is very slow. Every effort is made to force these cases to walk without spastic varus or toe flexor spasm. The use of the excellent apparatus designed by Professor Amai is greatest at the time of the first period in his classification , and we have not been able to apply it so much at the Granville owing to being, so to speak, a station en route. Captain Fletcher, who has since returned to Canada, made a number of interesting observations on the use of the same. 414 Conclusions. To recognise as early as possible the percentage of disability in an arm or hand, make it the subsidiary organ and push the re- education of the sound one. To utilise some of the wasted time during a stay in hospital -to fill educational defects. To utilise to the fullest extent the " active passive " treatment of the patient, plus gymnasium and curative workshops. To carry on a certain amount of propaganda work for the information of certain permanently disabled cases. 415 GYMNASTIQUE MEDICALE ET MEDECmS- GYMNASTES. PAR LE DR. A. DE MARNEFFE, Professeur a 1'Ecole Normale de Gymnastique et d'Escrime de Belgique.* La " Conference Inter-alliee sur les questions interessant les Invalides de la Guerre en mai 1917 " dans sa section lere sur la physiotherapie , a prouve une fois de plus combien peu de per-: sonnes connaissent la signification exacte des termes Gymnas- tique medicale et medecins-gymnastes. Beaucoup ignorent les mots ; certains les comprennent mal. Cette ignorance, d'ailleurs, pour certains physio therapeutes est tout a fait inexcusable. Je pense que tous les medecins devraient connaitre les grandes lignes de> la gymnastique medicale, ses principes fondamentaux ei ses indications les plus generates. Cela leur permettrait d'entrevoir quel merveilleux agent therapeutique helas trop peu connu ! elle constitue pour eux. C'est pourquoi j'ai ecrit cet article, tout de generalites, en laissant de cote, a dessein, les details techniques d' execution pure qui ne sont utiles qu'aux practiciens specialises. La science de la gymnastique medicale n'est rationellement et academiquement enseignee qu'a Stockholm. Dans d'autres pays certes, en Angleterre, en Ecosse, en France, des medecins et certaines societes ont entraine et forme des masseurs et des masseuses. En Ecosse, certaines E coles sont merne assez reputees. Toutefois, j'ai eu 1'ocasion de posseder pendant quelques mois des masseuses, diplomees par les E coles ecossaises, mais je regrette de devoir avouer qu'elles sont loin d'atteindre nous le comprendrons aisement plus loin le degre d 'instruction medicale et de pratique gymnastique des medecins- gymnastes suedois. La guerre a vu naitre a juste titre, puisqu'elle etait peu prevue et que Ton ne possedait pas beaucoup d'autres elements competents ; necessite fait loi, plusieurs " ecoles de massage" qui achevent leurs cours en quelques semaines ou en quelques heures et qui les dispensent a toutes les personnes de bonne volonte ! L'Universite de Gand est la seule institution d'en- seignement-superieur, je pense, qui marchait sur les traces de Stockholm. Elle parvenait deja a " sortir " de bons professeurs de gymnastique et elle se preparait a former des Directeurs de gymnastique et des Medecins-gymnastes. * Je vois remercier Miss E. M. Loveday, Gr.D., Medecin-Gymnaste diplomee de Stockholm. Professeur a la Ville de Bruxelles, qui a cree et organist les deux interessants et importauts services de gymnastique medicale et de Re- education motrice collective a 1'Institut de physiotherapie de Beausecours et qui m' a donne de preceeux Elements pour la redaction de cet article. 416 Pour faire comprendre la valeur du diplome que possedent les- gymnastes medicaux suedois, qui sont aux masseurs ce que les chirurgiens sont aux infirmiers, je dois passer rapidement en revue ce qui se pratique a 1'Institut Central et Koyal de Stock- holm. Get Institut est un etablissement d'enseignement superieur special, comparable a une grande faculte universitaire. II a pour but d'enseigner les sciences gymnastiques sous leurs trois formes : (a) gymnastique pedagogique ou scolaire ou de developpement ; (b) gymnastique militaire , comprenant les escrimes ; (c) gymnastique medicale. II forme des professeurs et des directeurs de gymnastique civils et militaires et des medecins -gymnastes . " La plupart des eleves qui suivent les cours de 1'Institut " nous dit le Dr. Lagrange, dans son ouvrage (La medication 11 par I'exercice) sont des jeunes gens de f amille ; il n'est pas " rare d'en trouver qui portent des titres nobiliaires et de grands " noms Aucun jeune homme ne peut etre inscrit " comme eleve de 1'Institut Central, s'il n'est pas muni du cer- " tificat de maturite, qui est, en Suede, 1* equivalent *de notre " baccalaureat. Pour les jeunes filles, on exige une sanction " scolaire equivalente, le brevet superieur." D'apres les instructions reglementaires , les candidats, entr' autres qualites particulieres , doivent posseder " une bonne con- stitution corporelle , une musculature robuste et bien developpee r " de la facilite et de la souplesse dans les mouvements, de " 1'assiduite dans le travail, une sante tres bonne et une dis- " position marquee a la conserver, une humeur bonne et egale, "etc." Le nombre des eleves etrangers, que 1'Institut admet tous les ans, est tres restreint ; ils doivent subir un examen peut etre plus difficile et plus severe que les nationaux. Les Suedois sont d'ailleurs favorises, grace a une education physique rationnelle, qui leur est appliquee quotidiennement depuis 1'age de sept ans et dont les principes theoriques sont enseignes dans leurs ecoles. Les cours a 1'Institut ont une duree de deux ans pour les femmes, trois ans pour les hommes qui sont obliges de suivre un cours de gymnastique militaire ; les medecins diplomas exceptionellement ne suivent les cours que pendant un an. ' Les "cours de gymnastique pedagogique, militaire et medicale sont " suivis simultanement par tous les eleves-hommes. II existe "trois diplomes differents, que Ton considere comme autant de " degres du meme enseignement, le diplome de pedagogic etant " le plus simple de la serie et le diplome medical le plus complet " (Lagrange). II y a done lieu pour le medecin traitant de s'assurer, en cas de doute, que le praticien suedois possede bien le diplome de G-ymnastik-Director (G.D.). Les cours de gymnastique medicale comprennent : 1'anatomie avec des exercices pratiques de dissection sur le cadavre, la physiologie, 1' analyse des mouvements, la pathologie, toute la theorie et la pratique de la gymnastique medicale proprement 417 . dite. Les eleves doivent consacrer, au moins trois heures par jour, au traitement des malades ; la salle de gymnastique medicale est en realite une salle de consultation et de clinique, ouverte a tout malade. Tout 1'enseignement suedois est d'ailleurs rarement livresque et presente toujours ce in erne esprit pratique. A cote de 1'Institut Central, il existe a Stockholm plusieurs " instituts " ou cliniques de gymnastique exclusivement medicale, a la tete desquelles nous trouvons des medecins tels que Kleen, Wide, etc. C'est dans le " Handbok i medicinsk gymnastik " de Wide, que j'ai largement puise pour cette note. L'Institut Arvedson, a Stockholm, reserve aux femmes, delivre, depuis quelques annees, un diplome de medecin- gymnaste qui est valable et reconnu en Suede. Le diplome de medecin-gymnaste permet aux Suedois si se procurer un certificat decerne par un jury medical legalement constitue, les autorisant a pratiquer la gymnastique medicale, en Suede, sous la sur- veillance medicale. Lagrange regrette que les medecins-gymnastes soient encore designes sous le terms general de masseurs. ' II regne ainsi dans " 1' esprit du public franc, ais une confusion tres prejudiciable aux " specialistes suedois De plus, la position, non " seulement de medecin-gymnaste mais meme de gymnaste, est " infiniment plus relevee en Suede que ne le sont, chez nous, " celles de masseur et de professeur de gymnastique " S'il arrive qu'un officier quitte defmitivement 1'armee et se livre exclusivement a la pratique de la gymnastique medicale , " il ne perd rien de la consideration qui s'attachait a son grade; " cette consideration s'augrnente, au contraire, de celle qu'on -.-' accorde a son talent de specialiste. L'un de ces officiers, ' M. Thure-Brandt, anclen major dans 1'armee suedoise. s'est ' acquis une celebrite europeenne. La methode qu'il a fondee, ; ' pour appliquer aux maladies des femmes la gymnastique et le ' massage, a fait une revolution dans la gynecologic, au moins : ' dans les pays ou elle a ete 1'objet d'une etude attentive, c'est- ' a-dire dans tous les pays scandinaves, dans toute 1'Allemagne, ' 1'Autriche et la Suisse." (Lagrange.) Les medecins-gymnastes sont connus depuis longtemps dans stains pays. Us etaient nombreux en Allemagne, en Autriche vt en Angleterre. Et cela se congoit. Ces gran des nations sont les plus rapprochees de la Suede. Tout Suedois connait et parle illemand et anglais, langues soeurs des langues scandinaves; ces >ntrees offrent a ces praticiens une clientele nombreuse et haute- tent remuneratrice , grace a la competence des professeurs I'universite et des medecins nombreux que les estiment legitime- lent et ne les confondent pas avec les masseurs, les rebouteurs, les charlatans et meme les soi-disant " masseurs suedois," usurpateurs non diplomes, qui font au systeme un tort con- siderable. Au contraire, dans les pays de race latine, ces medecins- gymnastes etaient rares pour les motifs inverses : eloignement 16524 418 du pays, difference essentielle entre les langues, ignorance dans laquelle etaient plonges a leur egard, la plupart des medecins. Je dis la plupart des medecins, parce que, dans tous les grands centres intellectuels et universitaires , il existait quelques medecins qui n'ignoraient pas 1' existence et le valeur de ces praticiens speciaux. Et a Bruxelles, par exemple, ou il n'y avait a ma connaissance qu'une demi-douzaine de medecins-gymnastes diplomes, les Heger, Depage, Spehl, Lemarinel, Mersch, Marique et leurs disciples faisaient tou jours traiter leur clientele civile speciale par ces gymnastes medicaux. De meme que le Prof. Depage a La Panne, nous, a Kouen et a Bonsecours, nous n'avons jarnais confie la gymnastique medicale et ses branches derivees qu'a des medecins-gymnastes diplomes de Stockholm. Je suis heureux de constater que, depuis la session de la Conference Inter-alliee pour les Invalides, certains physiotherapeutes francais, italiens, anglais et portugais font appel a ces specialistes et organiserit leur service de gym- nastique medicale comme nous 1'avons fait a Bonsecours. Au commencement de la guerre, 1'Allemagne et principalement 1'Autriche ont engage a prix d'or tous les medecins-gymnastes scandinaves qu'ils pouvaient attirer. C'est ce qui explique pourquoi leur nombre est actuellement si restreint dans les autres pays. - * # * * * La gymnastique medicale a ete divisee en manuelle et en mecanique. Cette derniere comprend la mecanotherapie, per- fectionnee par Gr. Zander, des 1857. C'est de la gymnastique medicale manuelle que je m'occuperai exclusivement dans cet article. N'oublions pas d'ailleurs que gymnastique pedagogique, gymnastique medicale et mecanotherapie ont des bases scienti- fiques et des principes fondamentaux communs. P. H. Ling, dans sa gymnastique medicale, divisait les mouvements en mouvement actif et en mouvement passif. Le M. actif est celui que le patient execute lui meme, par sa propre force et de sa propre volonte. Le M. passif est le mouvement que le patient (P.) subit et qui est execute par 1'intermediaire d'une autre personne, appelee gymnaste (G.) ( 4 ) Ce mouvement comprend 11011 seulement des mobilisations de segments, mais encore toutes les manipulations qui peuvent etre effectuees sur ces segments et qui englobent done les differentes manoeuvres qui ont ete classees sous la rubrique francaise de massage. C'est a tort, d'apres moi, et certes con- trairement aux idees de Ling, que certains auteurs veulent tracer une demarcation entre le massage et la gymnastique medicale. Le massage fait partie integrante de celle-ci et c'est pourquoi je place constamment sous le titre de gymnastique medicale, le massage, la kinesitherapie manuelle et la reeducation motrice ; Pour abreger, j'indiqne la patient par P., et Je mcdicin-gyranaste n t, nn.r O . tiratant par 419 cette derniere n'etant qu'une combinaison synthetique et une application de la deuxieme. Le mouvement avec resistance est execute par le P. mais le G. exerce une resistance, variable avec la force du malade et avec 1'effet recherche. Si le muscle actif pendant le mouvement se raccourcit, le mouvement est appele concentrique. Ex. ; le P etend 1'avant-bras sur le bras malgre, pourrais-je dire, la resist- ance du G. Muscle actif : le triceps brachial quo se raccourcit. Dans le cas confcraire, le mouvement est dit excentrique, les muscles actif s s'allongent. Ex. : Le G. saisit 1'avant-bras du P. et execute une extension du coude malgre la resistance du P. Muscles actif s, les flechisseurs (biceps, brachial ant., long, sup.), qui s'allongent. Nous voyons done que, dans les mouvements passifs et les mouvements avec resistance, le G. regie la force. L' application scientifique et methodique de ces mouvements avec resistance est restee longtemps 1' apanage exclusif du systeme suedois. Je dois dire, en passant, que les expressions telles que " mouve- ments passifs avec resistance," "mouvements activo-passifs ou passivo-actifs " sont totalement incorrectes et doivent etre abandonnees. A proprement parler, la gymnastique medicale n'a pas un besoin absolu d'appareils., ni d'engins speciaux. C'est ainsi que le rnedecin-gymnaste, qui doit parfois traitei* a domicile, se sert alors d'appareils de fortune, tels que des objets de mobilier qu'il trouve a sa portee. Mais il est certain que, chez lui, dans son institut ou dans son gymnase medical, il doit posseder des engins tres pratiques qui facilitent les applications gymn. Le haut-plint (hog-plint) sert pour certains mouvements du tronc et de la colonne ; il permet la fixation des jambes et des pieds, la position assise, la position a calif ourchon , etc. Le. bas plint (lag-plint), dote d'un dossier mobile et d'une rallonge pour les jambes et les pieds, sert dans les massages, permet le decubitus dorsal ou ventral, la position assise, demi- couchee, etc. La bomme, sorte de poutre horizontale glissant entre deux rnontants et qui peut se placer a des hauteurs diverses. L' espalier medical suedois, large echelle que chacun connait. Les perches rerticales jumelees, mobiles afin d'etre rapprochees a volonte. Des petites tables de dimensions speciales et en nombre suffisant. Des sieges a hauteur variable, avec ou sans dossier; des tabourets ; des escabeaux ; des sangles diverses avec poignees en bois, des coussins ; etc. 1R24 2 420 Certains de ces engins sont etoffes et doubles a certaines places pour en adoucir le contact et la pression. Le velours vaut mieux que le cuir, parce qu'il ne permet pas aussi facilement le glisse- ment du membre. Les plints et les tabourets sont visibles sur les parties laterales de la figure; la bomme, 1'espalier, les perches sont visibles dans le fond de la salle. Positions. En gymnastique medicale comme en gymnastique pedagogique, quand on se prepare a executer un mouvement, il faut prendre d'abord une position prealable qui est bien determinee. Je rappelle ici, ce que j'ai deja dit ailleurs, que toutes nos fonctions, quelles qu'elles soient, doivent s'effectuer dans une position non indifferente mais bien determinee pour faire rendre a la fonction son effet maximum et optimum. La civilisation et les vices de 1' animal humain ont souvent altere et modifie etrangement ces positions, logiques et ancestrales, au detriment de la fonction elle-meme ! Beaucoup de positions differentes peuvent etre prises pour permettre 1' execution d'un mouvement gyrnn. ; mais il est une regie bien etablie, que chaque mouvement necessite une position de depart bien determinee, que le medecin-gymnaste competent connait ou peut facilement trouver. C'est principalement dans le choix de ces positions initiales que le med. gymn. incompetent se devoile, en commettant des erreurs et des fautes parfois grossieres. Ces positions servent a donner un point d'appui fixe au segment qui doit se mouvoir et permettent ainsi de doser et de localiser le mouvement, en evitant la propagation inutile et nefaste des synergies musculaires, et " d'isoler " le segment. Les engins, de leur cote, ne font que faciliter, dans certains cas, cette fixation. Je ne puis donner ici le detail de toutes les positions qui sont tres nombreuses et qui toutes individuellement exigent un place- ment bien prevu pour chaque partie du corps et une correction qui sont minutieusement etudies et presents dans les traites speciaux. Je ne puis egalement donner chaque fois les explica- tions scientifiques de toutes ces pratiques qui semblentquelquefois, a priori, a Tesprit non initie, un peu mysterieuses ou incompre- hensibles. Cette difficulte d' interpretation ne depend que d'un defaut de notre enseignement general, qui omet de nous expliquei suffisamment en detail la physique et la inecanique generales, en meme temps que leurs applications a 1' anatomic et a la physio- logie humaines. Je ne puis que renvoyer aux auteurs suedo]\ c qui ont ecrit beaucoup sur ces questions : Hartelius, Zander Kleen, Wide, Levertin, Levin, etc., aux publications periodique; scandinaves sur les gymnastiques, la physiologic, la pathologic et, en francais, au merveilleux traite de physiologic de Langlois. 421 En gymnastique medicale comme en gymnastique pedagogique, les positions ont ete divisees en positions fondamentales et en positions derivees. Les positions fondamentales, an nombre de cinq sont ; debout, assise, couchee, en suspension, a genoux. 1 Position fondamentale debout. Talons joints, pieds a angle droit, jambes et cuisses etendues, colonne etendue et droite, ventre rentre, poitrine saillante et dilatee, tete haute, nuque etendue, menton rentre, regard porte en avant un peu au-dessus de 1'horizontale, epaules effacees en arriere adduction en arriere, bras tombant naturellement, tres legerement flechis aux coudes, aux poignets et aux doigts, doigts reunis et colles contre la face externe des cuisses. Cette position peut servir de modele pour beaucoup d'autres. 2 Position fondamentale assise. Bassin et cuisses reposant sur un siege horizontal, genoux et cous-de-pied a angle droit, pieds poses sur le sol ou sur un soutien, cuisses et jambes rapprochees, bras pendant librement le long da corps, etc. 3 Position fondamentale couchee. Corps etendu avec sa face posterieure reposant sur le plint, jambes rapprochees, bras reposant le long du corps, etc. Ce n'est pas une position de repos, parce que certains muscles doivent agir pour permettre de la conserver. La veritable position de repos pour le corps humain est la position demi-couchee, cuisses et jambes demi- flechies, avec toutes les articulations dans la position moyenne, c'est-a-dire entre la flexion et 1' extension, etc. 4 Position fondamentale en suspension. Suspension par les mains ecartees d'une distance egale a la largeur des epaules, le dos des mains dirige vers la face du patient (pronation). Elles saisissent 1'engin qui est eleve de facon que les pieds ne touchent pas le sol, bras, tronc, jambes etendus completement , tete legerement flechie en arriere, etc. 5 Position fondamentale a genoux. Peu employee. Ces positions fondamentales donnent naissarice a des positions dericees par un changement on uri deplacement d'un ou de plusieurs segments : une ou deux jambes, un ou deux bras, tronc, rtc. Je citerai rapidement les positions derivees les plus usuelles, sans en donner aucun detail. LA POSITION FONDAMENTALE DEBOCT domie, comme positions derivees : (a) Par le changement des bras. Mains aux hanches ; (augmente la stabilite de la cage thoracique et sert dans les mouvements de tete, tronc, jambes). Mains aux epaules; (premier temps de 1'extension des bras). Mains aux clavicules. Bras lateralement ; (qui donne elle-meme deux derivees tres tisitees en gymnastique medicale : bras lateralement avec coudes a angle droit et horizontaux ; Bras lateralement avec coudes a 16521 ;; 422 angle droit, avant-bras, verticalement vers le haut). Bras horizontalement en avant. Le meme avec appui des mains centre resistance. Mains a la nuque ; difficile de faire correctement au debut). Bras ver- ticalement au dessus de la tete. Appui de 1'aisselle ; (sur une bomme, par exemple, qui soutient 1'aisselle comme une bequille sert dans les scolioses, les torti- colis). Certaines, parmi celles-ci, peuvent s'accom- pagner d' appui ou de soutien des mains. (b) Par le changcment des membres injerieurs. Pieds joints; (dans toute leur longueur). Sur la pointe des pieds. Genoux demi-flechis ; (angle droit). Sur pointe des pieds, genoux flechis. Station avancee: (un pied en avant de 1'autre a une distance de deux longueurs de pied). Station oblique avancee. Station ecartee ; (pieds ecartes de deux longueurs de pied) ; dans les stations, le poids du corps doit tomber au milieu de 1'espace qui separe les deux pieds. Flexion et elevation d'une jambe. Fentes : etc. (c) Par le changement du tronc. Flexion tronc en avant ; en arriere ; de cote ; rotation. Flexion tronc avec appui des cuisses ; (partie moyenne anterieure des cuisses prend appui contre 1'engin; sert dans les scolioses) . LA POS. F. ASSISE peut voir executer les memes changements des bras et des jambes mais ces positions sont peu usitees. Dans certains positions assise, (tronc flechi en arriere), il faut veiller a fixer les pieds ou les jambes solidement, pendant tout 1'exercice. LA POS. F. COUCHEE donne les derivees suivantes : Ms. hanches. Ms. a la nuque. Bras au dessus de la tete, (dans le prolongement du corps; employee freqaemment chez les enfants). Cuisses et jambes flechies. Jambes pendantes ; (nombreuses applications). Position demi-couchee , jambes etendues ou flechies. Couche ventral total. Couche ventral, tronc et tete depassant le plint. Couche lateral ; etc. LA POS. F. EN SUSPENSION pent s' executer avec les bras flechis, avec soutien des pieds, etc. II existe en suedois, pour ces positions et pour les mouvements, toute une terminologie tres pratique avec abreviations et mots conventionnels, qui epargnent les periphrases et facilitent le commandement. Cette terminologie a ete facilement traduite en allemand et en anglais. En francais, jusqu'a present, malgre 1'essai tente par mon confrere et ami le Dr. Tissie, de Pau, qui emploie des mots conventionnels faisant image, on s'en tient aux abreviations des mots ordinaires. Ainsi, le mouvement de flexion laterale du tronc dans la position de depart de station ecartee avec mains a la nuque s'ecrit : St. ec. ; Ms. N. Fl. lat. Tr. 423 Mouvements gymnastiques. Pour prendre les positions quo je viens de decrire, on doit executer evidemment des mouvements ; mais ces positions lie constituent pas a proprement parler ce que Ton nomme mouve- ments en gymnastique. Elles precedent le mouvement vrai, sont niaintenues en partie pendant celui-ci et sont reprises lorsqu'il est termine. La tout constitue un exercice. Ainsi dans 1'exercice St. ec. ; Ms. X. Rot. Tr. je me place dans la position de depart de St. ec. ; Ms. N. puis j 'execute le nombre ordonne de mouvements de rotation du tronc a gauche et a droite, puis je re viens a la position de depart. Souvent le mot mouvement est employe dans le sens d'exercice. Les mouvements les plus communement usites en gymnastique medicale sont les suivants : Hachement Tapotement Percussion. Petrissage Sciage Pression. Trepidation Vibration. Frictions Effleurage. Soulevement Tension Elevation. Flexion Extension Adduction Abduction et leurs derives. Torsion Houlement Attitude Suspension, etc. HACHEMENT. Le H. s' execute avec differentes parties de la main suivant la region et suivant 1'effet recherche. II demande line grande pratique pour etre bien fait. II a une action stimu- lante parce qu'il atteint une grande quantite de fibrilles nerveuses peripheriques. H. de tete. On emploie les extremites des doigts et des H. rapides et forts, pour stimuler, dans la somnolence, 1'apathie, la fatigue, lorsque le travail physique et intellectual se fait sans Teriergie et 1'assiduite habit uelles. Si Ton veut obtenir une action calmante, chex les rierveux, les surmenes, dans 1'insomnie, on emploie la face palmaire des doigts, tres lentement, legere- ment, pour passer petit a petit a de legeres et lentes frictions avec toute la main. Cette manipulation donne de tres bons resultats ; plus des 10% des malades dans les cliniques gymn. recoivent ce traitement. H. du dos. Indique dans la douleur, la fatigue du dos, inflam- mation et faiblesse de la musculature dorsale, chlorose, affections du coeur et des poumons, etc. H . du Coeur. Sur la region precordiale, s'accompagne toujours d'autres mouvements ; est usite dans les affections cardiaques. J'en rej)arlerai dans 1'exemple de traitement que je donnerai phis loin. H. des muscles. TAPOTEMENT. Se pratique avec toute la paume de la main. 16524 4 424 T. du thorax. Est le plus important et le plus usite. Employe dans les bronchites, 1'essoufflement, 1'emphyseme, etc. Nous verrons combien nombreux et efficaces sont les mouvements que ]i gymnastique medicale possede pour ameliorer cet emphyseme pulmonaire si rebelle aux traitements ordinaires. Par ce T. et par la vibration, la respiration devicnt plus complete, plus pro- fonde en meme temps que 1' expectoration est facilitee. Le T. est encore utilise dans certaines paresies, paralysies, hypo- sensibilites, etc. Sur le muscle le T. peut suivre le petrissage. PERCUSSION. La percussion est le plus energique des trois mouvements, le H. en etant le plus faible. La percussion se donne avec la main fermee. Elle n'a pas beaucoup d'indications : rhumatismes et inflammation des muscles de la hanche, nevralgie sciatique, etc. La percussion du sacrum est la plus commune ; dans les affect - tions des organes du bassin : atonie du rectum et de la vessie, organes genitaux des deux sexes, etc. Elle est quelquefois executee avec la main formant une con- cavite ou ventouse (T. ou perc. a air comprime). PETRISSAGE. Pet. des muscles, (inflammation musculaire, rhumatisme, paresies,) les recherches nombreuses et directes par Mosso et d'autres ont prouve que le muscle peut produire un travail beaucoup plus grand, apres avoir subi une seance de petrissage. II est done indique dans diverses affections, chez les convalescents et les alites, ou il remplace 1'exercice musculaire qui leur manque totalement. Ge petrissage des muscles a encore une grande valeur comme mouvement de circulation dans les affections du coeur. Bien que la difference ne soit pas considerable, ce petrissage mouvement n'est pas tout a fait le meme que le petrissage du massage. Ce dernier n' envisage qu'une action locale sur un ou plusieurs muscles determines et se fait plus prof ondement , tandis que le premier vise a une action stimulante generate beaucoup plus qu'a une action locale. C'est pourquoi, dans ce cas, on ne dit jamais petrissage de tel ou tel muscle, mais petrissage du bras, de la jambe, etc. Petrissage de-T abdomen. Ce terme est quelquefois employe d'une maniere generale pour designer non seulement le petrissage mais les pressions, les vibrations et les frictions qui forment toujours les manipulations courantes du traitement gymn, ou massage du rentre. Ses indications sont fort nombreuses dans les affections de rabdomeri, du coeur et dans les affections generales. SCIAGE. Le sciage ressemble an petrissage et s' execute avec le rebord cubital de la main. II se fait plus ou moins prof onde- ment selon que Ton veuille agir sur la peau ou sur les couches musculaires plus ou moins profondes. II ne se pratique plus que sur les muscles de la nuque, oii il est moins fatigant que le petrissage. 425 PRESSION. Employee principalement pour stimuler les nerfs, elle s'accompagne d'une legere vibration et est pratiquee par 1'extremite du doigt. Exercice tres agreable pour le patient, s'il est tres fatigant pour le G. Le G. arrive, par des pressions rapides speciales, a produire une reaction dans des nerfs, qui ne reagissent plus au courant electrique. Pression sur les nerfs du dos. (Myosites, paresies, douleurs, scolioses, chlorose, etc.) Pression au-dessus du pubis. Dans les affections de la vessie, des organes genitaux de la femme, prolapsus ani. Cette pression ne vise pas un viscere specialement mais plutot le plexus hypo- gastrique inferieur. Elle entre d'ailleurs, avec les frictions, les vibrations et le petrissage de 1'abdomen, dans le traitement de la ressie que Branting, Hartelius et Wide ont perfectionne. Le traitement perineal est de moins en mois pratique, parce- qu'il peut, chez les jeunes gens, donner naissance a de 1'excitation genitale, inconvenient que ne provoquent pas d'autres mouve- ments qui le suppleent facilement. Le traitement de la vessie par le rectum emploie un appareil en forme de baton ou un vibrateur mecanique. Le traitement de la prostate se pratique an moyen de Findex introduit dans le rectum ; il est tres fatigant pour le G. D'ailleurs, toutes ces manipulations gagnent a etre combinees entre elles. TRKPIDATIONS. VIBRATIONS. Elles sont d'un emploi tres etendu. C'est sur leur principe qu'est base le " fauteuil trepi- dant " que Charcot employait dans certaines affections nerveuses. Ce sont elles qui, inconsciemment , forment quelquefois ces cures " miraculeuses " chez des malades pelerinant en train ou en carriole ! Elles calment le coeur, fluidifient et detachent les mucosites dans les affections catarrhales. Souvent, elles sont pratiquees par des machines : percuteurs, concusseurs, vibrateurs, qui donnent des mouvements moins legers, moins fins, moins agreables que la main, mais plus reguliers et plus egaux. Les appareils ne sont employes que dans des cas bien determines. On peut faire vibrer le segment ou le corps dans sa totalite ou bien exercer des vibrations sur tin point bien localise ; ce sont deux mouvements differents. La trep. du segment. Jambes, bras est tres fatigante pour le G. et peut etre avantageusement remplacee par le petrissage, le hachement ou la pression des nerfs. Pourtant, la trepidation du thorax est importante dans les affections du coeur et des poumons ou elle agit comme le tapote- ment. Elle sext a calmer 1' irritation du coeur, comme les memes mouvements appliques sur le dos. Elle est specifique contre remphyseme pulmonaire. A cette trepidation du thorax, on ajoute un soulevement du thorax, dans le traitement des malades alites et atteints d' affections pulmonaires ou cardiaques. Elle 426 constitue d'ailleurs le mouvement respiratoire le plus leger que Ton utilise en gymnastique medicale. Vibration de V abdomen. Agit sur les visceres abdominaux et sur le coeur. Elle soulage les douleurs et les coliques et ameliore 1'appetit. Appliquee sur la region gastrique elle est utile dans la dilatation de 1'estomac. Les vibrations s ' applique nt encore au larynx et au pharynx. Pour ce dernier organe, nous conseillons de ne les laisser executer que par les medecins special istes en rhinologie. FEICTION. L/a friction presente trois actions differentes : 1 mecanique, (exemple : friction du colon dans la constipation) ; 2 reflexe, (friction de 1'abdomen qui reveille les peristaltiques) ; 3 calmante. Ces actions varient suivant 1'energie et la pro- fondeur des manipulations. Elles s'appliquent sur toutes les parties du corps. Friction de tete. Termine le hach. mais peut servir indepen- damment dans di verses 'affections nerveuses : migraine, insomnies, etc. Dans certains cas, on la donne extremement legere, telle- ment meme qu'elle ne touche plus le patient. Qu'on 1'appelle magnetisme, hypnotisme, comme on veut ; le mot signifie peu de chose, puisque le mouvement se montre sou vent efficace. Fr. du coeur. Accompagne le hach. Fr. des bras et des jambes. Se pratique du centre vers la peripherie ; action stimulante et contraction des capillaires cutanes. Fr. de I 'abdomen (de 1'intestin, du colon) rentre dans le traitement du massage du ventre. Fr. des sphincters massage anal traitement du rectum, de 1'anus : atonie, hemorroides, prolapsus, etc. II s'y ajoute des vibrations. Peut se pratiquer a 1'exterieur ou a 1'interieur. Pour les manipulations internes on emploie un embout special. Per- sonnellement ce traitement gymn. apres une vingtainc dc seances, m'a debarrasse depuis deux ans, d'une fissure a 1'anus. extremement douloureuse, que 1'electrotherapie, (haute frequence) et d'entres moyens n'avaient amelioree que temporairement. Je concois tres bien que la fissure intersphincteralgique qui est presque toujours la manifestation d'une nevrite, dont la patho- genie exacte me sera donnee par 1'avenir, soit heureusement influencee par des manoeuvres qui se montrent si emcaces dans les affections des nerfs. Fr. des nerfs. Se pratique avec le bout des doigts, les ongles du pouce, de 1'index, etc. Tres utile dans les cephalalgies et dans les nevralgies de la tete. Sur les autres nerfs les pressions peuvent suppleer aux frictions. Toutes ces frictions n'ont rien de commun avec Veffleurage du massage. Elles se pratiquent dans le sens centrifuge et sur les vetements et n'ont pas, comme lui une action locale directe sur 427 le systeme veineux et lymphatique , mais une action sur les nerfs de la peau. I/EFFLEURAGE se fait dans le sens centripete, dans le sens de la circulation veineuse. II est leger et lent. 11 est antiphlo- gistique et anesthesiant et s'emploie alors dans des lesions aigiies : synovite aigiie, inflammation des parties molles, tissus rouges, tumefies, chauds, douloureux, etc. II pent durer une demi- heure, une heure et meme d'avantage. LA FRICTION DU MASSAGE n'est egalement que de 1'effleurage, mais plus energique, et peut par consequent se pratiquer dans les affections chroniques et subaigiies et faire progresser les exsudats ou resorber les produits d'inflammation. SOULEVEMENT. Ne s' applique qu'aa thorax et sert de mouve- ment respiratoire. Utilise chez les patients faibles, cardiaques ou pulmonaires graves, dans I'emphyseme, etc. II peut etre pratique unilateralement dans les affaissements unilateraux du thorax, consecutifs par exemple aux pleuresies. Dans tous ces mouvements de respiration, des regies tres strictes sont edictees pour cadencer et rythmer les deux temps de la respiration d'une maniere opportune. TENSION. Ne s 'applique egalement qu'au thorax. Est un tres bon mouvement respiratoire et plus efficace que le precedent. Employe dans les deviations de la colonne, les poitrines plates, la coqueluche, etc. ELEVATION. S' applique quelquefois aux suspensions et confine a la gymnastique pedagogique, mais est encore tras utile en gymnastique medicale. Quelquefois le G. aide legerement le P. en le soutenant soit par les handles, soit par les jambes, soit en donnant aux pieds, un soutien. Est employe comme traitement orthopedique dans les deformations de la colonne, rachitisme, thorax aplati, flexion anormale de la tete, epaules tombantes, etc. Elevation des bras. S'execute dans des positions initiales et dans des directions differentes. Mouvement respiratoire remar- quable ; 1'inspiration s'effectue pendant que les bras se trouveni a a dessus de la tete. Mouvement correct!! du tronc tres tisite dans les scolioses. FLEXION EXTENSION. Ne doivent pas etre pris dans leur sens arthrologique. Comprennent tous les mouvements qu'nn seg- ment peut eft'ectuer dans les differents plans: flexion, extension adduction, abduction, flexion de cote, mouvenients lateraux, etc., exception faite des rotations et des circumductions. Us com- prennent beaucoup de mts. passifs, mouvements avec resistance et meme les mouvements actifs purs comme coax de la gymnas tique pedagogique. Us n'agissont pas senlomont localement sur !< segment manipule, mais encore, comme jo Tai deja signale, sur les segments eloignes : ainsi, des mouvements avec resistance 428 de flexion des bras sont tres efficaces centre les deviations verte- brales ; dans les scolioses ils sont pratiques lateralement ; les mouvements des jambes agissent sur le bassin et 1' abdomen ; etc. D'apres la forme generale de ces mouvements, les Suedois leur donnent des noms speciaux : balancement, bercement, traction, ebranlement, ballottement, battement, etc. Ainsi, sous le terms de ringning (mouvements de cloche) ils font executer au tronc un mouvement passif de ballottement, soit lateral, soit antero-posterieur, tres efficace centre 1'insomnie. Eappelons-nous d'ailleurs 1' action sedative tres connue du bercement. TORSION. Rotation du segment autour de son axe longitudinal trosion du pied en dedans, prescrit dans le.pied plat; torsion en dehors, dans le pied bot. Nous connaissons tous 1' action de la torsion du tronc sur le thorax et sur 1' abdomen ; etc. ROULEMENT. C'est, comme mouvement passif, la circum- duction en gymnastique ; tres utile, non seulement pour agir sur 1' articulation mais encore comme mouvement circulatoire local et general. RouL du tronc. Tres usite dans les affections des organes digestifs. RouL des bras (dans les affections cardiaques, il faut etre prudent et quelquefois ne pas depasser 1'horizontale). RouL des jambes. Comme mouvement circulatoire, s'execute principalement en dehors. RouL des pieds. Tres efficace centre les " pieds froids." ATTITUDES. Ne sont pas a proprement parlerdes mouvements, puisqu'elles constituent des positions speciales, qui sont con- servees et ne changent pas, et pendant lesquelles aucun mouve- ment n'est execute. Utilisees dans les deformations, deviations, etc. Traitement gymnastique d'une affection cardiaque. Maintenant que nous sont connus les moyens d' action, les mouvements-medicaments, voyons comment ils seront adaptes a un cas determine. Je ne choisis ni une affection traumatique. ni une affection orthopedique, parce que leur schema est extreme- ment complique, bien que les medecins en soupgonnent assez facilement les principes directeurs. Je prends un cas simple d' affection cardiaque. La gymnastique medicale est tres efficace dans les lesions cardiaques et possede sur elles une action plus durable que tpute tiutre medication. Pour ces lesions, la gymnastique medicale cherche a alleger le travail du coeur en ameliorant la circulation generale; souvent, le ineilleur moyen consiste a degorger le 429 systeme veineux congestionne. Le systeme suedois possede trois grands groupes de mouvements passifs, qui ,ont cette action heureuse sur la circulation : le petrissage, les roulements et les mouvements respiratoires. Le petrissage des muscles et les roulements font progresser la circulation dans les segments peripheriques ; les mouvements respiratoires le font dans la poitrine et indirectement dans 1'abdomen ; sur ce dernier, s'ajoute aussi evidemment 1' action du petrissage abdominal. Le petrissage des muscles agit mecaniquement et favorise la circulation veineuse non seulement dans les muscles mais dans les espaces intermusculaires et dans les autres parties molles. Le mouvement actif a d'ailleurs la meme action et sera employe lorsque 1'etat du patient le permettra. Au petrissage des muscles s'ajoute celui du ventre qui favorise la circulation dans les gros troncs veineux de 1'abdomen et dans toutes les veines des organes digestifs, qui sont toujours engorges dans les affections cardiaques. Ce petrissage abdominal, par son action mecanique, excite les nerfs splanchniques qui, de leur cote, activent et facilitent la circulation arterielle et veineuse du ventre. Les experiences de Levin sont concluantes a ce sujet. Les frictions rapides, qui terminent habituellement le petrissage, cooperent au travail circulatoire , en irritant la peau et en amenant une contraction des capillaires cutanes. Les petrissages que 1'on emploie de preference sont ; le petrissage des bras , des jambes et le petrissage du ventre. Les roulements, ai-je dit, sont des mouvements de circulation. En effet, par ces mouvements, les veines subissent des allonge- ments et des raccourcissements successifs et alternatifs. Pendant son allongement, la veine, augment aux de volume, aspire le sang veineux et degorge les branches peripheriques, favorisant la circulation de retour ; le raccourcissement , suivant immediate- ment, a pour resultat de diminuer le volume de la veine et de chasser le sang vers le coeur. Ce mouvement de bascule se repete frequemment et atteint toutes les veines qui sillonnent et embrassent le segment autour de 1' articulation mobilisee. A 1'epaule et a la hanche meme, grace a certaines aponevroses, cette action s-exerce plus energiquement. (Braune.) Les roulements les plus habituels-toujours comme mouvements passifs-sont : roulement des mains, bras, pieds, jambes, tete, tronc et circulaire. II y a lieu de ne prescrire aux cardiaques le roulement de tete qu'avec prudence et lorsqu-il a ete demontre qu'il supporte facilement les autres mouvements de roulement. Le R. du tronc agit sur les veines caves infer, et sup. II faut veiller que la flexion en arriere ne s'exagere pas et ne demande pas trop d'effort aux muscles abdorn. qui, dans ce cas, generaient la respiration. L'influence dc la respiration sur la circulation est connue de tous. La respiration sert a hematoser le sang. Le cardiaque, 430 ayant une circulation difficile, doit done pratiquer une respiration tres complete et profonde, non seulement pendant son traitement, mais en tout autre temps. L 'inspiration, comme une pompe, aspire le sa'ng dans le thorax et agit sur la petite circulation (pulmpnaire ,) sur la grande cir- culation (veines caves,) et sur la circulation lymphatique (canal thoracique). De plus, le diaphragme en s'abaissant comprime le contenu de 1' abdomen et coopere a. faire progresser le sang veineux des gros troncs abdominaux vers le coeur. Les mouvements respiratoires les plus communs sont : soule- vemeiit et tension du thorax, elevation des bras. Ce dernier mouvement rappelle la respiration artificielle d'apres le procede de Silvester. On prescrit, en plus, d'autres mouvements passifs qui ont la propriete de calmer le coeur ; soulevenient du thorax avec trepida- tions, vibrations du dos, etc. Le traitement local, sur la region precordiale, comprend les hachements, tapotements, vibrations et frictions, qui sont calmants ou stimulants, suivant le mouvement et son intensite. II y a egalement lieu de tenir compte de 1'influence psychique de ces mouvements. Wide a constate que les frictions et les vibrations calment la tachycardie de 10 a 20 pulsations par minute, tandis que les hachements et tapotements, au contraire, augmentent le travail cardiaque. II arrive parfois que certains patients ne supportent pas bien certains mouvements. Le Dr. Levin a, pendant 10 ans, suivi scientifiquement et cliniquement traces sphygmographiques et manometriques tons ses malades atteints de cardiopathies et a nettement conclu que les pulsations sont diminuees par minute : de 8 a 12 par la vibration, de 9 a 10 par le soulevenient du thorax avec trepida- tion, de 8 a 10 par le petrissage de 1' abdomen, de 7 par la vibration du dos, etc. Eappellons que . Huchard appelait le massage abdominal, " la digitale des doigts." Tous ces mouvements passifs sont tres utiles et sont precrits en premier lieu. Mais certains mouvements actifs, judicieuse- merit choisis et ordonnes, peuvent etre indiques ; tels sont ; flexion et extension des mains, des pieds, des avant-bras, des jambes. Je rappelle que les mouvements des bras doivent etre executes prunemment et, dans certains cas, ne peuvent pas depasser 1'hori- zontale. D'ailleurs souvent la gymnastique s'en tient, pour ce segment, au roulement et au petrissage. Les mouvements de jambes sont souvent tres bien supportes, parce qu'ils ne parvien- nent jamais a gener la respiration, ce qui, au contraire, arrive souvent, par les mouvements des bras. Ces mouvements des jambes sont " derivatifs " parce qu'ils attirent, dans ces parties, dans les volumineux muscles en activite, par une vaste dilatation physiologique, une gran de quantite de sang qui est " derivee " des autres parties du corps. Cette action favorable des mouve- ments des jambes dans les cardiopathies explique pourquoi la cure 431 de " terrains " attribute a Oertel, de Munich, dans certains cas de coeur graisseux on de nevrose cardiaque, a donne quelques resultats, Men que son principe soit d'une autre nature que celui de la gymnastique medicale. Toutefois, je 1'estimedangereuse dans la plnpart des cardiopathies organiques serieuses. N'oublions pas que le muscle qui travaille produit et deverse dans le sang des substances qui ont pour propriete d'exciter le centre respiratoire et, par consequent, de reagir sur la circulation. Pour obtenir un resultat durable, le traitement des affections cardiaques doit etre quotidien, durer au moins une heure et se pratiquer au moins pendant trois mois. Beaucoup de cardiopathies relevent de la gymnastique medicale, principalement les affections de la fibre musculaire les lesions valvulaires, les affections non compensees, la dilatation cardiaque, etc. Evidemment, cette therapeutique ne debarrassera pas le patient de la lesion valvulaire elle-meme, mais elle ameliorera tres rapidement les symptomes les plus graves : palpitations, dyspnee, cyanose, oedeme, douleurs, angoisses, etc. Quelquefois, il est meme necessaire de recommencer le traitement a plusieurs reprises, mais n'oublions pas que ces affections sont essentielle- ment chroniques et qu'aucune autre medication ne donne d'aussi bons resultats. Les Drs. Kleen et Wide citeraient de nombreux patients qui, depuis des annees, suivent ce traitement, sans lequel, au lieu de rester des hommes encore actifs, ils auraient ete condemnes a la chaise-longue ou au lit. Voici un type de schema de traitement pour une affection valvulaire de gravite moyenne : (I.) pos. assise. Soulevement du thorax. (II.) pos. demi-couchee. Roulement des pieds. (III.) pos. assise. Bs. lat. Petrissage des bras. (IV.) pos. a calif ourchon. Koulement circulaire du tronc. (V.) pos. demi-couchee. Petrissage des jambes. (VI.) pos. id. id. Soulevement thorax avec trepi- dations ou pos. debout appui des bras. Vibrations du dos. (VII.) pos. demi-couchee. Roulement des jambes. (VIII.) id. id. id. Petrissage du ventre. (IX.) id. id. id. Vibration et friction region pre- cordiale. (X.) pos. assise. Soulevement du thorax. Ce dernier mouvement est prescrit au commencement et a la fin, et s'intercale tres frequemment dans le schema et meme apres chaque mouvement, si c'est necessaire. ****** Les indications de la gymnastique medicale sont extremement iiombreuses. ' Depuis plus de 60 ans, dit Lagrange, de 432 " nombreux medecins-gymnastes appliquenfc dans des ' Instituts ' " publics on prives le traitement gymnastique a des malades que " nous soignons en France, sans le moindre succes, du reste, f: par 1'immobilisation. Le domaine de la gymnastique medicale, " qui est, chez nous, tres lirnite, s'etend la-bas a presque toutes " les maladies, tant internes qu'externes. Non seulement les " deviations de la colonne vertebrale et les maladies des articula- " tions, mais aussi les affections de la poitrine, du coeur, de " 1'estoinac, les maladies du systeme nerveux, de 1' uterus et meme " les maladies de la peau, ont ete soignees avec succes par la "gymnastique suedoise." La gymnastique medicale a, pour chaque maladie et pour chaque symptome, son medicament-mouvement, son precede therapeutique. Elle est indiquee non seulement dans les maladies chroniques et subaigues, mais meme dans tin grand nombre de maladies aigiies et son domaine de contre-indications se retrecit de jour en jour. Ses contre-indications sont bien connues des praticiens specialises, mais nous avons vu des medecins com- petents et habiles 1' employer et la prescrire avec succes dans des affections aigiies, febriles et infectieuses, ou, a priori, on la croirait contre-indiquee ou dangereuse ; rhumatisme aigu , synovite et arthrite blennorragiques aigiies, plaies turgides et infectees, fractures exposees, etc. J'ai rappele ailleurs que le Dr. Cyriax, de Londres, deja en 1910, ecrivait qu'il traitait, suivant la methode de Kellgren, les plaies septiques par le schema suivant : vibrations et mobilisation de la peau, friction des nerfs profonds et superficiels, petrissage et mobilisation passive et active suivant les besoins. Pour etablir sa "prescription medicale," son schema, le medecin-gymnaste ne considere pas seulement 1'entite de la maladie mais encore le malade lui-meme : son age, ses forces, sa constitution, son metier, ses conditions d'existence, etc. De plus, cette prescription variera en suivant 1'evolution des symp- tomes et de la maladie. Les mouvements de cette prescription sont minutieusement choisis et se suivent dans un ordre judicieux. On ne peut fixer a 1'avance un schema systematique ; ici, comme en therapie chimique, le sujet reagit d'une fagon personnelle. II y a, entre tons ces moyens, une progression. Nous 1' avons vue pour les hachements, tapetements, percussions. La progression utilise encore la vitesse, la duree, le nombre, le rythme, la diffi- culte et la combinaison qui peuvent varier pour les mouvements et pour les seances. De meme, les mouvements doivent se suivre dans un ordre determine. Souvent, il faut eviter que plusieurs Mts. agissant sur une meme partie du corps ne se suivent immediatement. Une seance doit toujours commencer et se terminer par un exer cice respiratoire. II faut introduire, au cours de la seance, autant de mouvements respiratoires et de mouvements derivatifs, que 1'etat du patient 1'exige. Pendant le cours du traitement, si le genre des mouvements employes ne donne pas le resultat attendu. 433 ici, comme en toute therapeutique, il est utile de changer les mouvements. Le gymnaste doit apporter un soin, tout parti- culier a la respiration de son patient, pendant les exercices, et indiquer, pour chacun d'eux, le rythme, la cadence et la place des deux temps de la respiration. II doit surveiller sa respiration propre pour eviter un surcroit de fatigue. La premiere seance ne comportera que six a huit mouvements, plus tard une seance peu comprendre dix et meme douze mouvements. Pour agir efficacement, il faut que la lecon soit executee sans precipitation ; que le gymnaste et le patient ' ' prennent leur temps. ' ' Le patient doit se presenter au traitement, quelques minutes avant 1'heure indiquee, pour etre calme, sans .essoufflement, sans sudation exageree. Apres chaque mouvement ou chaque groupe de mouvements, il est accorde cinq minutes de repos, pour permettre de recuperer le plus de force possible pour les mouvements suivants. Un certain degre de fatigue, loin d'etre condamnable, est quelquefois utile et physiologique. Le gymnaste evitera pourtant d'atteindre un degre inaccoutume de fatigue chez son client. Le traitement ne pent pas etre donne au patient etant tout a fait a jeun, ni immediatement apres son repas. Contrairement a la gymnastique pedagogique, la gymnastique medicale ne necessite pas de vetements speciaux. Pendant le traitement, gymnaste et patient doivent etre attentifs exclusivement a ce qu'ils font; pas de conversation inutile, pas de distractions qui, dans certaines lesions soit inflammatoires, soit douloureuses, soit traumatiques, pourraient devenir extremement funestes. De plus, le medecin-gymnaste doit travailler avec tranquilite et regulierement , porter dans son travail et dans sa personne de la vie, du gout, une certaine vitesse et urie bonne humeur tres communicative. C'est ce qui frappe les etrangers qui visitent les instituts suedois. Cette gymnastique avec une certaine variante pent encore s'appliquer aux individus qui ne sont pas " malades " a pro- prement parler : les sedentaires, les convalescents, les faibles, les surmenes, qui ne peuvent pas ou ne veulent pas s'adonner a la gymnastique pedagogique. Dans ce cas, la gymnastique medicale devient une gymnastique dietetique et hygienique. Elle est evidemment preferable a tous les exercices hygieniques que le medecin recommande souvent, sans en connaitre toujours 1' analyse et les inconvenients, et sans en donner une prescription bien nette et bien dosee : jeux et sports divers qui exigent quel- quefois beaucoup de temps et d'argent, qu'il eSt tres difficile de doser exactement, qui sont parfois unilateraux et deformants, quelquefois insuffisants, malgre rengoument du public et des medecin s. Nous voudrions voir le Service de Sante Militaire creer et organiser, dans une de ses formations sanitaires en Belgique, un 434 centre de gymnastique medicale, apres avoir fait donner pre- alablement, en Suede, a de jeunes medecins, un enseignement complet de gymnastique. La Belgique militaire aurait ainsi 1'honneur d' avoir la premiere en dehors des pays scandinaves, introduit officiellement la gymnastique medicale suedoise, comme elle introduisit la gymnastique pedagogique dans son armee et dans ses ecoles, grace a 1'impulsion energique, tenace et intelligence du Colonel Lefebure. 435 THE TREATMENT OF WOUNDS BY CONTINUOUS BATH. BY MAJOR LINDSAY SANDES, M.A., M.D., S.A.M.C. This treatment is by no means new. Before the present war the Germans, among their therapeutic measures for diseases of the skin, had erected an installation for continuous immersion at Hamburg. Again, in England, at the Cambridge Military Hospital, a series of 4 baths was erected for the treatment of 'battle casualties. In May, 1917, we completed at Richmond our series of 6 baths, and when the tests of mechanical efficiency were satisfac- tory, at once brought them into use. Of their value in suitably selected cases and their suitability seems in proportion to the extent, severity and septicity of the wounds we at the South African Hospital are convinced. In the limited time at my disposal I shall briefly outline the structure of the baths, the mechanism controlling the flow of water of a constant homogeneous temperature, and some of the advantages and faults of this line of treatment, acquired by about 10 months' experience of its use. Our series consist of a range of extra wide and deep, fire clay, enamelled baths 5' 6" 6' 0" long inside, each fitted with ordinary hot and cold supplies, and waste pipe at the foot end. In addition there are 4 6 inlets at the sides near the bottom for admission of the continuous flow of temperature regulated hot, or tepid water controlled by a valve with index dial. TW T O or three overflows are provided each with a waste and plug, thus regulating the level of the water to accommodate fche patient. Hot and cold water are laid on in the usual manner. Hot or tepid water only to the continuous feed inlets at the bottom of the bath. Hot water is generated in a boiler connected to a storage hot w r ater cylinder with flow and return mains. This storage cylinder is again connected to two cylinders so arranged that as soon as the desired temperature is obtained in No. 1 cylinder a thermometer which controls all operations switches in electric gear, operating a 3-way valve, passing the water to No. 2 cylinder. No. 2 cylinder, being a sort of side track, contains water at a temperature considerably lower than that in No. 1 cylinder. The hot water, therefore, from the storage cylinder mixes with the cooler supply in No. 2 cylinder, and this mixed and cooler water is passed on through a separate pipe to No. 1 cylinder. When the temperature in No. 1 falls about 1 deg. 2 deg., the original 436 direct connection between the hot water storage cylinder and No. 1 cylinder is once more re-established by the regulating thermometer and the 3-way valve ; the supply then tends to in- crease in temperature again. Thus, there is a slow uniform fluctuation of the temperature of the water supplied to the bath of about \ deg. 1 deg. on each side of a mean temperature of about 99 degs. Thermostats record and chart the temperatures of the different supplies and that distributed to the baths. In addition, there is an automatic arrangement of alarm bells to meet any emergency or failure of the mechanism ; and in the last resource the patient has means of readily and insistently summoning the attendant. Since the inception of the baths we have only twice had defects in the working of this system. In both cases, through the frosty weather freezing cold pipes exposed outside, otherwise the mechanism of the system has been extraordinarily satisfactory and worked perfectly as exemplified by any of the charts shown herewith. Mr. H. A. McFerran, Chief Engineer to H.M. Office of Works, designed and erected our plant. Before the arrival of the patient the bath is filled. A canvas hammock or cradle is placed in the water. This is adjustable by means of straps and buckles, which hang over the side and fix to the floor, to the required depth and position for the comfort of the patient and convenience in attending his wounds. The canvas cradle has apertures to allow the free circulation of the water. On this a sheet is placed. This is a softer support. It requires occasional changing, as otherwise it accumulates the purulent discharges on its surface. The patient is lifted straight into the water. Irrigation tubes of the type and system devised by Carel are adjusted. These are then connected to the continuous hot water supply main by a rubber tube and controlled by a small tap. It is advisable, before admission to the baths under a general anaeesthetic , to thoroughly explore and expose every sinus and pocket of the wound or wounds, and to affix the irrigation tubes so as not to allow the accumulation of secretion in any ere vice r and so that the water may sweep all the infected surfaces. He is now covered by boarding fitting in sections over the top of the bath ; on this a canvas cover is placed, a blanket and a quilt. His shoulders project above the water, and he reclines against a water pillow at a comfortable angle. The arms, unless they require immersion, rest, as a rule, on the outer surface of the bath cover. He can usually wear some form of protection about his neck and shoulders. 43T Thus, in a semi-reclining position, with all he is likely to want papers, books, tobacco, jig-saw puzzles, &c. within easy reach on the surface of the bath, he passes, as a rule, fairly happily the tedium of the worst part of his convalescence. A word or two as to the advantages and objections to this method of treatment : No dressings are required. In an exhausted patient, the daily pain and shock of removing layers of gauze, wool and bandages, in washing, cleaning and recovering extensive wounds are factors of considerable moment in depressing the mentality, the physical condition and in general in retarding recovery. Severely wounded patients have stated they can hardly sleep at night anticipating the torture of the dressings of the succeeding morn- ing. ' Here, beyond the occasional adjustment of a slipped tube, broken and aching limbs are not disturbed often for 3 or 4 days at a time. Again, the economy of dressings is a material con- sideration, and should be balanced against the initial cost of the baths. The wounds are kept constantly clean. They are soon .covered with granulations. There is little or no absorption. The patients' spirits begin to rise, his temperature and pulse rate to fall, and after the first night (when the apprehension induced by immersion in a strange medium may render him restless) he sleeps well. (See graph representing the combined charts of the last 40 patients who have passed through the bath ward.) His appetite presently returns, he takes an interest in his surroundings, and the journey on the road to recovery is definitely inaugurated. There is a great saving of time. It takes a medical officer or skilled nurse and an assistant half an hour at least to attend to the wounds of a badly injured septic case, and these are the cases we put in our baths. This helps materially to lighten the work in the general wards. The buoyancy reduces the weight of the patient by that of the displaced liquid. Thus, he rests extremely lightly on the sup- porting sheet; this is conducive to great comfort, and bed sorea heal with celerity. Disadvantages. Some patients never feel at home in the water, though it was originally their native element. This is, however, a rare occurrence. It cannot be combated. They had better be returned to bed. Again, after about 2448 hours, complaint is frequently made of pains in the feet and hands if these parts are submerged. This is a dull, boring discomfort, analagous to the pain of pressure on the heels, which worries the bed-ridden. On examining the painful extremities, the skin is sodden, or perhaps raised and crenated. Beyond this, however, there is nothing to be seen. This discomfort is, I believe, due to pressure on the tactile 438 -corpuscles (probably those of Wagner and Meisner, which are superficially disposed and numerous in the hands and feet) by the epithelial cells, distended by the absorption of water. We en- deavour to avoid this by raising the feet and hands above the surface of the water, or, if this cannot by nature of the wounds be conveniently done, coating the skin with vaseline or thick grease, or wrapping them up as far as possible in vaselined gauze. Calcium salts are deposited, particularly about the pubis, if the patient is long immersed and not occasionally washed with soap. 1 think the local hard water is responsible for this trivial detail. If the pressure of the water in the irrigation tubes is too great that is, if the tap on the main is open too much and one or more of the terminal tubes happens to be inserted in some easily lifted, cellular plane, it is liable to become distended and the infection may be widely spread. The subcutaneous tissue is the most usual site for this complication a gentle flow in the irrigation tubes is quite sufficient. The appearance of a widely disseminated postular rash is not uncommon , no doubt due to penetration of water-carried organism into the hair and sweat follicles, cracks or breaches of the skin. For the same reason, nurses and attendants who manipulate the patients, inserting their hands into the water, are liable to infection. They should wear gloves. We have found it ad- visable to connect to the irrigation tubes a reservoir of antiseptic /usually cresol), which, controlled by a screw clamp, keeps the surface of the wounds laved with a weak antiseptic solution, diminishes the activities of the pyogenic organisms floating in the water of the bath, and obviates the rashes of the patients and infections of attendants. Splints offer no trouble. They are employed in the ordinary way. Those made of wood must, of course, be weighted or anchored. With regard to the emunctories there is no difficulty. To pass water and use the bed pan the large waste pipe is opened the bath empties in a minute, the bed pan is inserted easily and con- veniently under the patient the covering of the bath is replaced. The temperature of the interior during the period it is devoid of w^ater only falls a few degrees. The refilling of the bath is an equally expeditious process. A debilitated patient micturates in the water without the bath being emptied. It is necessary to accentuate that successful treatment by con- tinuous bath is, like other forms of success, acquired by the exer- cise of care and assiduity ; this to a large extent depends on per- sonal daily supervision of the medical officer. The arrangements and disposition of the tubing may want alteration a fresh abscess may require opening, other difficulties and complications may arise from time to time that must be solved by the medical officer himself; similarly the bath-ward should have its own staff of adaptable, intelligent nurses and attendants. With many patients 439 it is advantageous to alternate 3 or 4 days in the bath with a few days in bed, and to continue and vary these mutations to meet the individual case. Nature of cases for treatment. One may repeat that the best cases for the bath are among the severe casualties, and by severe T mean to convey the more septic. For example, multiple infected gun-shot w^ounds or those involving the long bones and* joints of the extremities. We have not required to put empyemata of the thorax in the baths, as they seem to be satisfactorily drained and kept clean by ordinary measures. As examples of eminently suitable cases, let me give two. No. 10818, Private G. E. E. E,- -, 2,/S.A. Infantry, Gr.S.W., involving the perineum, tearing up all the soft tissues, cutting the penis and urethra and destroying both testicles. The dressing of this case was a tedious and exceedingly painful task, his groans and cries most pathetic. Once in the bath he was at rest ; he remained there 13 days. When removed to bed once more the acutely sensitive parts were greatly reduced in size and coated with a layer of anaesthetic granulations. A fractious, terrorised and emaciated patient had been metamorphosed to a contented and comparatively healthy individual. L.-Cpl. P. G. -, No. 6346, 2/S.A. Infantry, G.S.W. Multiple. Eight leg amputated by the guillotine operation in France, leaving a painful pyramid of meat. Left hip shattered, and discharging torrents of pus from many sinuses. Left shoulder and humerus similarly disorganised, a large bed sore and huge abscess in the lumbar region. This man, I am of opinion, would have succumbed had it not been for the bath. The continued diffuse and violent sepsis, shock and pain could only have had one result. He is still, while writing this paper, in a somewhat parlous state, but improving with each succeeding day. It is an excellent subjective testimony that patients who have once been treated in the bath are anxious to return there if a later occasion arises. Number of cases treated. Average stay. We have put over 100 seriously wounded cases through the baths, many of them for three or four separate sessions, in about 10 months. The average duration of their stay there was about 7 days. Expenses of system. The expense of our system of 6 baths was 700 odd ; with some modifications and simplifying of the apparatus the installation could be erected at a cheaper cost. Number of baths required. 10 baths are sufficient for a hospital of 1,000 beds (i.e., 1 per cent.), taking in recent casualties. 440 If time permitted it would be of interest to discuss the physical processes and expressions of molecular energy between the con- stantly immersed unprotected wound surface and the water. In brief, however, it may be fairly stated that there is a continual but diminishing loss of albumen, salts and all constituents of the lymph by filtration, diffusion, and probably in the earlier stages by direct leakage through torn lymphatic vessels and patent cellular spaces. In the contrary direction there is no doubt some small absorption of water by osmotic pressure. The essential of success in this treatment is the continuous removal of both noxious micro-organisms and the products of their activities, and if a thorough examination of the wounds be first made and the irrigation and drainage system be rationally adjusted, this, I consider, can be obtained with advantage and efficacy by the bath system. 441 RESULTS OF OPERATIONS ON PERI- PHERIC NERVES. PROFESSOR G. VERGA. Out of about one thousand cases of peripheric nerve wounds treated at the Neurological Centre of Pavia under the direction of Professor Camillo Golgi, up to the present about 160 have been operated upon, as follows : 80 Neurolysis (25 middle n. ; 28 cubital n. ; 14 radial n. ; 9 sciatic n. ; 3 popliteal external sciatic n. ; 1 cutaneous muscle n.). 63 Sutures (17 radial n. ; 18 sciatic n. ; 11 middle n. ; 11 cubital n. ; 6 popliteal external sciatic n.). 3 Alternate Sutures (2 cubital n. ; 1 radial n.). 9 Sutures with plastic, having peripherical edge (4 radial n. ; 2 sciatic n. ; 2 popliteal external sciatic n. ; 1 cubital n.). 5. Anastomosis for peripherical grafting of the radial n*. on the middle n. These cases were undertaken with the incessant collaboration of the neurologist of this institution, Prof. Guido Sala. The latter not only supervised the clinical examination and closely followed the post-operatory course of the individual cases, keep- ing track of the results by means of repeated electro-diagnostics, but also assisted directly at all the operations. This close collaboration between the neurologist and the surgeon constitutes the special characteristic of our work, and, as such, confers on all the operations we have performed a parti- cularly rigorous scientific character which increases the depend- able nature of the results achieved. It is too soon since the operations were performed and the number of notes is still too limited for us to be able to draw any conclusions of a general nature as regards the results that have been obtained. The latter are both scientific and practical. , From a scientific point of view the operations that have been performed on the peripheric nerves have supplied the best of proofs of the accuracy of the centralistic theory on the regenera- tion of the nervous fibre so authoritatively^ sustained by Perroncito and Ramon y Cajal in the experimental stages. They 442 have, besides, allowed us to follow with much greater minutiae than could be done on animals the different modalities of the renewal of the organs of the severed nerves, and to decide as to the laws that determine the manner in which the clinical symptoms of the regenerating process declare themselves with regard to the motility, to the objective sensibility and to the electrical reaction. Moreover, they have enabled us, by means of the direct electrical excitement of the uncovered nerves, to make the clinical observation of the most delicate localisation of the topography of the nervous centres. Finally, they have supplied us with rich anatomical-pathological material where- with to investigate the nervous scars due to wounds caused by firearms. From a practical point of view, the operations have already resulted in a satisfactory number of complete recoveries and improvements, even of those extremely serious cases, that had resisted all kinds of physical therapeutical treatment. By limiting ourselves to the sole consideration of the 82 cases that were operated upon some time ago, and of which the post- operatory course was followed for a period long enough to enable us to express an opinion as to the achieved results, we may be said to have obtained, out of 82 cases, 43 recoveries (52 '4 per cent.) ; 31 improvements (37 '8 per cent.) ; and 8 negative results (9*7 per cent.). The negative results occurred in connection with cases that were complicated by grave osteo-articular and muscular altera- tions ; however, even in these cases, although remaining without result as regards the function of the nerve, the operation caused no inconvenience to the patient ; on the contrary , it enabled us more than once contemporaneously to correct a concomitant deformity. Complete recovery, with total re-integration of the nerve and of its function, were verified and controlled by repeated electro- diagnostic examinations, not only in cases of neurolisis, but in those of direct suture, often preceded by the re-sectioning of pseudo-neuromics or by cicatrisable tracts of the nerve centre. The most particularly favourable results have been given by the radial n. and by the sciatic n. No complete recoveries were obtained, only simple improve- ment, and sometimes only negative results, from the intervention of other modalities (alternate sutures, plastics with peripheric edge, anastomosis, &c.). In two cases of grafting the peripheric root of the radial n. to the centre of the middle n., we obtained only the renewal of the function performed by the radial muscles, not that of the finger extensors. For this reason we are still confronted by the problem : What is it best to do in cases of ample diastasis of the nervous stumps 443 where it is not possible to attack the roots so as to proceed with the direct suture even by giving a special set to the limb ? The length of time that has been necessary for the organic renewal as a result of neurorrhaphy has varied according to the depth of the wound, and its date, to the size of the nerve, to the more or less satisfactory general and local conditions of the patient ; but it has always been for a period of several months , sometimes for over a year, and this because of the slowness with which the process of regeneration of the nerves takes place in the human body. 445 APPENDIX. THE CANADIAN PENSIONS ADMINISTRATION. By Major HUME BLAKE, formerly Vice-President of the Pensions' and Claims' Board, O.M.F.C. Canada recognizes, as do most nations, that the rehabilitation account is taken of previous occu- pation, income, or condition in life. Canadian public opinion favours equal compenastion for equal disablement. There is therefore no provision, like the alternative pension of Great Britain, for compensation for economic loss occasioned by enlist- ment or service. Canadian pensions vary according to rank, but there is, or at any rate was, a movement, strong in Western Canada where democratic ideals prevail, to make pensions for equal cause the same for all ranks. (2) Pension is awarded to a disabled member of the forces in direct proportion to the extent of any disability, which became apparent during, or was due to, the naval or military service of such member. (3) Pension is awarded to certain dependents of a member of the forces who has been killed, or has died, when death occurred during, or was due to, the naval or military service of such member. Theoretically, pensions are War Risk Insurance. In war as in civil life the individual should bear the ordinary risks of existence for himself, and the State should only compensate for disability or death due to war risk. In practice, the difficulty of determining with certainty, what is, and what is not, due to war risk, is so great as to make that ideal impossible. It has therefore resulted that the tendency of Canadian Pen- sions Administration, like that of Great Britain and other countries, has been to make the State compensate for death or disability occurring or becoming apparent during service from risks of any sort, excepting only those of wilful misconduct. The recognition of the necessity for some measure of Health Insurance is modern social organisation has probably helped to induce this change. (4) Disability or death, found to have been due to the aggrava- tion during service of a condition which pre-existed enlistment, is pensionable as if wholly due to service when (a) the pre-existing condition was neither apparent nor wil- fully concealed at enlistment, and did not become apparent for a reasonable time thereafter : or (b) the pre-existing condition, though apparent at enlist- ment, was then considered to be negligible. 447 (5) Disability found to have been due to the aggravation of a condition which pre-existed enlistment and was wilfully con- cealed, or which, being apparent at enlistment, was then con- sidered sufficiently serious to prevent enrolment for general service, is only pensionable to the extent of the aggravation during service. Canadian public opinion favours pensioning the entire dis- ability existing at discharge, including that proportion which pre-existed enlistment, unless the latter was either wilfully con- cealed or clearly apparent at enlistment. (6) When disability or death -was due to intemperance or improper conduct, pension is not awarded unless dependency exists and the circumstances are exceptional. The words "intemperance" and "improper conduct" have not been defined. In practice they are considered to mean the persistence in (and not merely an isolated instance of) intemper- ance, vicious or criminal conduct. It may be stated that the trend of Canadian opinion is towards pensioning for death or disability, even though due to mis- conduct, and especially if dependency exists. On the other hand it is interesting to note that in the United States, under the War Risk Insurance Act, pensions are payable for death or disability suffered or contracted " in the line of duty," and it is stated that up to the present time these words have been so strictly construed that no pensions have been paid for death or disability occurring during leave, even though the result of an enemy act. It should also be noted that while Canada, like most countries, gives free protection by pension to certain dependents, restricted according to their relaionship and need, she has not yet decided to afford relief to her disabled men from the increased cost of Life and Accident Insurance occasioned by their enlistment and disabilities. (7) In considering each case a medical estimate of the extent of incapacity to earn a livelihood in the untrained labour market is made. This is based, as far as possible, on a Table of Dis- ablities prepared and revised from time to time, in accordance with actual experience, by the Canadian Pensions Administra- tion. In establishing disability, previous or existing occupation and income are not considered, only the injury to the human machine and the resulting incapacity for ordinary labour being taken into account. No reduction of pension is made because industry or some special aptitude enables a disabled man to earn a good living, nor is pension increased because a disability specially incapacitates for particular work. Disability pensions are awarded in direct proportion to the extent of the resulting incapacity for ordinary labour. There 448 are 20 classes, ranging with 5 per cent, intervals, from total to 5 per cent. The pension payable to a totally disabled man of the lowest rank is $50.00 monthly. If married he receives in addition an allowance of $8.00 monthly for his wife and a like amount for each child not over 16 years of age, if a boy, or IT years of age, if a girl. Moreover, if so helpless as to require constant attendance, he may be granted a further allowance of not more than $25.00 monthly. A partially disabled man is classified in accordance with the percentage of his incapacity, and if married, receives propor- tionate additional allowances for his wife and children. Those disabled to a smaller degree than 5 per cent, may receive a single payment not exceeding $100.00. The allowance for a child may be continued until the age of 21 if, owing to mental or physical infirmity, the child is unable to earn a living. Step-children, adopted children, and illegitimate children are pensionable if the relationship had existed at the time of the appearance of the disability. In case of death, pensions for dependents are provided as follows : (a) The widow, if she was married to deceased at the time his disability was incurred or aggravated, receives $40.00 monthly until she re-marries, when she be- comes entitled to a gratuity equal to one year's pension. (6) The children of deceased, if boys not over 16 years old, or girls, not over 17 years old, each receive $8.00 monthly, or if they are orphans, $16.00 monthly. A child's pension may be continued until the age of twenty-one, if, owing to mental or physical infirmity, the child is incapable of earning a livelihood. (c) The " unmarried widow " of deceased and his illegiti- mate children may, if the circumstances are such as to make it appear just to do so, be pensioned as above. (d) If no widow or pensionable children are left, a parent or person in the place of a parent, wholly or mainly dependent upon deceased, may receive the same pen- sion as the widow would have received, and dependent brothers and sisters are placed in the same position as children would have been. (e) If a member of the forces, who has been pensioned in any of the first 5 classes, dies, leaving a widow or " un- married widow " with whom the relationship had been established at the time of the appearance of the disability, or leaving children by such widow or " unmarried widow," his death is regarded as having been due to his pensionable disability and such widow and children are pensionable accordingly. 449 Canada also recognises that the national responsibility for the disabled soldier is best undertaken by a Central Administrative Authority controlling 1 executive agencies as required. To this end, the Canadian Government has quite recently appointed a " Minister of Civil Re-establishment " under whose control are placed all matters in this connection, including the work of the Board of Pension Commissioners for Canada, which has been the Pension Authority of the Dominion since September, 1916. Since the outbreak of war, and more markedly since the appoint- ment of that Board, great advances have been made in both the liberality and the comprehensiveness of Canadian Pension Regulations. Without attempting to particularize the changes that have taken place, the following points may be mentioned : (1) The maximum pension payable to a totally disabled man of the lowest rank has been increased from $22.00 per month for himself, $11.00 per month for his wife, and $5.00 per month for each child, to $50.00 per month for himself, $8.00 per month for his wife, and $8.00 per month for each child, and pensions of all the lower ranks, up to and including that of lieutenant, have been increased proportionally. (2) The classes in which the extent of disability is estimated have been increased in number from 4 to 20, ranging from 5 per cent, to 100 per cent., thereby ensuring that pension will be much more accurately based on actual disability than was formerly possible. (3) The allowances for a wife and children have been extended to apply proportionately to all degrees of disability. (4) The pension of the widow of a soldier or sailor of the lowest rank has been increased from $22.00 per month to $40.00 per month for herself and from $5.00 per month to $8.00 per month for each child, and pensions of widows of all lower ranks, up to and including that of lieutenant, have been increased proportionately. (5) Allowances for orphan children have been increased from $12.00 to $16.00 per month for each child. The Board is composed of three Commissioners appointed for 10 years and removable only for cause. It has exclusive jurisdiction and authority over all matters pertaining to the granting, distribution and administration of pensions. Its Head Office is in Ottawa, and it has established a British Branch at 103, Oxford Street, London. It also has District Offices in about 20 of the larger Canadian cities. Through these branches it keeps in personal touch with pensioners, each one of whom is seen or visited at least once a year. In this way 16524 P 450 it is enabled to ensure that pensions are adequate and are being properly expended. It also has power to provide medical attendance and treatment, artificial limbs and appliances, and vocational training, for pensioners, and, in general, to exercise supervision over their welfare. Payment of pensions is made monthly in advance. At the present time about 25,000 persons are receiving pensions, and it is estimated that the cost for the coming year will be about $15,000,000. 451 PROBLEMS AS TO WAR PENSIONS IN ITALY. BY AVVOCATO GIOVANNI GIURIATI, Major. I. The Legal Aspect. Introduction. Prior to the war in Libia, no special laws for war pensions existed. The wounded and disabled simply received the normal yearly pension due to every State employee, or to his dependents, consequent on injury or death encountered in or on behalf of State service.* The occasion of the service rendered was absolutely excluded as influencing the right to claim pensions even in doubtful cases. To the widow of the deceased or, in default, to his children under age, the pension conceded was equal to half of that which would have gone to the disabled man ; the same pension was assigned to the parents, orphan brothers and unmarried sisters under age solely in case the deceased had been their only support. In order that the Conference may form an idea as to what these compensations amounted to, it is enough to point out that the maximum pension assured to the soldier was 675 lire (a little under 27 at the normal rate of excha.nge) a year, while the maximum granted to the widow of a soldier killed in war was lire 202.50 (about ^8 at the normal rate of exchange) per annum. Such was the treatment accorded to our valorous combatants in the African War. But we have since then learnt much from the war in Libia. The Government appreciated the necessity of guaranteeing the future livelihood of these brave soldiers, and also of alleviating their moral sufferings by securing to them less deplorable pensions. Thus, Italian legislation decided upon Special War Pensions for the first time.f For infirmities and death encountered on the battlefield, the Law of 1912 decreed an increase of one-fifth on the ordinary special war pensions, but ordered that, as regards men serving both in the Army and Navy, the Act of 1911 was to serve as basis for the legislation in fixing, the maximum and minimum * "Testo Unico." (Collection of all the various laws.) 21st February, 1895 f Art. 1 of the Act of the 23rd June, 1912, No. 667, introduced "privileged war pensions " for officers and men of the Italian Royal Army and Navy fight- ing in the Italo-Turkish War and in all future military campaigns, fixing a maximum of lire 3,000. 16524 P 2 452 pensions. This Act fixed the maximum pension for the disabled soldier at 1,260 lire (about 50 at the normal rate of exchange), while the pensions due to the widow, to children under age, to parents over fifty years of age or to the widowed mother, to orphan brothers or unmarried sisters under age, were raised in proportion. These measures hold good, as we shall see, for a few ranks of the services , even during the present war ; for others they have been considerably ameliorated. But more recent decrees provide for more liberal treatment in the matter of pensions. Legal and Moral Aspect. The sacrifice which the State to-day demands of its citizens whom it calls to arms, the dangers and suffering, and moral and material loss, to which it exposes them, constitute a heavy burden almost beyond human strength to bear. Conditions are funda- mentally changed since the times when fighting was a trade, more or less like any other trade, which men engaged in under contract for a given term of years and a given monetary com- pensation. These were times when any allowance from the Sovereign to his superannuated or wounded soldiers might properly be regarded as an act of grace. The present titanic conflict, in which the old-world professional armies would appear as pigmy forces, fatally involves the whole strength and resources of the nations in agression or self- defence. In these circumstances, from whatever point of view the ques- tion may be considered, whether from that of individual or public right, the juridical basis of war pensions is clear. There are two aspects of the loss and injury incurred by the fighters in war. While one is beyond all possibility of material assessment or compensation, there is another, the more tangible one, for which it is the direct duty of the State to make repara- tion, as far as possible, by ensuring, in the greatest possible measure, the previous material well-being to the injured man and means of subsistence to the families of the fallen. The duty of the State in this respect is analagous to the insurance of workmen against accident. The workman, like the soldier, is exposed to some degree of necessary danger in the interest of society, which benefits by the results of his labour. Even as regards the contract of location of work, which binds the work- man to his employer, there is no essential difference between his case and the soldier's, it being clear that in point of fact he has far less choice in the matter than appears on the surface. This comparison between the risks of war and workmen's risks raises the point of the relation of cause and effect which must exist between the war and the injury giving rise to claim for compensation. Italian law in this regard was, until quite recently, unduly rigorous. Even during the war in Lybia the principle was main- 453 tained that special war pensions were due to soldiers only in cases in which wounds or disablement were occasioned " in a clearly ascertainable manner, from the fatigues, events (incidents) or dangers of service, and when same were contracted by the soldier " in consequence of the exercise of his functions." When, how- ever, the exercise of these same functions was merely incidental to the accident causing injury, as often happens in war the unfortunate man was entitled to no compensation. The interpretation of the law was not less rigorous than th^ law itself. Italian jurisprudence of that period abounds in truly painful examples of refusal of pensions in cases in which it is quite clear that war service, if not the only or main cause of injury, was at least an essential condition. A sophistical distinc- tion was made between " special incidents of service " and " service in general," and pensions were granted only in those cases when " a specific incident of service " was proved to be the only and direct cause of disablement. All this severity has by now been mitigated. The new r war has demonstrated the necessity of a radical revision of rules. The protracted discomforts of life in the trenches, the arduous daily fatigues, the suppression of nightly rest, the use of ever more powerful and cruel weapons (capable of producing injuries not always immediately developed), the maddening detonations and concussions produced by heavy shells, poison gases, microbes perfidiously diffused all these novel horrors of modern warfare are capable of causing infirmities of which it would be difficult to prove the origin. It would be iniquitous if, after having exposed our fighting men to such a combination of horrors and dangers, the State were to evade the obligation of assuring them against the consequences that might result therefrom. A first step towards more equitable legislation was made by the decree of May the 1st, 1916, No. 497, which simplified and ex- pedited enquiries arising from claims. It was established that proceedings to ascertain the dependence of disability or injuries received in the service must be conducted by the State officials ; that the approval of the Administrative Council of the regiment, required by the regulation of 1895, could be dispensed with, when no special occasion for demur or doubt existed, that in cases of death from wounds, frost-bite, infectious or skin-disease, the death certificate and declaration by a doctor should suffice. These facilitations, however, were more a matter of form than a radical reform. No proper attention was given to the ques- tion of the merits of the case until the Decree of September 2nd, 1917, No. 1385, which in its first article disposes: 'To the effects of the granting of war pensions, all wounds, injuries, and illnesses, leading to the disablement or death of soldiers on terri- tory declared to be in a state of war, when these have been received or aggravated in the course of service, are presumed to be dependent on the service." Also that : " No pensions will be allowed in cases of fraud or serious disobedience of rules, as in the cases foreseen in paragraph 2 of the Decree of the 1st May, 16524 P 3 454 1916, No. 497." This law, which clearly indicates the admir- able progress made, has moreover a double bearing : in the first place, it admits the presumption of dependence on war service, thus doing away with an enormous series of tedius exceptions, and, in the second place, it limits the onus of proof solely to cases where fraud or serious disobedience to rules are suspected. Furthermore, Article II. of the Decree of the 2nd September, 1917, disposes : " Special war pensions are granted in cases in which the death or disablement of a soldier is caused by accident while on war service, even when occurring beyond the war zone.'* In short, while (by virtue of Article I.) the mere fact of service in the war zone is sufficient to justify the required presumption of cause, Article II., which extends the right to compensation to accidents incurred even beyond the war zone, requires proof of the connection between cause and effect. Especially in view of the fact that there are many comparatively dangerous forms of service in the war zone and many very dangerous ones outside (e.g., anti-aerial defence of open towns) and also that the men in the fighting zone are presumably the better fit physically, this distinction appears not altogether justifiable and leaves room for yet broader and more equitable revision and reform. Injuries or infirmities received on war service were classified according to their gravity so as to serve as a basis in determining the amount of pension due. I shall refer briefly to this "point, seeing that it is rather a medical than a legal question. It will suffice to note that in the 1895 Regulation these dis- abilities were reduced to three categories, of which the first comprised the total incurable loss of sight and the amputation or total loss of two limbs ; the second included twenty-two infirmi- ties, which would gravely hamper without totally incapacitating the disabled man from working ; the third comprised wounds , injuries, or infirmities not included in the preceding categories, but which, nevertheless, rendered the soldier incapable of further service with the forces. These classifications were revised and improved on later (Decree of the 20th May, 1917, N. 876), when fresh categories of dis- ablement were introduced on " grounds of the degree of inability to undertake profitable work," thus implicitly admitting what was later explicitly affirmed, i.e., that pensions might be paid even to soldiers who had remained in the service or who had retained sufficient ability for a given work. On the new scale, wounds and infirmities were classified under ten categories ; but of these only the first eight entitled the dis- abled man to a life annuity.* Those composed in the ninth category can only claim a temporary allowance for a period * Under the first three categories the maximum pension is paid ; under the successive seven categories respectively in the measure of 80, 75, 70, 60, 50, 40 and 30 per cent, of the maximum amount. (See Appendix for list of maximum 455 varying from three to six years, while those comprised in the tenth are entitled to an allowance for six months only. The Decree of the 20th May has further determined the basis of classification of functional injuries, stating, among other things, that the " total and permanent loss of organs, limbs, and parts of limbs is regarded as equivalent to the actual loss of the limbs, while the permanent lessening of functional power can in no case be regarded as equivalent to such anatomical loss, and is included in one of the categories of minor disabilities." The general principle of the Civil Code, by which laws are effective solely for the future, was opportunely derogated from in the matter of pensions, in order that the most favourable pro- vision should apply retrospectively. This exception was specified in Article 4 of the Decree of the 2nd September, 1917, Number 1385, which disposes : "The Decree of the 20th May, 1917, Number 876, is applicable to cases of disablement attributable to wounds or injuries received before the said Decree came into force only when favourable to the disabled man." ' The same regulation applies to cases of disablement attributable to other causes, when the Administration or Medical Authorities, having examined them, are able to ascertain that such disablement itself is anterior to the coming into force of the Decree of the 20th May, 1917 (i.e., the 7th June, 1917)." This regulation, no doubt, suffers to some extent from the haste with which the reform had to be introduced. The decision that the new classification should apply, in the case of disabilities contracted prior to June the 7th, 1917, only when more favourable to the disabled man, implicitly admits that if the old rules happened to be more favourable in any particular case, they should hold good. It follows from this that soldiers disabled by wounds or disease after June 7#/z,, 1917, may receive " less favourable " compensa- tion than their comrades wounded before that date, and this represents an anomaly and an injustice which clearly demands, and, I have no doubt, will soon receive re-adjustment. A clause of considerable importance to the totally-disabled is contained in Article 5 of the Decree of the 20th May, 1917, No. 876, which concerns cases of disablement in which the victim " is compelled to depend on the care and assistance of others." In such cases of more serious infirmity a supplementary pension of lire 150 annually, not transferable, is conceded to the disabled man ; this may be doubled in the event of the soldier losing all four limbs, or when several reasons of grave disability are co- existent. This pension can be revoked when the disabled man is provided with assistance from public institutions, or when he refuses to be housed in one of the aforesaid institutions. 16524 P 4 456 Having glanced at Italian legislation referring to direct pen- sdons, let .us now briefly examine the question of indirect or transferable ones. The surviving families of soldiers killed in the war are entitled to a pension equal to half of that which the man himself would have received. The following relatives of soldiers killed in war are entitled (under the law of the 21st February, 1895) to pensions : (1) the widow ; (2) the orphans ; (3) the father ; (4) the mother ; (5) brothers and sisters. Reversion of the claim from the widow to the orphans, and from the father to the mother of the deceased soldier was, moreover, allowed in cases in which for some clearly denned reason the parties mentioned had forfeited their claim. t In the course of the present war gaps and incongruities became evident which it was necessary to obviate. The measures of reforms introduced by the scheme of May the 24th, 1915, are numerous and important. First of all, consent was given for soldiers to marry by proxy (Decree 24th June, 1915, No. 913), thus enabling them to pro- vide, with full efficacy also for the recognition of illegitimate children (Decree 14th October, 1915). In this manner, the recognised illegitimate children of soldiers were admitted to the enjoyment of pensions (Decree 12th November, 1916, No. 1598), and altogether more liberal and simple rules were enacted in this respect. The mother of the illegitimate child who had been legally recognised as such, was also recognised as being entitled to a pension. The same right was conceded even to the mothers of soldiers when abandoned by their husbands and, lastly, to soldiers' mothers whose hus- bands were serving a term of imprisonment (Decree 12th November, 1916, No. 1598). Some provision was thus made for the support of members of the deceased soldier 's family who would otherwise, under the rigorous laws relating to the " next-of-kin " (ordine di vocazione), have been excluded from all benefit. Thus the deceased's parents were, under certain clearly-specified circumstances, entitled to take action for maintenance against the pensioned widow r , or, in cases in which only the illegitimate children of deceased had prior claim, to demand a certain proportion of the actual pension, while the abandoned mother or children of deceased could claim a part of the pension otherwise due entirely to the father ; and , finally, the principle of reversion of a pension from parents to children of deceased was established. In the case of a pension due to the father (aged over fifty), or blind, to the widowed mother, or orphan minor brothers, or unmarried sisters of deceased, Article 123 of the Law of the 21st February, 1895, made it a condition that deceased should have been their " sole support," while the Decree of the 12th 457 November, 1916, mitigated this condition with the words " necessary and sole support." The parents of the deceased soldier are entitled, under the same law, to claim maintenance from the pensioned widow. The present Minister of Pensions, Signor Bissolati, is now actively and earnestly engaged in correcting the imperfections of these laws. In the matter of direct pensions, the Minister has proposed the following reforms : (1) With regard to the circumstances of the injury causing disablement, that : (a) " Wounds, injuries, or maladies, contracted under what- soever circumstances of time or place, either actually incurred or aggravated while the soldier was on terri- tory declared to be in a state of war, shall be presumed to depend on the service. (Article I.) (b) " The privileged war pension concerns those whose dis- ablement, or death in the service, has been caused by wounds received or aggravated in the course of war service, even when occurring outside the war zone." (Article II.) Signor Bissolati further proposes : (2) To extend the right to pension to soldiers who have received wounds, injuries, or infirmities during the period of captivity, and to the families of soldiers who have died in the enemy's prisons. (This reform would fill up a grave and inexplicable gap in our legislation) ; (3) To concede to the totally disabled a supplementary allow- ance of lire 100 a year in respect of each legitimate, legitimised, or legally recognised natural child under 21 years of age (pro- vided they are unmarried, in the case of girls) who are born or conceived before the date of the granting of the pension ; (4) To extend to the first three categories of disablement the possibility of obtaining the personal, non-transferable, allowance only assigned to the first category in Article 5 of the Decree of May 20, 1917, for those totally disabled who are dependent on the care of other people. (5) To regulate in the most equitable manner the assignment of temporary pensions conceded by Article 8 of the Decree of the 20th May, 1917, in cases in which the military medical authori- ties cannot pronounce definitely on the degree of the gravity of the infirmity. As regards indirect pensions, the changes proposed by Signor Bissolati strike deeper and are more far-reaching ; they can be summed up as follows : 458 I. The recognition of the claim to pension (to the extent of one-third of the maximum) on the part of indigent parents of deceased soldiers, notwithstanding pensions already paid to the widow or children ; the concession of pensions to ascendant and collateral relatives who were not in the indigent condition required by the law at the time of the soldier's death, but only became so afterwards ; extension of the right to the grandfather and grandmother in default of others having a prior claim ; a more liberal estimate of the definition of the condition of " indigence " for the purpose of such claims. II. Eecognition of the principle that, in the case of the death of one of the parents, the surviving parent should be entitled to receive the entire pension. This to apply also in the case of the death of one of the brothers or sisters or one of the grandparent?. III. The concession to parents who have lost several sons in the war of a supplementary allowance in respect of each subse- quent son who has fallen in battle after the first. IV. Eecognition of the claim to receive pension, not only of the unmarried mother but also of the natural father and the natural children. V. A more correct and more humane estimation of certain family ties.* VI. That parental authorisation should no longer be regarded as an essential condition to matrimony for the purposes of the law on pensions. This reform would hold good in the case of all matters affecting the legal rights or standing of the widow. Indeed, with striking and praiseworthy audacity, the proposed scheme would consider as legally binding even the declaration verbally expressed by a soldier in danger of death. VII. An increase of widows' pensions in respect of children under age to the extent of lire 150 for each child ; an increase, in equal measure, of the orphans' pensions, when there are more than two, even if there be no widow. VIII. In respect of pensions granted to disabled soldiers and transferable to the widow and children in recognition of the latters' claim in the case of marriages contracted within two years from the date of the granting of the pension, provided the marriage lasted for not less than five years. * The projected law provides that : The mother of a soldier killed in war who, in consequence of the son's death, is left destitute of adequate means of sub- sistence shall be admitted to the enjoyment of a war pension, even though unmarried, in cases where, from a cause not imputable to her, she is not living with the man at the time of the son's death. The mother, in such cases, still has a claim to half the pension, even in cases when the man, from whom she is living apart (being the natural father of the deceased soldier), is in a position to establish his right to receive a pension. 459 All comment appears to me unnecessary regarding the above proposals which are characterised by a bold spirit of innovation and liberality beyond all praise. The Problem considered under its Political and Social Aspects. The financial burden that will have to be borne by the State with regard to war pensions, independent of contributing insti- tutions, of which we shall speak further on, will be very heavy. On the 31st March, 1918, the number of privileged war pen- sions inscribed in the National Life Annnuity Debt amounted to 125,724 for a total yearly sum of Lit. 89.588.923,19. But, taking arrears into account, the burden of these pensions already amounts to Lit. 137.067.259 for the current fiscal year. The anticipated amount of the Army budget, closing 30th June, 1918, is two hundred million It. lire. If, however, we consider the large number of pensions that are awaiting inquiry (on the 31st March they were 79,527), the number of disabled men whose treatment is as yet uncompleted, and of the missing soldiers whose fate will probably remain unknow r n until the end of the war, and bear in mind also the legislative reforms at pre- sent pending, it is no exaggeration to foresee that the total debt will in the end be over half a billion solely for the pensions under the Ministry of Pensions. This is without calculating the heavier burden that will be placed on our country if the war be prolonged. When one remembers that this last figure represents about one-fifth of the total amount of the budget, as quoted prior to the campaign, one certainly cannot accuse the Italian Govern- ment of not having faced with great energy and generosity the problem which is herewith submitted to the investigations of the Conference. The responsibility of the Government and of Society does not end with the payment of pensions. We must allude, however briefly, to the measures that have been taken in addition to the payment of pensions, otherwise the description of these efforts and achievements of a social and political nature would be incomplete. (a) Pensions represent merely an insurance, a guarantee of the minimum necessary to support life. But the whole life of the disabled men must be taken into account, and, seeing that work, apart from all monetary considerations appertaining to it, is per se a fundamental necessity of our being, it is essential to teach our disabled men that there is practically no form of dis- ablement which excludes all possibility of useful occupation, and to console them with the knowledge that they possess much latent and valuable energy. Thus only can these martyrs of war be reconciled to their destiny. 460 In Italy this noble work is undertaken by the National Institu- tion for the Assistance of the Disabled in War and a large number of private organisations.* Those measures by which the State ensures remunerative work to the disabled are to be regarded as auxiliary to pensions. Our Treasury recently inaugurated a competition for certain Government posts, reserving for the disabled men the same number of posts as for civilians. Other public administrations have adopted the same system which, we hope, will before long become general. Moreover, by degrees, as vacancies occur the State reserves for disabled men or for the families of those who have fallen in battle, the retail sale of State monopolies (such as salt, tobacco, &c.), and lottery-receiving offices, which in certain districts are very profitable concerns. Equally important measures have been taken for the care of war orphans whose protection the State took over under the Act of the 18th July, 1917, No. 1143. This beneficent law extends assistance not only to the minor (or deficient) orphans, legitimate or recognised illegitimate who have lost either father or mother in consequence of the state of war, but also, under certain definite circumstances, to the un- acknowledged illegitimate children. It also extends the benefit to the children of those disabled in war who were conceived prior to the date of the injury which produced the disablement of the father. Such State protection is exercised through the medium of a National Committee and of Provincial Committees, whose functions are mainly economic, while a specially appointed magistrate, with full powers in the matter, acts as legal guardian and trustee to the orphans. * The most important of these are the following : Ancona. Marchigiano Committee for the Disabled. Bologna. Society for the Aid of the Crippled and Disabled in War, piazz Galvani, 1. Rome. Italian Red Cross, 149, via Nazionale. Florence. Committee for the After-Care of the Disabled, piazza della Signoria. Genoa. Ligurian Committee for the After- Care of the Crippled, Disabled and Blind in War, via Garibaldi, palazzo Municipale. Milan. Lombardy Committee for the Disabled in War, via S. Margherita, 24. Naples. Neapolitan Committee for the Disabled in War, via Chiatamone, 55. Palermo. Sicilian Committee on behalf of the Disabled and Blinded in War, villa Belmonte. Rome. Society for the After-Care of Blind and Disabled Soldiers, piazza Cavour, 3. Turin Piedmontese Provincial Committee for After-Care of Workers Disabled in War, via Monte di Pieta, 32. Florence. Union of Munition Committees pro Mutilati, piazza della Signoria, 8. 461 Among the most important committees whose valuable efforts are auxiliary to those of the State, on behalf of the orphans, I should mention the following : The first, in point of date as also the foremost, is the National Society for the care of the Orphans of Peasants fallen in war and for the Children of Permanently Disabled Peasants (legally recognised since August, 1916). This Society is under the presidency of Signer Luigi Luzzatti. Another important society is the National Society for the Civil and Keligious Care of War Orphans (legally recognised, 9th November, 1916). This Society carries on its work through the medium of local sub-committees arid is presided over by Prince L. Boncompagno. Its aim is specially to assist orphans belonging to the working classes arid to the lower middle classes in town and country. Other initiatives worthy of note for the assistance to war orphans are the National Confederation on behalf of War Orphans, with head-quarters in Milan, via Monforte 26, presided over by Senator Conti, and the War Orphans' Industrial Foundation, recently constituted for collecting the contributions of manufacturers and for helping the various national Aid Societies that already exist and have been organised in this country. This Institution at present has a capital of nine million lire, and by the end of the year this will reach fifteen millions. Finally, there are numerous other institutions for the purpose of assisting the families of disabled and fallen soldiers. But these are less important organisations due to private initiative and sometimes of a religious or political character; for this reason, I consider it wiser not to speak of them at great length before this Conference. The Problem considered under its Working Aspect. 1. If there is a subject of which the form of organisation is of substantial importance, it is precisely that of war pensions. With a very few exceptional cases the war represents a power- ful cause of economical loss to the men now engaged in fighting. Professional men have had to abandon their clients ; farmers can no longer devote their personal labour to their farms, which is the one way of making the latter remunerative ; artisans and commercial men have had to close their workshops and shops ; in fact, the arrest of individual earnings or its reduction nearly with everyone. Thus it is that wounded soldiers, on being dis- charged from the hospitals, badly need the allowances that are theirs, so as to re-arrange their affairs and to provide for their own and for their families' urgent necessities. Every delay means further hardship and sometimes serious loss. To give promptly may, therefore, often be quite as important as to give enough. " La forme emporte le fond." 462 Unfortunately, the legislative precedents were far from being either adequate or helpful in this matter. The formalities of the Medical Boards were, and, in part, are still disastrously slow and long-winded. The Italian Health Bureaucracy is a slow and heavy machine, founded on a tiresome system of manifold controls each of which demands delays, experiments, transmissions of documents, documents that cannot always be to hand, given the vicissitudes of war. Wounded soldiers, before beginning the proceedings for obtaining their discharge with pension, have to go through numerous examina- tions held by Commissions, each of which means journeys, orders and delays. When the advisability of granting the discharge with pension. is finally admitted (which often occurs, as in my case, more than two years after the applicant has been wounded), the Medical Board, the Health Director of the Army Corps, and the Health Inspection Bureau must all three give their adhesion to the proposal. Only at this stage of the proceedings are the payments of the pension begun. These proceedings, prior to the constitution of the Ministry of Pensions, were similar to those for the usual civil and military pensions, and were principally based on the Royal Decree of October 5th, 1862, N. 884, on the jurisdiction and debatable procedure of the Audit Court (Cour des Comptes) of the Kingdom of Italy, modified by the Royal Decree of May 127i, 1864, N. 1777, and by Art. 116 and the following in the Regulations of September 5th, 1895. It was a question of a regular written examination, during which the petitioner as well as the Counsel from the Crown were entitled to presenting statements and final decisions in support of their case. Once the examination was concluded, the scheme of payment was made out by the Treasury Auditor, and an official to draw up a report was appointed by the President. The deeds were then transmitted to the Attorney-General for his written decisions, but both parties could (Article 119 of Kegula- tions, September 5th, 1895) " present or have presented to the Court statements or other deeds in support of their petition." All these documents had also to be communicated to the Attorney- General. Finally, on the date previously chosen by the President, after listening to the report presented by the Delegate Councillor, the decision of the Court was given out in Council. 2. It became evident that all these lengthy proceedings ought to be curtailed, for the very slight economy deriving from them could never compensate for the harm that was caused by such endless delays. The Decree of August 5th, 1917, N. 1266, was a first step towards this- reform. According to Article 2 of this Decree, pensions to widows and orphans of soldiers killed in war were to be granted without the intervention and final decisions of the Attorney-General, with the exception of his right to appeal to the United Sections of the Court, within a period of ninety days 463 dating from the date of the announcement to the interested party. But an organic reform was only obtained by the constitution of the Ministry of Military Assistance and War Pensions. This Ministry has been constituted for the duration of the War and for one year after the proclamation of Peace, as per Decree of November 1st, 1917, N. 1812, and its attributions were determined by the Decree of December 6th, 1917, N. 2067. According to Article I. of this second Decree the new Ministry provides for the parliamentary enquiry, for the actual granting of war pensions, and for the advancing of stated amounts ; and in Article II. it is said that : With regard to war pension : The Minister exercises all the attributes of the Audit Office and of the Attorney-General with the exception of appeals, as referred to in the following Article III., and of the control of the Court itself with respect to the regulating of payments to be made in execution of the grants made by the Minister. To this end the Minister is assisted by a committee connected with the Ministry, and having as chairman the Divisional Presi- dent of the Audit Office, and composed as follows : (a) Four councillors and four referendaries of the Audit Court. (b) Two medical officers of high rank belonging one to the Military Board of Health, the other to the Naval Board of Health. (c) A Councillor of the Court of Appeal and a Deputy Attorney-General of equal rank. (d) Two committee-me,n appointed by the Minister. The members of this committee shall be appointed by Koyal Decrees, with the approval of the Council of Ministers. Article III. determines the right of the interested parties to appeal to the Audit Office against the Minister's decisions with regard to payments. It is hardly necessary to observe that these regulations simplify the proceedings to an enormous extent. It does away with the cross-examination before the Court, the final decisions of the Attorney-General and finally with the latter V power of appealing to the united divisions of the Court. The only appeal admitted is the one presented by the petitioner. In addition to this modification there is the further advantage of a group of officials having been appointed for the payment of war pensions, and a special committee for winding up; it will thus be readily understood how, by means of the institution of the Ministry of Pensions, the problem of obtaining rapidity of the proceedings has approached its practical solution. 464 A few figures will serve as proof of the above : The Ministry of Pensions was created on November 1st, 1917, but did not actually 'start working in a practical way before March 1st, 1918. From November 1st, 1917, to February 28th, 1918, 23,203 pensions were granted. These grants, for the reasons stated above, were still effected by the Audit Office, at a monthly average of 5,800. However, during March, 1918 that is, during the first month of this Ministry's practical exist- ence no fewer than 15,191 pensions were dealt with and granted by the Ministry itself. If one considers besides that this new organisation was con- fronted by the numerous legislative reforms, already mentioned in the first part of this report (and any legislative reform invari- ably causes interruption in office routine, owing to the need of according it a correct interpretation as well as an equitable appli- cation both matters that require a certain amount of time), and that, the work being of an entirely new description, it was some time before a number of the Ministerial employees and officials got familiarised with it, we must admit that the figures just quoted give us the brightest of outlook, and that they fully justify the warm words of praise and approval which the new Minister, the Hon. Bissolati, addressed to his collaborators quite recently. 3. The work of this Ministry is so very heavy, however, that it would not be possible for the Head Office to handle all the cases on the rolls alone. For this reason, the Hon. Bissolati thought to remedy the matter by opening several branches in the pro- vinces, where the pensions are dealt with locally (see Circular Letter No. 9, December llth, 1917). These branches have the following programme, as indicated in the instructions issued to them by the Minister : 1. To compile and complete the action taken by the Local Municipalities, by getting together all the detailed information with regard to the applications for pensions. 2. To keep the interested parties informed as to the actual developments of the inquiries instituted with regard to their applications, at the Ministry. 3. To provide all legal and medical assistance considered necessary, for the purpose either of vouching for the applications in the regular manner, of appeals against negative decisions, or against decisions granting insufficient sums. Under each of these three headings, but more especially the first and third, the Minister has given numerous and detailed instructions. According to these, the Provincial Offices must not only provide all the necessary documents that are to accom- pany the applications for pensions, but they must also supply all the information that was previously obtained, with a consequent great loss of time, from financial institutions, from the military and from the civil police officers. 465 At a later date (Circular Letter No. 21, llth February, 1918) the Minister drew up a regular schedule for these Provincial Offices, stating their organisation, aim, attributes, composition and mode of procedure in detail. Their aims were stated to be the following : (a) To hasten and to co-ordinate all action taken by Local Municipalities, by completing the documentary evidence connected with the applications for pensions. (b) To impart to the interested parties all information re- garding the actual development of the inquiries that have been instituted at the Ministry of Pensions with reference to their applications. .OO oooooo CN o to THOOOOCOCOCO i-i CM T-" r^ Oi 05 CS '^CCOOCOiOOOi-i OOOUT5OOO OOOOOOO CO ' O5 'i iCOCOt^COOOOrH CO CO lO I>- OS O CO CO CO CO 1-1 C>- "* 000000 oooooooo o > o > o <>j c o > o > o o o o co* *$* 01* c^oicioi co'oioooooo O -^ O: Oi i i 1-1 'OOi^OOOOO SO CO O to CO O OOOOOOO OCOOtOCOO OOOOOOO 2 2* SI S SS S3 3! I 2 S S S 9 S S : & 24 f^i to O* ^^ <^> f^ O> ( O < O "^ to O CT^ O* OOO ^^ 1 "O ( O C^C^lOOO |OC O i-I t> CO O5 O5 iO lo'oOOO C^IO 'tO-^tOOO i-HiO t^Oli (OC^ ill! 472 PUj-L DOOOOOO i-Ht-OOOOO OiGOiO^C^OO CN 3-COGO -^ co i QO co r> n CO ^ ^T O CO GO GO GO 8 8 p r of both ; (b) of one forefinger, accompanied or not by the loss t of one of the last three fingers of the other hand ; (c) of the last two phalanxes of one forefinger and of two other fingers of either hand (not including those of thumbs and other fore- finger) ; or of those of the last three fingers of one hand, or of four between the two hands; (d) of the last two phalanxes of both forefingers; (e) of the ungual phalanx of both thumbs; (/) of the ungual phalanx of one thumb, together with that of another finger; (g) of the ungual phalanx of 5-6 fingers of either hand (thumbs excluded) or even of 4 fingers if a fore- finger is included. Loss of a great toe and corresponding metarsus. Total loss : (a) of 2-3 toes, including one great toe, or of 4 toes, excepting the great toes; (b) of both great toes, or of these and of the ungual phalanxes of 1-2 toes; (c) of one great toe 4T8 or of the lingual phalanxes of 3-4 other toes; (d) of the lingual phalanxes of 7-8 toes, great toes excepted. Obstinate nevrosis, but not of such a serious character as to be placed on same level as the infirmities set forth in the preced- ing categories. X. Stenosis due to scars of the external ear channel or injuries of the ala of the ear, involving a notable disfigurement. Total loss: (a) of a little finger; (5) of the last two phalanxes of two fingers, excluding those of thumbs and forefingers ; (c) of the ungual phalanx of one of the thumbs ; (d) of the ungual phalanxes of both forefingers or of 4 fingers (thumbs and fore- fingers excluded), or of 2 fingers if a forefinger is included. Total loss : (a) of 2-3 toes between the two feet, great toes excluded ; (6) of one great toe, or of the ungual phalanx of both great toes, whether accompanied or not by the loss of the ungual phalanx of 1-2 toes ; (c) of a great toe or of its ungual phalanx, together with that of 4-5 other toes ; (d) of the ungual phalanx of" 5-6 toes, not including the great toes. 4T9 COMPULSORY TREATMENT. BY DR. A. BASSETTA. The existing laws in Italy relating to accidents to workmen are all to be found in the paragraph No. 51 of the Decree, dated 31st January, 1904, and in the Regulations for its execution, approved by Decree, dated 13th March, 1904, No. 141. In no article, either in the Law or in the Regulations, is any mention made of compulsion for the injured person to undergo that surgical treatment which might diminish or cure his infirmity. The Article 103 of the Regulations compels the workman only to comply with the visits of control in cross- examination between the curing physician and the fiduciary physician of the Insurance Institute or Medical Panel instructed by the Insurance Institute with the object to ascertain the cause of the accident. However, there are symptoms of an incipient evolution tending to remove the rigidity of the principle of recognising in the individual the unconditional right to dispose of his own bodily safety, which is proved by recent legislation, as also by various judgments pronounced by tribunals, that in determined circumstances of fact it has been considered logical and existing the obligation of undergoing that treatment pointed out as necessary for the cure of the invalid. In these cases, however, the opinions differ when it is a question of appraising the amount of the indemnity to be awarded the invalid ; some opine that the compensation should be commensurate with the damage suffered by the accident independently of any treatment ; others, that it should be commensurate with the importance of the invalidism persisting after the treatment, whether it be improved or aggravated by the effect of the treatment. Others do not recognise and do not compensate the damage and neither the death that may have occurred as result of the operation freely chosen by the invalid, such damage or such death being a fact not directly secondary to the industrial accident because it has with same no relation of causality. For such reasons the idea of the non-obligation to undergo surgical treatment, at present upheld by the laws governing civil accidents, is not only dis- cussed in its essence, and here and there contradicted by the judgments of competent tribunals but attacked in its application which may cause as consequence a diminution in appraising the compensation. Another notable action tending to destroy this principle of non-obligation to undergo surgical treatment results from the provision in the Decree, dated 25th May, 1913, No. 668, which approves the Regulations governing workmen's accident insur- ance in the Tripolitania and in the Cirenaica. In fact, one reads in Article 24 that: " Among the treatments foreseen in 480 the present law are not comprised surgical operations except minor operations." An identical clause is found in the Bill for Compulsory Insur- ance Against Accidents in Agricultural Labour, which was passed into law by the Decree, dated 23rd August, 1917, No. 1450. Further, it is opportune to remember that in 1914 the Republic of San Marino approved, in the sittings of the 23rd May and 18th July of its Grand and General Councils, the law relating to workmen's accidents in which a comma in Article 19 is thus formulated: " If a workman . . . refuses to submit to an adequate treatment or even to a trifling operation which does not reasonably import preoccupation for his life the Insurance Institute may refuse payment of any compensation." In any case, it is a fact that for workmen's accidents is still in force, without modification, the law dated 31st January, 1904, which does not oblige the workman to submit to surgical treat- ment to improve or cure his infirmity. A slight restriction, however, is made in the case of minor operations, for which is admitted the compulsion in the law relating to workmen's acci- dents in the Tripolitania and in the Cirenaica, and in the law on the insurance against agricultural accidents. Similar laws are in force in the Republic of San Marino for the minor operations which do not import reasonable preoccupa- tion for the life of the invalid. In *the Italian Army Medical Corps the regulations which govern the conduct of the soldier in face of the proposal for surgical treatment do not admit the compulsion to the treatment. The regulations are based on the Art. IX., 323 of the Regula- tions relating to the Recruiting of Conscripts dated 2nd July r 1890, which provides that no conscript may be subjected to a serious operation with the object of rendering him fit for military service without he himself consents to such operation. The Inspectorship of the Army Medical Corps extended the provision of this article to those wounded in war, stating, " Regarding refusal on the part of the injured soldier to submit to a surgical operation, this Inspectorship has already expressed its opinion, that it is contrary to any operative intervention if same is refused by the injured soldier, which opinion is moreover supported by 323 of the Regulations relating to the Recruiting of Conscripts.* as also by the law and the regulations on workmen's accidents." The Decree dated 1st May, 1916, establishes the lules for the payment of war pensions to soldiers who refuse treatment in these terms " When according to the opinion of the Medical College of the Army Medical Corps Administration and of the Army Medical Corps Inspectorship it results that the cure of the soldier depends uniquely on the non-execution of the treatment, no payment of pension will be made. If. however, the authorities of the Army Medical Corps hold the opinion that the proposed treatments impede only an improvement, the person will be paid only for the lower category to that which the infirmity is judged ascribable, provided, however, that the soldier is unable to continue or to reassume later on service." 481 For this reason, owing to the present regulations which are in force in the Army Medical Corps, the physician cannot avail himself in any way of his persuasive action, or of his authority, to impose a treatment, because a soldier who refuses treatment, exercises his right, a right that cannot be contested by the physician when the invalid exercises it in the manner prescribed by the law, and he submits to the pecuniary consequences mentioned. It is, however, evident that whilst on one part the military law recognises and admits the right of the wounded soldier to refuse a medico-surgical treatment, it exercises in reality a coercion, inasmuch as it limits this right of refusal to the treatment with the suppression or reduction of the war pension. This constitutes a grave social error and creates a harmful disparity in the effects of the application of the law, because whilst the well-off can easily renounce all or a part of the war pension, maintaining whole their invalidism, the poor person, the workman who lives by his labour, is unable without grave detriment to consent to this renunciation, and whatever he may do he will always be damaged : damaged if he submits to the treatment, because he will either recover and will once more be exposed to all those risks from which the infirmity had spared him, or will improve and lose the advantage of the pension ; or will get worse, and the increased pension will never compensate him for the aggravation of his invalidism; damaged further if he refuses the treatment because in addition to losing the opportunity of being cured or at least of improving his invalidism, he loses entirely or in part the rights to his pension. In addition he is lost to the nation as a soldier arid as a workman ; neither can he defend it at the Front, neither can he contribute to the industrial and commercial -revival which will commence immediately after the cessation of the present hostilities; a new war, not bloody, it is true, but none the less fierce, for the conquest of the world's markets, for the commercial expansion, for the consolidation of the national fortune. Under present conditions the refusal of the injured soldier to undergo the treatment is due in greater part to the complete deficiency of his psychological and moral preparation for the period after the war. The invalid does not take into considera- tion that he has not finished, with the completion of the medico- surgical treatment which free him from the obligation of military service, all his painful odyssey, and that another will commence as soon as he becomes again a citizen, and more black, more painful, more solitary, if his private means or remaining capacity for work will not be such as to permit him of augmenting some- what to the limited resources provided by his war pension. He confides too blindly in the future, calculating more on his neigh- bour than on himself, more on the work of others than of his own work. It is necessary to remove these too dangerous illusions, to give him a vivid image of his moral, economical and social conditions 16324 Q 482 as they will be after the war, a time not so far ahead, and it is certain that the war invalid who refuses that intervention which might improve or cure his infirmity may still be redeemed of his error, treating him like a man and a citizen. A last attempt to redeem an invalid who refuses the treatment might be made in this manner : When the invalid has irrevocably stated his refusal to underg v o the treatment and has been proposed for consideration of the War Pension Appraising Board, he should be discharged definitely and irrevocably without liability to revision, even if the nature of his invalidism might give hopes that with appro- priate intervention a cure might ultimately be effected. The right to the war pension should be appraised by law according to the nature and degree of invalidism, and the injured soldier should be assured that the amount of his pension cannot be reduced whatever improvement may be found in his condition, either by effect of the diminished invalidism as a consequence of opportune treatment or by the effect, of vocational re-education. The payment of the pension should, however, be conditional, .and in like manner as the law obliges injured soldiers capable of being re-educated to attend the school of re-education, with very few exceptions, which have to be approved in every case by the superior authorities, it should be made compulsory for the injured soldier refusing the treatment, and now free from the pre- occupation of military service to pass over to a place of concentra- tion, specially created for the purpose, in which the indisputable ability of the medical officers, their moral and persuasive force, the favourable example of companions more pliant and more judicious, may cause him to alter his decision and to accept that intervention which he had up to then refused. The injured soldier, if after this trial he still refuses to undergo the intervention of the surgical operation, should be dismissed and would then come under the regulation of the Decree of 1916, cited above. On the other hand, the injured soldier who accepts the intervention, would maintain his right to the pension to the full amount allotted him by the Appraising Board, what- ever may be the betterment that results from the intervention to which he submits, and acquires the right to a relative increase of pension if the result of the intervention aggravates the con- ditions of his invalidism. The irreducibleness of this pension, even if the coefficient of the invalidism diminishes, should constitute a premium of encouragement to the goodwill of the injured soldier and should be the clearest demonstration that the insistent exhortations which from all sides are made to him, that .he allows himself to be treated, have not for their motive the paltry speculation on the reduction of the military pension, as, unfortunately, the injured soldier is all too often prone to believe, but have their reasons in motives much more elevated, more nobler and more powerful, and, namely, in the indispensable coalition of all the 483 forces of the Nation for its social, industrial and economic libera- tion after the war. The eventual burden to the State would be largely compensated by the economic advantages to the Nation if only half of the invalids, who are now effectively lost to it as soldiers and as workmen, might regain, at least in part, their energy for labour, their aptitudes for a trade, and in addition return with the oppor- tune vocational re-education important elements in the emula- tion of work and in the National production. On the other hand, the prudence and the long experience of the medical staff would easily succeed in discovering all attempt at fraud, promptly eliminating every case in which there is suspicion that the first refusal to the treatment was based on an ignoble speculation on that invalidism contracted combatting in the sacred name of our Mother Land. 484 FUNCTIONAL EXERCISING OF MUTILATED LOWER LIMBS. By Dr. A. BASSETTA. The technique of the surgical ait in the performance of an amputation, provided that the hand of the surgeon is not forced by contrary elements, certainly constitutes the essential factor on which depends the success of the operation, but when the operator has to work under difficulties, when the urgency of the case imposes a hasty intervention in adverse circumstances, without means of assistance, and when the general condition of the patient and the local conditions allow but a limited choice of methods, the probability of the crippled soldier having later on, after complete surgical treatment, a stump having the best possible functional and operative efficiency, diminishes rapidly in marked proportion. , Those who in times of war previous to the present have occupied themselves, or those who are occupying themselves at the present time in this special chapter .of war surgery know how often the more or less happy result of an amputated stump, and sometimes its complete anatomical and functional deficiency, may depend on a trifling detail of technique which at the time of the inter- vention, and in face of greater exigencies, appeared of secondary importance which could be neglected without danger of ulterior damage. More or less efficacious arrest of bleeding, sutures of the deep parts and of the superficial parts of the stump, which at times should be tight and close together and at other times loose and far apart, the interposition or no of a draining tube, the thorough- ness of the immediate medication, the care in the confection of the bandage, the posture assumed in bed, etc., are all so many rocks on which the technique of the amputation may come to grief. Between the complete closing up of all the planes of the stump which aim at obtaining cure by prisnam, and the cure by second intention of a stump left completely open and stopped, there exists quite a series of intermediate methods (tubular diainage of the deep parts, points of support of the muscular mass, points of approach of the skin) in each of which the surgeon may put into practice a deal of observation and opportune means that his experience has taught him for securely obtaining a stump capable of moving in its nearest articulation, rich in soft morbid parts and not adherent to the bone, not sensitive to pain, not infilteied, with cicatrised line away from the part sustaining the load ; in a word, a stump to which can be applied in the shortest time possible a good prothesis apparatus. 485- Amongst the auxiliary means adopted for the immediate and successive treatment of stumps, one of the most widely adopted is certainly that of the continual traction by weights ; but of the many variations of the method which we read in the surgical literature, I do not remember to have yet seen that which was applied in our Department for War Cripples, and which has always met with success insomuch as to induce us to extend its use as far as possible. Like all the modifications to a technique of very vast application it is employed with advantage only in certain cases which answer to special requisites ; but as these cases are all other than rare I believe it well to describe them rapidly in the hope that it may be useful to those of my colleagues who may wish to experiment. In our department arrive not rarely persons with amputated thighs who, either by force of necessity under which the ampu- tation was executed, or owing to the setting in of successive phlogistic and septic processes, or by the diverse coefficient of retraction of the soft parts which surround the. remaining bone, have gravely defective stumps. Sometimes it is a case of a true conoidal stump, at other times a case of cicatrice in the terminal plate, largely adherent, hard, fragile and absolutely intolerant of even the slightest strain of friction or of traction, or of wide saws and abundant secretion, real growths of granulations of a serious nature, for the greater part to be cured only by the most attentive care over a long period and with local results quite unadapted to the application of the prothesis. In these cases the surgical intervention imposes perhaps nothing else than to re-establish the tension equilibrium of the soft parts which have retracted on the rigid parts of the skeleton. But the operative intervention, however correct and perfect it may be, does not guarantee against the return of the conoidic state of the stump if the soft parts that surround it be left aban- doned to the effect of their spontaneous retraction ; and if they are not continually drawn in peripheric direction, either by con- trasting to their elastic coefficient, or by contrasting to the tendency often unrestrainable on the part of the invalid suffering from amputated thigh to put his stump in flexion. It is indeed known that the position in flexion of the hip is not rarely the greater cause of the conical shape of the stump in this segment of the limb, not only by reason of the passive falling of the soft parts towards the roots of the leg, but also by reason of the pre- ponderent function of the erect muscle at the front of the leg, which, deprived of its peripheric attachments owing to the absence of the knee, can no longer put itself in tension when its shortening by contraction has occurred. The continual traction by weights on the soft parts of the mutilated limb is certainly in this case an inestimable advantage. But even with only small experience of war cripples and of their psychology, one will easily recognise that the application of the classical permanent traction by weights encounters some diffi- culties. Often the patient has had a long experience of this method of treatment with but small favourable result, for which 16524 Q 3 486 reason he is not too well disposed to accept or absolutely refuses- a fresh intervention if the lying in bed has to be prolonged or aggravated by the tedium of the continual traction; often it is advisable to attenuate to the patient the importance of the inter- vention which he should still undergo, promising him that in a few days he will be able to leave his bed; often again, as has frequently occurred in my case, it is the case of a worthy crippled soldier, willing and active, who has already progressed in his- vocational re-education. In fact, we have had the occasion of commencing the ambu- latory traction of the stump in the School Department, thus obtaining that the treatment did not interrupt, except for a few days, the attendance of the classes. The technique of the ambulatory traction is very simple ; it may be applied in a very early stage, as soon as is exhausted all local reaction successive to the intervention, whether it is- tlie case of a real amputation or an adjustment of the stump or a simple liberation of a segment of a mutilated limb. A strip of good adhesive plaster is supplied circularly to the roots of the limb, first by a w r hole turn which grips the skin,, and by a second turn which covers half-way the first. Between the two turns one engages the four ends of two other strips of plaster, arranged in form of loop in the axial direction of the stump, and in manner that, crossing one another perpendicularly, the one comes to lie in the sagittal plane and the other in the front plane of the limb. Their ends thus meet near the roots of the thigh, at the extremes of two diameters of the limb, perpendicular between them, and lying approximately the one in the front plane and the other in the sagittal plane of the stump. The strips are long enough that their point of union is about four inches below the free end of the stump, and upon it, fastening by a strip of plaster, is adapted a thin circular board having a hole in its centre and a little notched on the circumference in that part corresponding to the four strips. In this way a small plate is obtained upon which is placed a lead disc gradually increasing in weight. The free space between the extremity of the stump and the weight is amply sufficient for allowing easy control of the stump as also for the necessary medications. The medication gauze is fastened securely by a crossed strip of soft gauze which passes in the spaces left free by the strips of plaster, and is fixed with a soft bandage on to the stump end of the pelvis. The patient can freely walk about with crutches, not feeling any incon- venience from the weights contained in the space of the trousers which are tucked up under it; learns easily to sit down, leaving his stump stretched out and, therefore, always subjected to the traction. When the patient returns to bed, the lead disc is removed and the ambulatory traction is transformed with facility into common traction by simply fastening the traction cord through the hole in the centre of the wood plate. 487 In the wide application which we have made in our Depart- ment for War Cripples of the Ambulatory Traction on the stumps of thighs, not only have we never encountered any case of intolerance, but, on the contrary, we have always found that it is easily tolerated. The ambulatory traction conquers the elastic inflammatory retraction of the muscular mass and the skin cover- ing; it substitutes to a certain degree the peripheric attachment of the muscle which the surgical intervention has removed, bringing the muscular bundle in opportune peripheric tension each time that a voluntary or passive contracted may have shortened it; it, therefore, counteracts the retraction of the muscular mass in the limb, a retraction which inevitably involves the retraction of the aponeurosi and the integuments. Thus is avoided the tardy conoidic development of the stumps which when it has not been determined by physiological reasons of the growth in length of the part of the remaining skeleton, but in the expression of the mechanical or phlogistic retraction of the surrounding soft parts, assumes, as is known, a particular and almost constant physiognomy for each of the segments of the limb upon which has fallen -the amputation, in correspondence with the particular coefficient contraction, and, therefore, of retraction which has every muscular group, considered from the point of view of its function. Not the least advantage of the ambulatory traction by weights is that, exercising itself in erect position, and, therefore, in the best position for the line of gravity, it acts without dispersion of force. The necessary weight is notably reduced; usually it is sufficient for the ambulatory traction in erect station a third of the weight winch has to be applied to obtain the same effect with the traction in bed. A lead disc weighing but little more than a kilogram has always been sufficient for obtaining excellent results in our case. The tendency of flexion of the hip is energetically contrasted; this fact is of extreme importance because it is not easy to extend a short thigh stump when the shortness of the lever of attachment conspires to impede the gradual extension together with the sinking of the pelvis in the thickness of the mattress. We have remarked a further favourable influence on the stump as a result of the ambulatory traction. In addition to the beneficial change of nutriment owing to the very slight stasis which it procures, it acts also, perhaps by the almost rhythmic traction of the oscillating weights, as a slight massage on the skin, pressing it on all sides in fashion that its mobility is gradual, rapid, uniform and complete. 105?4 Q 4 488 NEW ERaOGRAPH FOR MUTILATED FOREARMS. By Dr. A. BASSETTA. A stump even though satisfactory from the surgical point of \iew may be inefficient from the point of i view of function if it- has not been trained by successive treatment and suitable func- tional re-education to avail itself of the false limb intended to replace the lost part. The movements and operations that a stump is capable of performing after it has been subjected to an appropriate and vigorous treatment may be developed to such a degree as to render possible functions that the surgeon had not- even had in view at the moment of the amputation and many of the inconveniences that the stumr may cause to the patient may disappear by improving its function. Having set to myself the task of training stumps of forearms by movements of pronation and supinatioii I desired to make use jf the mechanic-therapeutic apparatus in current use, adapting it with particular devices for the hold and the attachment on the stump. But I soon realised that the difficulties encountered rendered useless my attempts, because even the best mechanical apparatus especially constructed for rotary movement of the forearm and! anatomically integral with it proved unsuitable when applied to a stump. The constant resistances of the ordinary apparatus, owing to the numerous frictions of the axis of rotation, due often to the manner in which the effort of the limb is transmitted to the gradual resistance of the machine, are generally too strong for a recently amputated stump, which is often in that state of functional paralysis that prevents for a certain period all aptitude to a certain movement. Besides, the erect position, with arm extended, that the patient must mainiain for the exercise of rotation of the forearm in the ordinary mechanic-therapeutic apparatus has an un- favourable result in the case of a person with a mutilated fore- arm. The limitation of movement of the stump, the deficiency of contractive energy in the residual muscular mass and often the loss of all notion of the technique of the various movements in the amputated limb, bring about the development of subsidiary movements in segments close to the limb so as to have the illusion and not the reality of the simple movements desired. Thus the person with a mutilated forearm to which is applied an apparatus of ordinary type for developing the movements of pronation and supination, not succeeding in conquering the resistance of the machine, has recourse to a spiral movement and especially to rotation of the arm. This movement is complicated by heaving of the shoulder for the movement of pronation and of 489 traction for the movement of supination; movements which rapidly cause a loosening of the gripping organ on the stump and produce play as in a pump in the sleeve which cannot be eliminated without having recourse to a tightening up of the sleeve which, however, cannot be tolerated by the patient. I have therefore endeavoured to eliminate these inconveniences by giving the patient a comfortable sitting position and develop- ing the movement of rotation of the forearm with elbow bent at an angle of 90 degrees. In this attitude the articulation humerus-cubit-radial acts as a stop-block to the movement restricting exactly to the forearm the excursion from pronation to supination. The apparatus consist essentially of a vertical shaft of slow rotation turning on two ball bearings. The shaft is supported by a bracket which in turn is supported on a strong column fixed to the base of the machine. A support slides on this column, adjustable to various heights, which supports the elbow and fixes same by special ligaments. The shaft terminates at its lower extremity in a sleeve with jaw* concentric to the axis of the shaft, and this sleeve, whilst assuring a firm hold of the stump also guarantees the exact correspondence of the centre of rotation of the forearm to the centre of rotation of the axis. At the top a flat disc is keyed to the shaft and follows every movement of same; its periphery is grooved and has a series of holes for attaching a rope which sustains the weig*hts. The movement of the rope for transferring the traction from the horizontal plane to the gravity plane is made around a system of two vertical pulleys which rotate on a vertical axis, which constantly maintains the plane of the pulleys in the direction of the rope stretched by the weights. The same rotary shaft carries in addition : 1st. A second disc, likewise keyed to the axis, of smaller dimensions and calculated so that the development of its rota- tion is reduced to half of that of the main disc. This disc pro- vides the attachment for the carriage controlling the pen for the graphic record of the movement. 2nd. Two pointers, loose on the axis, and taken up in the movement by a stop pin for measuring the angle, both in pro- nation and supination. 3rd. A graduated dial, also loose on the axis, for the appraisal in degrees of the amplitude of the movement. 4th. A large disc or flywheel of cast iron, weighted at its rim, which at will can, by a simple pin device, be made fast or loose upon the centre shaft. With these devices the function of the apparatus may be active or active-passive. Active function. The crippled person is seated comfortably, the relation between the chair and the plane of support of the 490 apparatus is such that, with chest comfortably erect the arm and the elbow rest in the support provided for that purpose almost in a horizontal position ; the stump of the forearm is vertical ; its extremity is fastened in the gripping device such as to con- stitute a quite rigid whole with the axis of rotation of the appa- ratus. Whatever may be the position of the forearm in relation to its axis of rotation, this position can always constitute the point of departure for commencing the exercise, simply attaching the rope sustaining the weights, normally, to the disc (position immaterial). The active rotation towards the pronation or supination can, however, be developed by moving the attachment so that in the initial position the stump is deviated by the traction of the weights in supination when the effort should be made in pronation, and vice versa in pronation when the effort should be made in supination. The relation between the amount of the weight raised and the amount of elevation gives in kilogram-meters the work computed. The graphic on the chimograph allows of studying the conditions of the function, not only in two directions of the movement but in the commencement of the movement, in its development, in the progressive fatigue and in the exhaustion. The reading in series of the graphic record, which are all recorded by the con- stant tracing of the chronograph to the second, furnishes the data for appraising the progressive amplitude of the rotary movement, the speed of the movement, the resistance to >the movement with constant weight, or with a gradually increasing weight ; in short, allows of securely controlling, by data which can be permanently fixed, the progressive development of the functional training. The pointers on the graduated disc show at a glance, and without having to calculate the total angular amplitude of the movement of pronation-supination, and, sepa- rately the angular value of pronation and that of supination. Passive function. Eliminating the attachment of weights, the loose flywheel is coupled to the axis of rotation. A slight thrust of rotation by the stump enlarges the movement by the inertia of the flywheel until the equlibrium between the initial thrust and the resistance to the torsion of the forearm is reached. The 1 elasticity of the torsion thus proved promptly recoups itself in the initial phase of the return movement, followed soon by a brief active phase and concluded by a passive terminal phase again determined by the inertia of the flywheel. Also these active-passive movements may be recorded on the ohimograph, obtaining from the graphic an exact document con- trolling the gradual development of amplitude of the movement of pronation-supination of the wounded limb. 491 MECHANICAL PROTHESIS FOR MANUAL WORK. By Professor RICCAEDO GALEAZZI, 'Specialist in Orthopaedics at the Milan Clinical Institute ; Director of the Lombard Institutes for the Training of Disabled Soldiers and Sailors. Of all the problems created by the question of assisting disabled men, that of the mechanical prothesis is, perhaps, one of the most important, the most difficult and the most urgent. Manifold are the difficulties which surround its solution, difficulties both technical and moral : Technical difficulties inasmuch as it is a question of providing a substitute for one of the most perfect organs of the human economy : moral difficulties, to conquer the deep-rooted prejudices that tend to inculcate in the cripple an instinctive mistrust of the possibility of his being re-educated to perform a really productive labour with an artificial hand. .For that reason we find ourselves before a closed circle, as, whilst the perfecting of the mechanical prothesis is by necessity subordinated to experiment which can only be realised by extended application, on the other hand, the cripple will only allow himself to be convinced of its utility when he is in posses- sion of a functional organ perfect enough to vanquish all his diffidences. It can, for this reason, be truly affirmed that the question of the functional prothesis of labour is still far from its solution and far from satisfying in every respect the disabled man, the technical expert and the re-educator. However, it can be said that great progress has been realised in the cycle of the few years which have elapsed' since the beginning of the world war, if it be considered that before that time there hardly existed a functional prothesis of labour, bar a few rudimentary apparatus in the various manual schools existing in Europe for the education of the crippled and mutilated. The painful evidence of the exceptionally great and increasing number of war cripples has imposed a character of extreme urgency to the study of the difficult problem of substituting in manual labour the natural hand, a problem in the solution of which the brains of the best technicians, orthopedicians and surgeons of all the nations at war are engaged. 492 The present report lias for its chief object to place in evidence the progress realised up to the present in Italy in this branch of assistance to disabled soldiers and sailors, and it will go to show, we are convinced, that the contribution of Italian skill in the solution of the difficult problem has been neither small nor un- important, but indeed that the studies commenced and conducted with great fervour give a sure warrant of fruitful results which will benefit the workers of all the peoples that have nobly shed their blood in the defence of their country and of liberty. Before entering on the examination of all the various forms of mechanical protheses for labour that have been conceived and constructed in Italy, I deem it opportune to refer to some ques- tions of a general nature still much debated and on which depends the line which should be followed in the construction of the functional prothesis for labour, and it will be opportune that these questions be widely and resolutely discussed by the competent persons gathered together at the important Jnter- Allied Conference in London. One of the first questions of paramount importance regards the kinds of manual labour to which it is opportune and urgent that the studies for the creation of perfect functional protheses should be directed. All the experts in re-education have repeatedly affirmed that in establishing the vocational training of the disabled man the nature of the mutilation is the most important factor to be considered, but it is beyond doubt that in the case of one-armed men the factor that governs such considerations is closely allied with the functional value of the prothesis of which the cripple can dispose, and which should be modified in accordance with the rate of his progress. This is so much the more true considering that the opinions which were ruling two years ago are already greatly modified. Two years ago it was affirmed by pretty well all re-educalional experts that, with rare exceptions, one-armed men should be directed towards those trades that require the use of a single hand>, or towards non-manual careers. From, the social point of view agricultural labour and mechanical industries are the most important branches. In view of the inevitable deficiency of agricultural labour after the war, it is logical that towards agriculture should be directed the great number of war cripples. The labour problem in the mechanical industries has certainly not the importance that it has in agriculture, but, for all that, seeing the marvellous development attained by this industry during the -war, considering the effort that will have to be made after the war for its progress, for the emancipation of this industry from foreign servitude, it is on-ly reasonable that a 493 considerable number of our brave war cripples with mutilated arms should be encouraged to apply themselves to the mechanical industries. With the foregoing, and owing to the necessity of imposing a limit to the treatment of this subject, which would be too vast if extended to the mechanical protheses for all occupations, I deem it useful to consider them principally from the point of view of these two groups of workers : agriculturists and mechanics. In the present condition of the mechanical prothesis the ques- tion oi the seat of amputation, a& will be readily understood, has an essential importance from the standpoint of vocational production, and, therefore, in the two groups of workers men- tioned different conditions are ruling. Whilst a man with an arm amputated high up near the shoulder may, with all hope of a sufficient productive capacity, be encouraged to take up agricul- tural labour, inasmuch as the present apparatus and those now being perfected answer very well even in the case of grave mutilations of the upper limb, it would not be advisable, with the present condition of the prothesis, to direct men with the arm amputated too near the shoulder towards mechanical industries. On the other hand, a man with an amputated forearm, thanks to the perfecting of the artificial hand which is in progress, and even in its present development, can attain to such dexterity in a trade as to give on an average the same production as that of a normal workman, whilst in the case of an amputation too near the shoulder the difficulties which oppose his exercising a trade increase too greatly in proportion. In their case, whilst the leverage of the arm is greatly reduced, the mass of the prothesis is on the other hand increased, and it is axiomatic that the functional value of a stump is in inverse ratio of the mass and of the protetic organ. Also, if thanks to the development of the surgical cineprothesis, many of the working movements become independent, the artificial hand in the case of those with an arm amputated too high up will always be but an auxiliary of the sound hand, and the sound hand will have to intervene always to aid the function of the other. One can foresee, therefore, that those having an arm amputated near the shouldier will hardly be able to succeed in producing a sufficient measure of useful work, even if endowed with the greatest of moral courage and with the greatest of aptitude. And as it is an undisputed law that the work of training of the disabled should not constitute a sacrifice either to the disabled man himself or to the manufacturer called to make use of his labour, these general considerations in the establishing of various branches of training for disabled men should be given attention in order not to expect from the functional prothesis more than it can give, and not to cause as a consequence in the disabled 494 man those delusions so prejudicial to the work of re-education and to his social redemption. Another question of a general nature and of summary import- ance from the point of view of the employment of men with mutilated arms in the mechanical industries should be examined before approaching our specific task of examining the new im- provements and perfections attained in the field of the functional prothesis; this is to ask oneself whether the efforts of the technicians should with preference be directed to the perfecting of the mechanical hand or to the transformation of the machine tools. In the first place, it appears logic to establish the general thesis that instead of adapting the machine tool to the disabled man, it would be preferable, wherever possible, to adapt the man to the machine tool, or to study devices which can be added to the machine, as it is not prudent to rely that after the war many manufacturers may be disposed to assume the expense of this transformation, in view of the uncertainty of the results and of the possibility of compensation for this expense. Besides, it is beyond doubt that the efforts of the instructors will have only attained their purpose when they have succeeded in reinstating the disabled man in the ordinary workshop without special privileges and without too sensible inferiority in respect to the work of the normal workmen. For these theoretical considerations it would seem logical that in this direction of the transformation of the machine tool, the movement should be proceeded with very cautiously and that in any case the creation ex novo of special machines for cripples is hardly advisable if there is the probability that after a thorough analysis it be resolved to create automatic or semi-automatic machines of which there are already many types on the market. In this connection it will be opportune to refer to one of these attempts made in Italy, which for its seriousness and importance merits attention and study. The machine constructors, Moretti & Croce, of Milan,* in the praiseworthy intention of utilising in mechanical industry the work of men with amputated upper limb has constructed a semi- automatic turret lathe which differs from the ordinary turret lathes in that the movement for operating the pincers which grip the work, as also the movement of the toolholder turret and of the cross toolholder are actuated, instead of by levers or hand wheels, by means of water. pressure which is regulated by simple water cocks. The lathe is operated by means of cylinders in which move in one sense or the other piston rods controlled by distribution cocks. * Moretti and Crocs. Special device for cripples with amputated upper limbs. Bulletin of the National Federation Committees of Assistance to the blind, crippled and mutilated. 1918, No. 2. 495 The water pressure is that of the ordinary main supply and the consumption practically negligible, the cylinders being of very small diameter. The bar having been placed in the lathe, the tools adjusted and the travel regulated, the operation can be effected with all ease with only one hand, as the effort required for operating the water taps is very slight. Within certain limits the travel of the tools may be regulated in relation to the resistance of the metal to be worked, by opening, more or less, the cock of the tap. The lathe can therefore be advantageously used for work in series on simple- parts and can, as is evident, be operated by a one-armed man. As a set-off to such advantages, however, is the fact that the operation of a machine of this type is controlled by organs of certain delicacy which require continual and precise maintenance and adjustment, which, of course, cannot be entrusted to the disabled operator. We are here confronted with a machine of indisputable indus- trial value, inasmuch as in many cases its use may represent an advantage in respect to the ordinary type of turret lathe, but we ought to make some reserve regarding its practical employ- ment as a means of finding work for disabled men in mechanical industries. In fact he who desires to perform really useful service for them should endeavour above all to acquire for them a vocational skill which, compatible with their physical deficiency, may endow them with an individual patrimony which may compensate them at least in part for their injury. However, this purpose is not attained by setting them to work semi-automatic machines like the Moretti & Croce machine, work in which technical skill and intelligence do not play a great part. It is further evident that the disabled man can operate such machines only if they represent an advantage to the manufacturer over the other types so as to counsel their purchase, because competition compels the manufacturer inevitably to endeavour to purchase at the lowest price possible. 9 One should moreover not lose sight of the fact that the eventual employment of the disabled man for the operation of special machines is limited to that special period in which the machines themselves represent a progress over similar types and pending their being supplanted in their turn by better types and, finally, to bear in mind that the disabled worker is in a certain fashion deprived of his liberty in the sense that he is obliged to work only in those workshops were such machines are installed, which fact may constitute a danger of exploitation, which it is not advisable to overlook. So that although applauding the firm of Moretti & Croce for their noble attempt to provide disabled men with a means for feeling less acutely their physical deficiency, although fully appreciating the advantages of the device, constructed with a view to easy operation and to require the minimum effort from 496 ilie workman, we feel that they should not be encouraged to persevere in this direction. It does not exclude, however, that the lathe may not be usefully employed in providing occupation for those disabled men for whom technical training has not been possible, or who have refused to avail themselves of it, not losing- sight, however, of the fact that such re-education is the real pivot on which rests the redemption of the disabled and that towards it should be directed all efforts. From the considerations premised and from the special ex- amination of these altered machines, it appears to us justifiable to affirm that the principle in general is not to encourage the alteration of the machine tool for the use of disabled men in the workshop . We have now to consider the general conditions which, logically, a functional arm should satisfy, bearing in mind that we intend to strictly reserve ourselves to agricultural labour and to the mechanical industries, leaving aside the pro theses necessary for the small work of many artisan trades or for those connected with office work. It has been repeatedly observed that the mechanical artificial arm should above all be an auxiliary of the sound arm and where possible to it should be entrusted the functions of minor impor- tance and precisely the functions of the left hand. This may be accepted as a general maxim, but not as a fast rule; experience teaches us that if many workmen succeed with great or relative ease and rapidly become " left-handed," there are many who learn this functional adaptation with great diffi- culty or do not succeed at all, for which reason a good mechanical prothesis should be able to adapt itself both to the functions of the left as also to those of the right hand, in a determined work. On the other hand, one cannot pretend with the present con- dition, of the prothetic technique of an artificial mechanical hand an excessive and too varied number of movements, because one of the first and essential conditions of such kind of apparatus is the simplicity of the Inechanism. However, the tendency to simplify the prothesis, according to my humble judgment, should not be pushed to excess. Ail of us have been able to prove that the tendency of disabled men to do Avithout the embarrassing prothosis often prompts him to work in unfavourable conditions ; to all of us have had occasion to observe cripples minus the upper limb intent on working with the shovel, availing themselves of the stump of the shoulder and the lever movement of the handle of the instrument, but everyone should recognise that working under such unfavourable conditions is not advisable, and that we should persuade the disabled man of the convenience of providing himself with those auxiliaries that may alleviate the fatigue and render the effort more remunerative. 497 Also, in Italy* as in France (Aubert) and elsewhere (Spitz), one has attempted to reduce to the simplest form the working- auxiliaries. I limit myself to mentioning the straps intended to substitute all prothetic apparatus in agricultural labour; no doubt that when these are well studied and arranged, the disabled man can manage any agricultural implement, but it is also beyond con- testation that with such means of purchase the implement enjoys minor mobility in certain directions and cannot be fixed as securely as required in certain phases of the work, for which fact the strap or any combination of straps give disadvantageous results in respect to other apparatus, for example, the Julian apparatus or to the functional limb made by the Officina N"azionale di Protesi (National Workshop for the Construction of Protheses), which we shall have occasion to describe later on. Other essential conditions which are required of the mechanical prothesis are those of complete functional independence of the sound hand, and of the maximum respect to all the residual physiological movements in the amputated stump. The disabled man is with difficulty trained to work with the stump in a forced attitude, being unable to restrain the instinc- tive improvised movements which are in contrast with that which the grip of the implement performs ; his work under such incon- venient conditions, especially in his apprenticeship, becomes thus frequently disturbed, and this alone may prompt him to abandon the work. If 'it is just, if it is our duty, to persuade the cripple of the necessity of making the effort to try and work with an artificial limb, it is so much the more important to avoid all factors likely to exaggerate the feelings of impotence already so profoundly rooted in the spirit of the greater number of gravely disabled persons. In short, the mechanical prothesis should not require the assumption of forced attitudes abnormal to the body, obliging the labourer to assume working postures diverse from those that the workman in that special trade has the custom of assuming. Every operation of a trade is bound up with a chain of move- ments in the performance of which the body and the limbs constantly assume special positions that the exigence of the mutilation, the necessity of the prothesis or the modification of the tool, with the object of improving the fitness of the disabled men for the work, should disturb to the least possible degree. An ultimate condition should be required of the prothetic organ adapted for manual labour; it is necessary that the appa- * Bottari Apparatus for facilitating one-armed crippled workmen the use of labour implements. Bulletin of the Federation of the Committee of Assistance, .&c., &c. No. 12. 498 ratus be strong so that the workman can rely on its resistance to the strain, and easily repaired, so that its damage does not occasion a harmful and too frequent interruption of work. II. Having referred to the principal questions of a general nature appertaining to the mechanical prothesis and to the essential conditions to which they should respond we have now to enter on the examination of the chief component parts of the prothetic organ. In this we have to distinguish: (a) the means of attachment, (b) the gripping organ. (a) Means of attachment. It is beyond doubt that the most ingenious toolholder is rendered useless if it. is not able, in the most complete manner, to obey the movement that the stump desires to impart to it, and to remain firmly adherent to the latter, whatever may be the forces that tend to shift it in all the movements of manual work. The experience encountered with the most rational form of armlet of attachment constructed for this object convinced us that none of them hitherto absolutely responded to these essential conditions of the mechanical prothesis. And truly the problem is not an easy one to be resolved owing to the changing morphologic functional conditions of the stump of the arm during the manual work, either owing to their habitual conoidic shape, especially in the stumps of forearms, or owing to the modification of volume and of shape, to which they are subjected during manual work, or, finally, owing to the necessity that the muscular contractions are not fettered in their energy by the organ of attachment. These difficulties connected with the attainment of complete utilisation of the residual muscular force in the stump naturally increase in proportion to the brevity of the stump, if it be desired that the transport of the force from the stump to the prothesis be effected in favourable direction and without excessive loss of force and without atrophy of the residual muscular force. With the ordinary means of attachment one often observes that the short stump either escapes from the armlet or is hindered in its movements by artificial arrests in opposition to the muscular contractions or to the liberty of its movements. In this regard we must bring under notice two recent inno- vations in this important part of the mechanical prothesis : Above all the shoulder belt of Putti which represents a rational perfecting particularly adapted for those cripples with mutilated arms, inasmuch as while assuring the most secure attachment, it allows to the arm its physiological mobility both in the sagittal plane as in the front plane. In this device the transport of the force from the articulation of the shoulder to the prothesis is carried out always in a favour- 499 able direction; and the load of the prothesis is conveniently and rationally distributed to the shoulder belt and to the body in manner that same is always easily tolerated. Another rational apparatus of attachment was constructed by the Officina Nazionale di Protesi for its new mechanical limb.* The armlet is constituted by a series of thin metallic rings joined together by three strips of leather reinforced by metallic sheets, which maintain their parallel and equi-distant positions. These rings are not closed, but alternatively hinged by their extremities to an elastic cord. The great simplicity of this apparatus is equal to its efficaciousness. This system of attachment, prompt, reliable and rational, has proved itself really answering to its important function. Its superiority is due to the fact that the metal rings slightly sinking into the soft parts of the stump create between them small skin cushions which absolutely prevent the sliding or shift- ing of the armlet to such a degree as to allow of the cripple raising with the stump considerable weights and to perform all those alternative movements of labour which usually occasion the shifting of the armlet in all the mechanical protheses hitherto adopted. On the other hand, the elastic nature of the lacing- does not in any way prevent those modifications of shape and of volume due to the muscular strains and to the diverse attitudes of the stump in the various operations of work. In order to render the grip still firmer, the lower portion of the ring sleeve which is applied to the arm is constructed in a special manner in order to compel it to stop at the projection -constituted by the skeleton of the articulation of the elbow in its posterior face. Only in those special cases in which the cripple has to perform work which compels him to exert frequent and considerable efforts of traction or of raising considerable weights, it has been found opportune to add to the armlet a shoulder belt which distributes over a more extended surface the excess of traction. This new armlet is tolerated very well by the disabled man, who even keeps it applied for more than 24 hours without the least inconvenience. Finally, it is worthy of note that even in cases of amputation above the elbow the armlet obviates the necessity of using a shoulder belt leaving to the disabled man the greatest respiratory liberty. (b) Gripping organ. In all times, and still to-day, many inventors have studied to construct mechanisms aiming at sub- * Officina Nazionale Italiana di Prothesi. An apparatus adapted for manual work for cripples with amputated upper limb. 500 stituting the human hand in all its imirvelkms and manifold functions, with the fingers and the phalanx independent and all their numerous articulations and opposition of the thumb, &c. Now, it is precisely to this tendency to the " anthropo- morphism" of the mechanical prothesis as it was justly designated by Vanghetti* that we owe the slowness of the progress in this branch of the prothesis. The most perfect types of artificial, hands capable of grasping clear proofs of the inventive genious of the human brain will, with difficulty, be surpassed in the perfection of their mechanism, but if they constitute something more progressive than the ordinary esthetic and inert hand, namely, a hand which permits of grasping witli sufficient firmness objects of various shape for the ordinary needs of life, will never be able to constitute a gripping organ adapted to take hold of and to grip with sufficient energy a tool and to perform with it a really productive work. Apart from the circumstance that at the present state of the prothetic science, these hands are delicate organs, fragile, costly, not even the best among them will perhaps ever give the move- ments of pressure, sufficient, precise and adaptable to the shape- of the object which the hand should grasp. Instead, the principal requisites of the gripping organ in an artificial arm capable of work are essentially the firmness and the rapidity of the grasp on the tool. It is, however, of capital importance not only to grasp firmly the tool but also to substitute it, reducing to a minimum the interruption to his work for this operation, so that the other causes of deficiency inherent in the man with a mutilated arm are not aggravated. The conviction of the deficiency of the systems hitherto adopted explains in great part the prejudicial resistance which the dis- abled man opposes in general to applying himself to a manual trade and explains why the disabled who do take up such work with great faith in the success of their efforts afterwards abandon it, owing to the disadvantages caused by the interruption of their productive activity, should cause the technicians to devote all their studies to the perfecting of the functional prothesis to promote rapidity and ease in changing the tools. It does not suffice, however, that the grip on the tool be firm and its substitution rapid, thanks to rational opening and closing devices; it is also necessary that from the firmest hold the tool passes to more ample degrees of mobility so as to allow of inclining and fixing the tool, if necessary, in all the planes of the space, arid also to work with it, in certain moments, com- pletely loose without releasing the grip. * "Vanghetti. Treatise on the cinematic prothesis at the Italian National Assembly for Assistance to War Invalids. Empoli. 1918. 501 ; Also with the greatest possible simplicity and with the maximum of substitution or modifications of the grip the func- tional prothesis should satisfy all the movements of a special class of manual work. It is indeed because the universal pincers proposed hitherto rarely satisfy these conditions that they have not met with unanimous approval, whilst the functional protheses created for .specially appointed work have met with more success. But on the other hand the too complete relinquishment of the idea that the creation of the universal pincers has inspired should not signify the acceptation of the idea of those who would wish to dis-associate all the movements performed by the work- man in special manual work, arriving at the opposite excess of creating a tool for each function. Too great dis-associations would mean the multiplying of the tools and necessarily complicate the functional prothesis and constitute an excessive embarrassment to production. Indeed the artificial hand should impose the least possible modification of the series of tools in use in each trade. The artisan who exercises at home the trade that he has learned in the training school, the cultivator who returns to his fields can, for once in a while, without great inconvenience, alter the tools which they are accustomed to use, but the mechanic or the carpenter who has to work in a workshop or factory should not have need of tools which vary to a notable degree from the ordinary working tools unless it be desired to place the disabled workman in an unfavourable condition in respect to his employer and of visible inferiority in respect to his fellow workmen, and diminish those conditions of complete independence which is one of the factors of his redemption Before closing this chapter I must refer to a question regarding- the technical construction of the prothesis for mutilations of the upper limb. The question of the seat of the mutilation in like manner, as it has great importance from the point of view of establishing- the direction and branch of training and of the working capacity of the disabled pupil, also creates diverse conditions for the pro- thesis, according to whether the mutilation has its seat below or above the elbow. In the latter case the prothetic difficulties are much more pronounced. And, nevertheless, there exists uncertainty amongst the technicians as to the convenience of introducing into the system the artificial articulation of the elbow as also in regard to the manner of opening and of attachment in the various useful angles. Undoubtedly this addition to the apparatus extremely compli- cates the work and creates difficulties to the workmen, obliging 502 them to make use too often of the sound hand, which results in a great loss of time and prejudices his labour production. For a great number of manual trades a stump of the arm well exercised and endowed with a complete liberty in the movements of the shoulder is able to perform all the labour operations with- out a forearm, and I deem that in all possible cases it is preferable to couple directly the toolholder to the terminal dome of the armlet. Where it is considered advisable to add a forearm it is always preferable to use an articulation that allows of the fixing of the artificial forearm in all the degrees of rotation and of flexion by a simple mechanism, strong and rapid. Such are in their general lines the requisites of the mechanical auxiliaries for disabled men doing manual work. III. We shall now give a rapid glance to the new types of functional protheses which have been invented or applied most recently in Italy, endeavouring to submit them to a critical examination. We should naturally limit ourselves to those items which repre- sent really a novelty or an essential perfecting of existing types, leaving aside all those which are deemed a simple modification in detail of known types, both Italian and foreign. We shall also omit the critical analysis of the new tools that have been proposed or of those which represent a perfecting of types already known, because we believe that their exaiiiinatioii would amplify to too great an extent the theme which we have proposed ourselves, already very vast and complex even though kept within the limits imposed by ourselves. For greater clearness and order in this report, it seems to me opportune to divide the functional prothesis into two groups : 1st Passive Protheses. 2nd Active Protheses or Cineprotesi. With the designation of Passive Prothesis, I will refer to those apparatus which have ao other function than to constitute the organ of transmission of the movement of the stump to the tool. Active Prothesis or, according to the very rational termino- logy of Yanghetti* cineprotesi, those that utilise any residual movements, in order to reproduce those naturally lost. IST PASSIVE PROTHESIS. The Officiiia Nazioiiale Italiana di Protesi of Gorla Priino { Milan) (the Italian Xational "Workshop for Protheses) has con- * Yanghetti, Report on cinematic protheses at the Xational Convention for Assistance of War Invalids. Empoli, 1918. 503 ceived and constructed a new functional limb,* which, as experi- ence goes to prove, represents a real and considerable progress to many which were hitherto proposed. Its model, in a recent competition for functional prothe.sis, was classed first by the technical jury among 103 competitors. The Officina Nazionale began its experimental researches studying the movements of the arm in the most common labours and on one of the most indispensable utensils, thus succeeding in establishing for each of them distinct groups of movement; a first group comprising the simplest exigences in which the tool had to be grasped firmly and maintained rigid in a pre-estab- lished direction and almost constantly in a line corresponding with the axis of the forearm. In a second group there was the functional exigence of the rigid grip, but with supplementary movements (chisel) Ho bring the tool into various directions. Moreover, in the greater part of the work the tools, although requiring a complete solidity with the stump, should, during their use, be able to perform movements of rotation corresponding to the manifold movements of the articulation radiocarpic which is developed in all the planes of the space (flexion, dorsal, palmar, radial and cubital pronation and supination). These experiments led to the discovery that only realising the- conditions that the grasping of the tool at once actively rigid and easily mobile in all the planes of the space, it would be possible to obtain that continuity between the arm and the tool that constitute in work a unique organ. The solution of the problem was found by giving to the handle a spherical form and creating a special vice, constituted by a ring, which has a concave surface, with which the sphere is embraced. The vice is opened and closed easily by means of a lever pawl (A), a screw diametrically opposed (B) adjusts the fixing of the grip and permits all the graduations in its mobility, from the most absolute rigidity to completely loose play. The operation of grasping and changing the tools is rapidly performed even without assistance of the sound hand ; it is suffi- cient for the purpose that tne cripple may have fixed to the work bench a projection which offers a point of support to the ex- tremity of the lever which opens and closes the vice. Such a prothesis works also excellently in the case of stumps amputated near the shoulder and can be adapted besides to partial amputations and to all the functional mutilations of the hand. To sum up, this new prothesis substantially realises those conditions which we have declared essential for responding to the * Nouvelle prothese de travail pour les mutiles du membre superieuiv " Revue interallied," No. 1, 1818. Paris. 504 functions of an artificial arm adapted for manual work, inasmuch ;as it can be firmly fixed on the stump, is strong, simple in its mechanism, leaves complete liberty of movement to the stump and to the workman, ensures a firm and rapid grip of the tools in all the planes of the space and with all the most ample graduations in its fixing, and finally does not implicate the use of special tools. The experiments made in the most varied manual work have proved the great practicalness of the new prothesis and the disabled soldiers, who are already making use of it, show them- selves very satisfied. The moderate cost of such apparatus is another advantage, which, if not of capital importance, is a consideration not to be neglected. For the mechanical industries the head technical instructor of the workshop annexed to the school for training disabled soldiers and sailors in Gorla Prime D'Adda has invented a functional limb for machine adjusters which presents uncommon advantages. It has been studied carefully in every single detail. Also in this apparatus we find the application of a sphere at the ex- tremity of the armlet, which is provided with gaps of shape adapted to the various tools which the machine adjuster employs in his work. The apparatus permits also, by means of a spring closing device, the fixing of the chisel. The instrument of the "Adda," fitted with a spherical swivel in the union to the armlet, is being experimented with in the School for Disabled Soldiers and Sailors in Gorla Primo, and it has proved itself to be of real practical use to the disabled man inasmuch as it allows him to perform, by the aid of the other hand, many, if not all, the operations required in the work of adjuster. Also meriting serious consideration is a gripping organ for men deprived of the arm invented and constructed by Casanova of Bologna. It consists of a work pincers, one of the movable jaws of which is made of a mesh similar to a multiple Gaul's chain which can be closed completely on itself by a screw controlled by the sound hand of the disabled man and allows of pressing in a firm manner the handle of the tool against the fixed jaw. The whole can be inclined around an axis and is applied to an nrmlet- by the intermediary of a sphere. The attachment of this apparatus may be at will rigid, or can o-ive to the pincers a certain oscillation for not too great strains. The essential advantages of this ingenious apparatus are a great, firmness of grip and its adaptability to objects of the most diverse shape, which approaches in its function of grasping to that of the natural hand. 505 A further quality of the instrument is the extreme rapidity of closing, for which reason it may be assumed that its eventual perfecting will render the pincers likely to be largely adopted for the mechanical work of disabled men. Zumaglin and Gruidi (Turin)* have proposed a universal pincers capable of grasping any object and guiding it in any direction by means of a spherical application fixed to the stump which merits special attention because it shows an accurate study and is adapted to practical application when perfected and a few inconveniences remedied. The gripping pincers are constituted by two arms joined together by a screw with a counter thrust spring. The screw serves at the same time for closing the pincers on the ball swivel and the tool-holder, so that it is not possible to give the pincers a rotary movement on the swivel during the work, because in such case, having to loosen the fixing nut, the grip of the- tool remains also loose. Further, in the system described, the pincers can be closed firmly on the swivel by means of incisions which the constructor has provided on the sphere in order to increase the friction, but it is to be feared that the sphere is too quickly subjected to wear and loses its primitive shape ; thus the closing would become- problematical. But it will not be difficult for the constructor, who has shown a clear knowledge of the problem to surmount these inconveni- ences and to render the pincers more useful for the purpose intended and more near to perfection. There is another device belonging to this group of functional prothesis which we desire to refer to inasmuch as it presents some constructional details realising some of the requisites which we have established as indispensable for a correct function of the prothesis. This is a prothetic arm invented by the orthopedic workshop annexed to the important institute for training disabled soldiers and sailors in Palermo. It is constituted by an armlet which approaches in its shape and in its function to that of the functional limb of the Officina Nazionale di Protesi in Gorla Prirno, to which is united a tool- holder with a spherical swivel which, if it does not allow by reason of its means of fixing the inclination and the mobility of the tool as much as might be desired, should, however, satisfactorily realise working conditions, and after successive inevitable im- provements, will be able to constitute a good functional prothesis. * Zumaglini. Universal pincers for cripples with one arm. Bullettino 'della Federazione Nazionale Italiana dei Comitati di Assistenza ai militari ciechi,. storpi e mutilati. No. 11. 1917. 506 2. FUNCTIONAL CIKEPROTHESES. It is intuitive that the creation of an artificial functional arm actuated by an active and voluntary force is the true object to which should tend the efforts of all persons studying this question. We should, according to Vanghetti, distinguish two forms of: cineprotheses : the mechanical cineprotheses , in which occurs only the mechanical transmission of natural residual movements, and the surgical cineprotheses, which are operated actively by generative motors, painful or non-painful. (a) Mechanical cineprotheses. The protheses of this group up to the present applied and which to our knowledge do not seem to have realised the conditions which we have shown to be indispensable for effecting a not too arduous manual work. The origin itself of the active movement is with difficulty re- concilable with one of the most essential of our premises, according to which the protheses should not engage useful move- ments of the stump, or movements of other articulations or of the body. The transmission of the -active force from distant points of the mutilation consequently implicates automatic control by means of cords and metallic levers which cannot give very satisfactory results owing to the loss of force by friction and the length of the path to be travelled and by the wear and the liability to damage of the cord transmitting the force. All the mechanisms hitherto known which serve for the purpose, besides being very delicate and incapable of movements of great strength and of firm grips, may be for the most part considered of some advantage as hands for asthetic purposes or present some usefulness for those disabled men who exercise independent professions. Few of these types have been studied in Italy. The model of Professor Pedrazzoli is worthy of a word of en- couragement. Professor Pedrazzoli had created, in 1916, a very rational and practical device for the transformation of the rotary movements of the stumps of forearms in the movements of grip.* The A. has now considered particularly the properties of their mechanism for the transformation of the movement (which, by being obtained by a system of inclined planes of long extent acting on a tie rod of much smaller travel, increases the force) in order to apply the system to a hand functioning like a tool either in the form of a pair of pincers, the jaws of which are kept closed by a spring, whilst the stump acts only for * Pedrazzoli Artificial hand for grasping. Bulletin of tbe Italian National Federation of the Committee of Assistance for War Invalids. September, 1916. 507 opening them by the supination ; either for operating a pair of pruning clippers or ticket punches for railway conductors, &c., &c. The new functional cinepro thesis has not yet been experi- mented, although the principle on which it is based contrasts with the general prejudice against the employment of phy- siological movement of the stump which has also prime im- portance in all manual work, it is however worthy of study and of experiment, either because the rotary movement of the stump which is employed in the grip may in part be compensated by movements in the functional articulations of the arm, or because further improvements may diminish the inconveniences of the system. I must not neglect to mention the ingenious invention of another apparatus which, I believe, may, by the novel principle of its system, be fruitful of results which may eventually have great importance. I wish to refer to the mechanical hand closing by hydraulic means of Vianello (Venice). This really characteristic mechanical hand is formed by two jaws, one of which reproduces the external shape of the finger and the other movable by means of hydraulic pressure. The water pressure is brought to the hand -by a rubber tube which communicates with a tank and a small pump applied to the heel of a boot. Standing on tiptoe and pressing on the heel the water is brought to a certain pressure depending on the area of the piston and on the pressure exercised by the foot. To obtain the complete travel of the movable jaw, 10 to 20* blows with the foot is required. To open the jaws the pump is provided with a suitable valve operated by the rotation of the foot on the heel, which allows the hand easily and quickly to let go the tool. The cripple provided with this apparatus succeeds in gripping firmly the most varied tools and also to work, performing con- siderable strains, which for the rest appears evident from the simple enunciation of the principle on which is based the apparatus. *> No doubt if later on some improvements are introduced into the apparatus which will have for effect to better harmonise the pressure on the jaws with the stroke of the piston and to improve the closing of the jaws, this original type of mechanical cine- prothesis may be largely used for manual work by disabled workmen . 508 (c) Surgical Cineprothesis. It is not here my task to show the value of the plastic cinematic, which for the rest is universally known . From the point of view of the working prothesis there is no doubt that to the clever idea of Vanghetti is reserved the best solution of such problem as far as the only and the true physio- logical solution renders it possible : to the progresses of the cinematic plastic will be due the merit of having reduced in extraordinary measure the importance of the functional damage of the loss of the hand ; in front of surgical cineprothesis should gradually yield the field any method of mechanical cineprothesis. But, unfortunately, hitherto the surgical technique in the creation of plastic motors which, from the cinetic and dinamic points of view are very valid, has greatly surpassed the prothetic technique in the construction of prothesis which permit of exploiting all the energies. Hitherto the examples of surgical' cineprothesis which have come to my knowledge all presented all the form of the grasping hand which we have demonstrated cannot at the present con- dition of the prothetic technique constitute an efficacious work- ing organ for the manual trades which require little considerable effort. Vanghetti,* with the name of " Ideal cinematic hand," describes an artificial hand formed of three groups of fingers, ach of which moved in flexor and extensor from its respective alternate loop. Certainly, such cinematic organ might modify our judgment on the practicalness of the anthromorphic prothesis, but on the other hand, the experience of the many who have tested this field of modern surgical orthopedia informs us that for the present such operatory result remains in the field of aspirations, however legitimate after the progresses already made. For the present the best result, as far as I can see, is obtained in the creation of a double plastic motor. I am not aware that as yet anyone has formed an exact know- ledge of the working value of a plastic motor provided with functional prothesis, for which reason I do not believe it will be deprived of all interest to communicate my results obtained with two cinematised supplied with a new and very rudimentary type of working cineprothesis. The experiment was made in the case of two men with ampu- tated arms, one with an arm amputated above the elbow and the other higher up in the middle of the arm, both provided with two plastic motors. * Bulletin of National Federation of the Committees for Assistance of the blind, crippled and mutilated. 1916. No. 2. 509 Both, were applied to manual work after many months of exercising* with the ergograph, designed by us for this purpose and we need not describe it here. The experimental researches performed with the apparatus had convinced us that in principle and by a long period of exercising it is not rational that the cineprotised maintain actively the grip on the tool with the permanent contraction of the cinetised muscle. As go to demonstrate our other researches, which are in course, regarding the physiology of the motors, these get fatigued at an early date. On the other hand, wanting, unfortunately, in the function of the organ which animates the sensibility, a long period of exercising is necessary before they regain a muscular sense perfect enough to render the grip which they effect constant and firm. It is due to this fact that we have found it necessary to limit the performance of motor to the functions of gripping and of letting go the tool, entrusting the grasp during the work to a mechanical arrest. When the work is finished, or for changing the tool, a new contraction releases the mechanical device from the position of arrest and a recall spring releases the tool. Certainly, it is to be presumed that by improving the func- tional quality of the motors. for energy, amplitude of excur- sion and muscular, sense may be arrived at in its active con- tinuative function during the work. The apparatus which we have for the time being applied (constructor, the Head Technician of the Orthopedic Workshop of the Institute for Rachitis Narcisco Castelli) consists of an armlet with metallic bars (A.B.), suspended to the body by means of a very simple system of straps arranged around the shoulder strap and the trunk. Owing to the brevity of the stump and to assure the attachment of same to the prothesis without hindering the muscular traction the armlet terminates in a dome (C) which embraces the apex of the stump. The two staffs are fixed to a disc (D), to which is coupled the toolholder by means of a giooved plate provided with an arrest (E). By means of a tie rod attached to the muscular loop of adjustable length, the cripple opens and closes the arrest which fixes the handle of the tool to the toolholder and can give it the desired inclination in three diverse directions. If the various tools are fixed in a rack within close reach of the stump and at the desired height, it is possible for the cripple 510 to effect the voluntary grasping and releasing of the tool without the aid of the other hand. The cripple who is applied to mechanical work makes use of the stump of the left arm for the grasping of the point of the file, placing, as is logical, the sound light hand on the handle of the tool. Both the file as the other tools (chisel, drill, calipers) are supplied with a device constituted by two small plates which can be fixed by screws, one of which is adjusted for fiat filing, the other is spherical for round filing. The other soldier was for experiment supplied with a cinepro- thesis provided with articulation at the elbow for the movement of which presides the two flexor and extensor motors, but the experiment demonstrated once again that for purposes of manual work in the case of stumps of arms the application of the tool- holder directly to the extremity of the stump is preferable, suppressing the articulation of the elbow and the forearm. Both these cripples are provided with grasping cinematic hand. IV. MECHANICAL PROTHESES ADAPTED FOR MANUAL WORK FOR FUNC- TIONAL DEFECTS OF THE UPPER LIMB. In addition to the disabled, also the wounded, who, in conse- quence of a nervous, muscular, articular or bone affection, have suffered a diminution or total loss of the working capacity of the upper limb, should be provided with a mechanical prothesis which permits them to recuperate completely or in part the deficient or lost function. In this gioup of protheses either the orthopaedic apparatus devised for the pseudoartroses of the various skeleton segments, the tutors of the extended parts of bone substance, etc., etc. I do not deem it opportune to dwell on the numerous varieties of orthopedic apparatus advised and experimented in all these cases; it is a task that the orthopaedic technician performs now, one can say, in a manner so perfect as to compensate the most grave skeleton and articular defects, and to suppress or to reduce to the least degree the functional incapacity. On the other hand, it seems to me opportune to make a brief reference to the working prothesis which it is well to apply in cases of nervous paralysis which have attacked the upper limb, because it very often happens that one does not always proceed in time to provide for re-establishing with a suitable prothesis the working capacity of this numerous group of disabled. *L'Officina Nazionaledi Protesi Milano Ed. Alfieri and Lacroix. 1916. 511 Whilst the problem is, one may say, resolved in the case of paralysis of the radial, it is not an easy question to intervene efficaciously with mechanical aids in the case of functional defects provocated by serious paralysis of the cubit. It is worth while, therefore, that be cited here the apparatus created for this purpose by the Officina Nazionale di Protesi.* It is known that the functional disturbance consequent to the paralysis of the cubit is characterised, besides the abolition of the adduction of the thumb, by the insufficient flexion of the first phalanx, and by the extension of the second and third phalanx in the case of interosseous and lumbrical affections. The apparatus constructed by the Officiiia di Protesi with a system of small levers operated by elastic traction corrects the contraction in extension of the first phalanx and extends the other two. Such apparatus already experimented in several cases has not only demonstrated that it can realise an efficacious prophylaxis of the deformity but that it is also capable of giving back aptitudes to work which owing to the deformity had disappeared. It has the advantage of leaving- free all the residual move- ments of the hand and for this reason it is to be considered a good working prothesis in the true sense of the word for this group of disabled workmen. In the functional deficiencies which owe their origin to multiple affections of the peripheric nerves of the upper limb or to affections of the plexus at its root more than in any other case the general rule should be followed that each prothetic apparatus should be individualised and studied case for case. In the total paralysis of the hand it is possible to apply work- ing auxiliaries which allow the man to perform a certain amount of work, but as a general rule it must be affirmed that there still remains a great deal to be discovered in this field of the working prothesis and it is to be hoped that it will be the object of a more intense study 011 the part of technicians, taking into account that the number of those rendered helpless by the effect of grave functional affections contracted in war, represent certainly a considerable portion of all the causes of Disablement. The preceding statement, although necessarily summary and incomplete, will suffice to demonstrate that the contribution of Italian inventive skill in the solution of the grave and difficult problem of the functional prothesis is really gratifying and repre- sents in the various studies, although not yet brought to that perfection which render them really practical, a sure promise for the future. Certainly, the researches, the experiments and the studies which are being so energetically undertaken by all the nations at war will result in a noble competition which is most essential for the bettering of the lot of our glorious disabled soldiers as it will offer them very soon the advantages of those mechanical auxiliaries which will enable them to enter once more in the ranks of the free labourers and to contribute to the economic rebirth of the country for whom they have so nobly shed their blood on the field of honour. But to arrive at this promising result it is necessary to repeat once more that in order to make headway in the technique of the functional pro thesis adapted for manual work, the studies should be followed on a strictly experimental basis, undertaking re- searches and classifying the single movements of the one or the other arm in all the movements of every manual work, establish- ing for each trade the classical attitudes and the vicious attitudes of the body and of the limbs, making the frequency of the rythmic returns of the same movement, analysing the directions and the constant axes according to their development in the various phases of the work, etc., etc. In addition it is necessary to appeal by all efficacious means (Meetings, awards, etc., etc.) to all those competent who are capable of giving a valuable contribution to the solving of the problem, canvassing especially the collaboration of engineers and mechanics and of the disabled men themselves. But in order to attain this result it is necessary to have the willing and active co-operation of the disabled men themselves to promote which it is indispensable that there be strongly developed in them a more elevated sentiment of human dignity, a more rigid conscience of their duties towards their Country, and it should therefore be the chief task of the teachers and of the public to call forth the moral and intellectual energies of the disabled man, which are undoubtedly of greater value than physical energies, in order that they may persuade themselves of the necessity that they also direct all their efforts to attain the ideal to which all aspire, namely that all those with crippled arms become once more useful and productive units in the work of the community at large. It appears opportune for us to sum up below the various theses sustained in our report. Conclusion. 1st. In establishing the branches of training to be given to cripples with an amputated arm in order to fit them for the mechanical trades it is necessary to follow rigorous lines in their selection in respect to the gravity of the mutilation in order not to ask of the functional prothesis more than it is able to give. 2nd. The alteration of machine tools for the employment of disabled workers in mechanical trades is not to be encouraged. 3rd. The working arm should be able to adapt itself both to the work of the right hand as to that of the left hand in every kind of manual work ; it should be simple in its mechanism ; it should allow the stump the maxiimim functional independence 513 of the sound hand and should respect the physiological move- ments of the stump, it should not compel the cripple to adopt forced attitudes, finally, it should be strong and easily repaired. 4th. The essential requisites of the working prothesis are : Secure attachment to the stump, firmness and rigidity in grasping the tool; possibility of adaption in all degrees of mobility of the tool up to' its complete fixing in all the planes of space ; possibility of satisfying all the movements of a trade without imposing exaggerated modifications of the tools commonly adopted. 5th. The problem of the working prothesis for functional helplessness should be studied by the technicians with more thoroughness and promptness. 6th. In order to realise decisive progress in the technique of the working prothesis it is necessary to adhere in the studies to the path strictly experimental appealing for co-operation to all those competent and capable of bringing an adequate con- tribution to the solution of the difficult problem. 7th. It is indispensable in order to attain the ideal towards which we aspire, to endeavour to obtain the willing and active co-operation of the disabled themselves. 16524 514 EXACT CONSTRUCTIVE DRAWINGS OF THE PROTHESIS AND ORTHOPAEDIC APPARA- TUS FOR THE LOWER LIMBS. By Professor R. GALEAZZI. In the prothesis for amputations below the knee, the leg case is attached to the thigh case by means of two articulations that constitute the ideal axis of the prothesis for the flexion and exten- sion of the leg on the thigh. Those with technical knowledge know that the principal defects in the working of the prothesis for mutilated legs are due to the functional defects in the prothetic articulation owing to the wrong position of the hinges in respect to the articulation of the knee. When the hinge is applied too low in respect to the articular centre, the leg case of the artificial limb, in the flexion of the knee, is displaced forward of the stump, whilst its posterior margin pinches the flesh of the calf ; conversely, when the hinge is placed too high, the leg of the prothesis in flexion is displaced posteriorly and it exerts with its anterior wall an annoying pres- sure on the tibia crest of the stump. The apparatus is equally defective when these hinges are main- tained too far forward in respect to the middle frontal plane of the limb, because the stump sinks excessively, thus causing it to exert pressure on the tibial condyle, or, when the hinges are placed too far behind, the stump is pushed out of the leg case during a sitting position. Consequently this has given rise to discussion among doctors of orthopsedia as to what should be considered the correct posi- tion of the hinges. Empirically, the greater proportion of orthopaedic mechanics hold to a horizontal line passing through the middle part of the patella. Cocht instead marks the articular line of the knee at a level of 3 lower than the patella, and establishes the seat of the hinge in the central point of the external half of the horizontal designed on the knee at this level. Hendrix fixes the axis of the knee on the condyloid tuberosity. taking as starting point the inferior extremity of the patella, and fixes the two hinges at the union of the f anterior with the fourth posterior of the contour of the knee. We wished to attempt this problem and directed our researches with the object of furnishing the constructor-mechanic with an 515 apparatus of prothesis for mutilated legs oi' an orthopaedic apparatus articulated at the knee, a means that with sufficient pressure avoids the inconveniences of the ordinary empiric directive. Of course it was well known to us that, owing to the anatomic tact that the evolving curve of the articular superfices of the femur does not represent a sphere but rather a spheroid with radii decreasing from the front to the back, and also that for the inequality between the two condyles in the superfices and in the radius of the curvature, and finally for the certain fact that the femoral condyles in the flexions of the knee do not limit them- selves to rotating on the tibial platform, but likewise submit to a slight slip forward, the axis of the knee articulation cannot be fixed, but must displace itself and follow the movement of the condyles. Consequently we knew beforehand that our researches would give no other solution than determining upon a conventional axis as had been established by Martin and Cruveilhier. Undoubtedly the ideal would be that of being able to obtain an automatic displacement in the artificial articulation, as theo- retically we must admit takes place in the living flesh ; but beyond this being a problem extremely difficult to solve, it would lead us to undesirable constructive conclusions. This has been demonstrated by Marck by his system of mobile metal rods on a leather thigh case which permits the thigh to displace itself in the flexion of the knee, a system which offers great inconveniences that have never allowed it to be of practical application. The ingenious attempt of Dueroquet has confirmed it : he created an articulation that allowed the extremity of the femoral rod to follow the displacements of the condyles in the movement of flexion. The author himself has had to recognise in the course of his experiments that it gives no practical result. The study of the question has, however, convinced us that in the creation of a prothetic axis the function and displacements of the natural axis of the knee formed a very arduous problem , but at the same time one so interesting and ^ seductive as to be worthy of being confronted in all seriousness. But the task that the " Officina Nazionale di Prostesi " has undertaken is for the present much more modest : it limits itself to seeking the most practical and rapid means by which the orthopaedic mechanic may establish in his apparatus the proihetic axis with the nearest approximation possible. Since for the displacement backwards that the articular superfices of the femur undergoes which is found in the flexion in the right angle in a plane further posterior than in extension and for the displacement upward consequent on the volute form of the condyles, it must be retained that the articular axis oscillates between C and C 1 . From this the hypothesis was advanced that a method which should succeed in establishing the hinges in a point intermediary between these two extreme points would reduce to a minimum the 16524 R 2 516 inconveniences attached to an immutable centre of the prothetic articular movement. In order to obtain a solution we thought it would be necessary : (1) to put ourselves in identically the same conditions as the prothetic apparatus works, with a reproduction of those resemblances that intercourse between the limb of the disabled man's leg and the prothetic apparatus in all phases of movement of the leg on the thigh ; (2) that the method ought to be strictly individual, bearing in mind the researches of Allby and Albrecht and those of Hiiter, which established that in the curvature of the femoral condyles notable individual differences exist which demonstrate that all geometrical con- structions created for the establishment of a universal standard for the prothetic axis of the knee must of necessity give rise to proportional errors to such differences and that only a method founded on individual measurements can be right. Basing ourselves on the foregoing judgments, we herewith give a brief and graphic account of the work done by us. As a rule it is necessary in every case to proceed in this quest as much on the mutilated leg as upon the whole one. On the two thighs a light binding with bands of plaster is first applied, well modelled on the condyles and sharpened at the extreme inferior in such a way as to allow of the complete flexion of the leg on the thigh without danger of the bandage being displaced. The patient is then laid on the opposite flank to the articula- tion upon which the experiment is to be made. The articulation to be measured is supported on a common drawing table upon which a sheet of drawing-paper has been fixed with pins. Before beginning the operation, care must be taken that the position assumed by the patient is such as to permit the move- ments of the articulation to turn in a perfectly horizonat plane, so that the pelvis shall have on its flank of support a normal position to the plane itself. Then successively the leg is fixed in flexion of about 100-120. At the extremity of the stump or of the normal articulation a pencil is attached by an appropriate apparatus that is fixed by means of a belt to the stump or leg. Hence the whole of the thigh is maintained absolutely immobile while, thanks to a square support, the leg on the thigh is deflected to complete extension. The pencil will draw a curve on the paper. This curve is divided! into sectors which are geometrically substituted by the approximate arcs of a circle. The radii corresponding 51T to such arcs of a circle intersect one another at points near the jxrothetic centre. Then with compasses or a square the radials can be traced in the point of intersection from which the prothetic centre has to be found. Numerous experiments carried out by this system on men who were whole, or mutilated or affected by lesions of the most diverse kind, have given us with singular regularity either a single centre or two centres extremely near to each other, between which it was easy to establish the intermediary centre approximately exact. In the prothesis apparatus constructed faithfully according to the instructions in respect to the prothetic axis, not only were there no inconveniences to be complained of, but also in several of the cases in which the apparatus showed itself defective, the operation for establishing the prothetic centre by this method, one may say, constantly revealed that the cause of the bad working of the prothesis was due to defective hinges, that, on being corrected according to the results obtained from the ex- periments, resulted in the disappearance of every functional defect. We would point out that the prothetic centre so determined is found at a point in which the evils bound up with a single move- ment are reduced to minimum terms. We have also sought to find reasons for this result and have naturally prospected hypotheses. It is highly probable that the centre obtained is that which allows the apparatus of the prothesis to preserve complete solidity with the soft parts of the articu- lation in all phases of its movement. For this the physiological displacement of the articular centre of the knee between the components of the skeleton no longer exercises a sensible influence on the functioning of the prothetic apparatus. We propose studying this interesting problem profoundly, but meanwhile we feel encouraged by the results obtained to advise orthopaedists to experiment with the new technics of measure- ment. We believe it will not be out of place to resume briefly the series of reliefs that the technical mechanic will have to obtain each time he has to execute an apparating of prothesis for a mutilated leg, protector or orthopaedic apparatus articulated at the knee : firstly he will obtain them from a healthy limb and then from an injured leg. The first time he will draw 'the contours of the limb as seen in perspective, marking the principal points of departure, viz., the malleola (ankle), the head of the femur, the interlinear articulation and the great trocjjanter. It is advisable, especially in limbs that are very muscular, that the pencil should press firmly for the whole of the contour of the extremity so that the inequalities of the skeleton shall be 518 clearly in evidence (peroneal head, femoral and tibial condyles, great trochanters). On the second trial the circumference of the articulation taken at different levels will be noted, and finally the profile of the limb in flexion will be drawn, from which useful data will be deduced for the construction of the apparatus, particularly the exact height from the anterior margin of the thigh to the point of the foot. We trust that technical experts in orthopsedia will experiment with the technics proposed by us and that our results will receive authoritative confirmation from the results obtained by them. Milan, 15th April, 1918. 519 MILITARY ORTHOPEDIC SURGERY: ITS SCOPE AND AIMS. By COLONEL SIR EGBERT JONES, C.B. I have been requested to state briefly the way in which we deal in this country with the group of cases which we classify under the term " Military Orthopaedics." Both at home and in America the definition practically covers the surgery of the extremities. The Army Council Instruction includes under the term " Orthopaedic " ankylosis of joints, deformities and dis- abilities of the feet, malunited and ununited fractures, injuries to the peripheral nerves, and conditions requiring the trans- plantation of tendons. This represents a very large proportion of the injuries of war, so that constant effort is being made to increase our accommodation which is at present inadequate. We opened our first Orthopaedic Hospital in Liverpool in 1915 with 250 beds, and now we have Centres scattered over Great Britain and Ireland with well over 20,000 beds. In organising an Orthopaedic Centre we decide to have every department represented, and that these departments should bear such a relationship to one another that while they interdigitated they should not overlap. Our experience of uncontrolled special departments led us to conclude that they were lacking in a sense of proportion, and that cases were being bathed, massaged or electrified which required fundamentally different treatment. Unless these special departments are guided by men with an orthopaedic training they might as well not exist. In one insti- tution which we visited we found several men being massaged who should have had their torn nerves sutured. There were others being electrified who required preliminary tenotomies, while others, the subjects of arthritis, were undergoing harmful movements on Zander machines. Again, attempts were being made to break down old septic joints which required the gentlest care. From all the evidence it was clear that special depart- ments should be controlled by well-trained surgeons, and remain in association with Orthopaedic Centres. An Orthopaedic Staff will consist of neurologists, operating surgeons and their assistants, and the chiefs of departments. Consultations are encouraged and take place between the chiefs of the various sections, and the powers and limitations of each department is soon appreciated. The co-operation between the departments is of the most friendly character, and the chief of massage is in constant touch with the chiefs of electrotherapy, hydrotherapy and curative workshops. 520 The departments for treatment consist of : (a) Curative workshops. (b) Gymnasium. (c) Massage. (d) Electrical treatment. (e) Baths. Perhaps the most interesting development is the curative work- shops. Obviously a very large proportion of the inmates of an Orthopaedic Centre are of a chronic type. Many of them have passed through various hospitals and have undergone several operations. Their moral fibre has been weakened by prolonged strain, and they have lived a life of painful indolence for many months. To such men occupation is essential to their recovery, and the curative workshop has been to them a priceless therapeutic boon. For the initiation and organisation of these workshops the nation is deeply indebted to King Manuel, assisted by the princely generosity of the British Red Cross. These shops have a double curative value the psychological and the mechanical. As soon as a derelict finds himself once again a productive agent he becomes transfigured. Hope replaces despair, and we find this mental reaction soon produces its physical changes. Although the Commanding Officer has the power to order a man to work, he practically never exercises it, for we find in practice that we obtain our ends more effectively by persuasion and example. Work is therefore very popular and is in addition accompanied by rewards and privileges. The mechanical therapy is of two kinds direct and indirect. A man with a stiff foot which he is disinclined to use may be given a job to do with his hands. In the interest which the work inspires he forgets to nurse his foot, which almost unconsciously and often very rapidly becomes again mobile. A knee joint which could not bear the continued strain of working a treadle will, perhaps, im- prove in function quickly, while the patient, forgetful of his injury, is working with a saw. This is the indirect method of attack. The direct is invoked when we give a man with a stiff shoulder, paper-hanging or whitewashing, in order to loosen it ; or screwdriving to pronate or supinate his arm, or a plane to mobilise his wrist. The governing principle in regard to curative work is founded on the well-grounded belief that active movements which mean voluntary movements are of infinitely greater value than passive movements which mean those imposed from without. Active movements by exercise in one of its various forms has a direct curative effect upon the muscular structure. Passive movements are sometimes essential in order to stretch or flex a joint in preparation for active exercise, but in war injuries such movements must be closely supervised by an experienced mind. Work in the gymnasium is rendered attractive by the introduc- tion of games carefully devised for definite objects. If these games are competitive they often prove most helpful to the functional element so often grafted upon the organic. Although associated regional types of disability are grouped in classes we depend mostly upon individual attention. A good instructor 521 has a hundred eyes, can detect and watch men with special disability and he always knows the danger of over-exercise. Massage and electro-therapy are governed by well-considered surgical principles, both in regard to the types of graduated contractions induced in order to simulate normal physiological action and the maintenance of uninterrupted relaxation in paresed muscles. We lay it down as a fundamental principle that muscles must not be massaged while they are under tension. In drop wrist, not for one moment is a patient allowed to palmar flex his wrist it must be kept dorsi-flexed while either being massaged or while undergoing electric treatment. In all the centres we have artists and modellers, and careful pictorial records are kept of the various types of deformities. We may have the pleasure of showing you around the Orthopsedic Centre at Shepherd's Bush while you are in London. It is typical of some 15 or 20 institutions run on similar lines and placed in large industrial centres over Great Britain and Ireland. Around each of these centres is grouped a series of auxiliary hospitals supervised by the parent staff. It is desired to make these institutions educational, in order to disseminate orthopedic knowledge among men who will have to deal with after-war problems. Intensive instruction is being given at Shepherd's Bush, Liverpool and Leeds, and in three months a well-trained young surgeon will have thoroughly grasped the fundamental principles of orthopaedic surgery. We have been immensely indebted to the United States, who, as soon as they entered the war, sent over my friend Major Goldthwait and 23 extremely well-trained orthopaedic surgeons. This is a delightful gift for the duration of the war. In addition to these, we have placed at our disposal from the same source 50 American surgeons of junior rank, who can both help us in our work and, at the same time, undergo a training. Even yet such has been the demand upon our young men we have very few Britishers undergoing training. This is most unfortunate ! A young surgeon would be so much more useful and adaptable at the front if he had under- gone an intensive training for three months. For educational purposes congresses are held twice a year, when the staffs from all the hospitals meet to discuss and relate experiences ; while every three months visits are arranged between centres geographically convenient in order that they may link up in efficiency. The operative work done in these centres consist largely in rectifying the deformities of war. Arthrodeses of joints in good functional positions when they are ankylosed in bad ones ; bone grafting and other reconstructive measures for bony deficiencies and non-union ; lengthening of shortened limbs and re-adjustment of malunited fractures; the fixation of flail joints in good functional position, and tendon transplantation for various conditions. We have included injuries of the peripheral nerves in our orthopsedic list because they often require pre-operative, opera- tive and post-operative treatment, and they were the type of 522 case which at the beginning of the war were found to be neglected owing to the pressure on beds. Such cases are most carefully examined by neurologists who work in close conjunction with the surgeon. In this way the nerve cases are under admirable control, and we endeavour more and more to segregate the cases requiring suturing under the care of those men who do the work best. A feature of the neurological work is the success which has attended tendon transplantation in irreparable damage to the musculospiral and post-interosseous nerves. Distinguished general surgeons overlook the work of each of the centres. There has been a very natural anxiety on the part of the War Office at the prolonged retention of men at the Orthopaedic Centres; but when the other side of the picture is presented, and it is realised that over 70 per cent, of the cases are returned to military life, it is evident that the patient care which has been devoted to them is justified. The Orthopaedic Hospital is the only link which makes it possible for the Pensions Ministry to make a useful citizen of a disabled soldier, The regret we must all feel is that so many of the deformities which we have to rectify might be avoided were surgeons more generally instructed in mechanical principles. More recently to expedite the process of cure, to diminish the time of hospital treatment, and to prevent the formation of these chronic disabilities steps have been taken to bring suitable cases from overseas direct to the Orthopaedic Hospitals. They are labelled " Orthopaedic " and taken in convoys direct to the centres. The stay in hospital is in this way much diminished, as the facilities and equipment are such as to ensure that the best thing shall be done, and at once. Another useful method of improving treatment is that of pro- paganda. Command Depots are visited monthly by orthopaedic surgeons, and the doubtful cases are discussed in groups. In- structions or suggestions are sent to the various hospitals all over the country dealing with preventive methods. The fol- lowing suggestions, drawn up by the consultants and sent round to all the hospitals in the country, may be useful as an indication of what is being done : (a) Gunshot injuries through the joints followed by suppuration, generally result in ankylosis. The position of greatest usefulness in such conditions are : Shoulder. The arm should be kept abducted to about 50 degrees. The elbow should be slightly in front of the coronal plane of the body, so that when it is at right angles, and the forearm supinated, the palm of the hand is towards the face. The arm is placed in this position, while the scapula retains its normal position of rest. The humerus being fixed to the scapula at the angle indicated, the arm can be lifted to a considerable height by scapular action. 523 The arm should not be kept more abducted than 50 degrees, otherwise scapular action will not allow it to be brought to the side. <% Under no circumstances should the joint be allowed to ankylose while the arm lies hanging down, for the functional result will be so bad as to necessitate an osteotomy later on to correct the adduction. Elbow. The position must always be influenced by the patient's calling, but in the majority of cases the best functional results are obtained when the angle ^between the humerus and the forearm is a little greater than a right angle, i.e., about 110 degrees. The forearm should be supinated so that that palm is directed slightly upwards. If both elbows are ankylosed, one should be about 110 degrees and the other 70 degrees. Wrist. All injuries of the wrist joint should be treated with ihe wrist slightly dorsi-flexed, with the fingers spread well out (see paragraph . " e " later). There should be no exception to this rule. Hip Joint. Ankylosis should be secured in the position of slight abduction, the thigh extended and slightly rotated out- wards. Knee. It should be fully extended, care being taken to avoid hyper-extension . Ankle. The foot should be kept at right angles to the leg, in a very slight varus position. A valgoid position of foot is to be specially avoided. (b) Gunshot injuries of joints followed by rapid healing. During the period of rest, these joints should be kept in the same position as indicated above. If there is no considerable damage to joint surfaces, movement may be expected in many of these cases if ample time is given for recovery from inflammatory change. Any attempt at breaking down such cases under an anaesthetic is to be deprecated. Such joints require very careful handling. The shoulder will serve as an instance. Without removing the shoulder abduction splints, the joint should be well massaged for a few days. If there is no reaction, it is safe to remove the arm a few degrees from the splint and let it down again. If this is not followed by reaction, it may be repeated every day, and the patient encouraged to lift it actively from the splint. When he can do this easily, the splint can be bent a few degrees (adducted) so that further movements can be practised. Massage and electric stimulation of the deltoid are indicated. The principle is one of alternative attack and rest. If reaction occurs a further rest of the joint is needed. A similar principle of treatment applies in similar injuries of other joints. 524 (c) Injuries involving tissues in the neighbourhood of joints, resulting in suppuration, deep scarring, fyc. No attempt should be made to break down these cases under an anaesthetic. The knee-joint will serve as an example. When by massage and other tests there is reason to expect no inflam- matory reaction, graduated movement may be attempted. If the knee is straight with, say, 10 degrees of movements, a splint is moulded allowing the joint to flex to 25 degrees. The limb is bandaged to the splint. When the joint ha's yielded so that the limb lies easily on the splint, it should remain in that position for recovery of the strained tissues to occur. Movements are then practised by the patient within the range of 25 degrees. If voluntary movement is free within that range, a greater angle is given to the splint and treatment is repeated. If the joint becomes tender and stiffens in the new position, it must be placed back in the straight position and rested. When movement has been secured to about 45 degrees, active and passive movements may be continued in the gymnasium. In all extra-articular lesions of the axilla and its folds, where ankylosis of the joint is not expected, the arm should be placed in the fully abducted position. (d) Injuries occurring at a distance from the joints, fractures, Sfc., with inflammatory changes occurring in the muscles. No joint, not the seat of an arthritis, should ever be allowed to stiffen permanently. In all fracture cases where it is possible to move the joint, without interfering with the fixation of the fragments, this movement should be practised. One gentle movement in each direction once in two days is sufficient. Passive movements, which involve frequent repetition of the same movement, are unnecessary, and often harmful. If the joint is A^ery stiff after prolonged immobilisation, and where the bone is supposed to have united, great care is required. The bones above and below the joint should be well splinted while movement is started if neces- sary under full anaesthesia. Unless the joint yields readily, the surgeon should be content with a few degrees of movement, the joint should be secured for a few days, and the surgeon may renew his efforts from time to time. Bone is soft for many months after a gunshot injury, and many fractures have occurred again as the result of attempting to move the joint without first protecting the bone from strain. This is especially true of fractures above the knee and near the shoulder joint. (e) Stiff fingers. All splints for dorsiflexion of the wrist, especially where frac- tures or inflammatory changes have occurred in metacarpals and phalanges, should be moulded in the position the hand takes when holding a cricket ball. Particular care should be taken not to over-extend the metacarpophalangeal range, as stiffening in this position is most intractable. The palmar arch should be maintained concave, the short dor si-flexion splint should leave 525 ample room for movement in the metacarpophalangeal range, and should be moulded to allow of adduction of the thumb. At the earliest possible moment active movements should be encouraged, and massage and passive movements should be gently practised. The so-called " breaking down the fingers," followed by swelling from effusion, retards recovery. The movements should be very gentle to be effective. GENERAL REMARKS. In all cases where the injury does not directly involve the joint, massage and active movements should be encouraged. Even when a joint has to be fixed in consequence of a fracture in the neighbourhood, early massage and electric stimulation is needed in order to prevent adhesions forming in the muscle sheaths. The patient should also be taught how to contract his muscles while the limb is splinted. Splints should not be applied to the fingers except where they are the actual seat of fracture or active inflammatory changes. In all fractures of the forearm, the hand should be supinated. All splints should be removed from the upper extremity at the earliest practicable moment. As bones take a very long time to harden, the lower limbs, inasmuch as they have to bear body- weight, should be guarded against deformity during walking. Neglect of this precaution has given rise to many cases of bowing and overlapping of the femora. All gunshot injuries of the joints have to be treated with great gentleness, and the breaking down of such cases under an anaesthetic is to be generally avoided. Our pre-war experiences are not applicable to the gunshot injuries which present themselves. All scars about joints should be kept extended during healing unless a contra-indication exists. Care should be taken to pre- vent equinus at the ankle taking place during the treatment of other lesions of the limb. As patients have to be discharged while still under treatment, it is imperative that full instructions should be given to the local Pensions Committee as to the further treatment that is needed. These instructions give the various surgeons many of whom have not had an Orthopaedic training fundamental principles upon which they can act. All the artificial limbs in the country were made first of all at Roehampton House in London. This hospital, though not included in the Orthopaedic scheme, is staffed by Orthopaedic surgeons. It was soon found necessary to decentralise, and limbless hospitals were started in Scotland, two in Ireland and one in Wales. Quite recently it has been decided to start fresh Centres in direct connection with the Orthopaedic Centres at Liverpool, Leeds, Manchester and Birmingham. Three of these have already started work. They are under the joint control of the War Office and the Pensions Ministry. The patient remains in the Army until his artificial limb is fitted. 526 But the Curative workshops can be utilised in an invaluable way by the facility with which they can turn out provisional limbs of a cheap but effective pattern, by means of which the soldier can be provided with a method of locomotion as soon as he can bear his weight on the stump. He can very soon discard his crutches and move about with a stick. A further boon has been conceded. He can go to his home on furlough with this provisional limb until such time as he i> required to enter the " Limbless " Hospital for the adjustment of the permanent artificial leg. Such are the means adopted to restore function, and render the patient fit to return to the Army or to go back to civil life. If sufficiently restored the patient may go to a Command Depot for further training, or be remitted direct to his unit, and become again a serving soldier. If he is so disableid as to be unfit for further service, he is discharged from the Army and becomes a pensioner coming under the supervision of the Pensions Ministry. The discharged soldier, now a pensioner, may be able to go back to his old trade, or he may find a new job in which he may be employed without further training ; or he may be re-educated for another trade or craft. Arrangements are being made by means of classes in the technical schools, through private em- ployers, or by the establishment of new institutions, in which he can get both training and treatment. Many of the Orthopa?dic pensioners require very prolonged treatment, necessitating close observation for a considerable time, combined with massage and electrical treatment, etc. For this purpose numerous out-patient clinics are required and set up. One paramount consideration should be kept steadily in view by the Ministry of Pensions 'in this connexion. Any pro- vision for the treatment of the Orthopaedic pensioner must be made so as to allow of adequate supervision, control and inspec- tion by an orthopedic surgeon. Continuity of treatment is lost otherwise, and the patient, careful work of months may be undone. The complete organisation in relation to the treatment and training of the pensioner should include : 1. An out-patient clinic, with massage and electrical instal- lation. 2. Beds for in-patients. Both these to be inspected and supervised through the nearest Orthopaedic Centre. 3. Hostels. 4. Means of re-education. 527 Military Orthopaedic Centres exist now in all the Commands. In the Scottish Command there are three at Aberdeen, Glasgow and Edinburgh. At all three, and at Dundee as well, arrange- ments have been or are being made for the correlated treatment and training of the Orthopaedic pensioner. In the Irish Command there are two Orthopsedic Centres at Belfast and Dublin. In Wales, the Welsh Metropolitan War Hospital, Whitchurch, near Caitiff , is the main Orthopsedic Centre. A second one is in the process of being established at Newport, Mon. Arrangements are now being made at Cardiff to co-ordinate the treatment of the Orthopaedic pensioner with the military Orthopsedic Centre at Whitchurch. In England there are two Orthopsedic Centres in the Northern Command at Newcastle-on-Tyne and at Leeds. In both the pensioner is to be dealt with by association of his treatment with the organisation of the Military Orthopsedic Centre. In the Western Command (in which Wales is included) there are in addition, Centres at Liverpool and Manchester. In the Eastern Command a Military Orthopsedic Centre is being organ- ised at the Military Hospital at Edmonton. In the Southern Command, Centres exist at Birmingham, Netley, Oxford, Reading and Bristol; and in the London area there are Shepherd's Bush and Tooting Military Orthopsedic Hospitals. For the orthopaedic pensioner it is necessary that all schemes of treatment shall be closely allied to these Military Orthopsedic Hospitals, so as to be able to take advantage primarily of the special knowledge and training of the staffs of these institutions, and when it is possible to make use of the establishments them- selves. The pensions beds must be either at or closely proximate to the Orthopsedic Centre, as it is impossible to re-duplicate staffs. Many more subordinate clinics are needed however in towns where recognised Orthopsedic Centres do not exist. Such insti- tutions should be affiliated to the nearest Orthopsedic Centres in the several Commands. As each Command possesses at least one Military Orthopsedic Hospital, these subordinate clinics should be set up by the Ministry of Pensions, after consultation with the War Office, and each should be periodically inspected by skilled orthopsedic surgeons. Such arrangements must be made if continuity of treatment is to be maintained and the pensioner is to be restored to health. The staffs for the pensioners' clinics should undergo an intensive training at an Orthopsedic Centre. 528 Such are the scope and aims of military orthopaedic surgery. Arising out of principles adopted for the treatment of crippled children, it has expanded into a huge organisation of extreme military importance first, with the object of receiving the serving soldier and sending him back to the fighting line ; and, second, to reconstruct and restore the functions of those so badly crippled as to be useless as fighting units but who, if properly treated, may take their places as useful workers and efficient members of organised society. 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