ference between representatives of the compensation bureau and the State bureau of rehabilitation. Without such conferences these two State agencies, each created for the purpose of assisting and protecting the interests of crippled people, will be working frequently at cross purposes, neither being familiar in many cases with what the other is doing or contemplates doing.

In stating this conclusion it should be thoroughly understood and expressly stated that we have no wish to assume responsibilities or authority not delegated to us under the law. The law expressly and very properly places with the industrial commission full responsibility and authority for determining when and how compensation shall be paid-whether in a lump sum, in the form of an advance award, or in the same manner as wages. We have no wish to trespass upon this prerogative. Rather we desire to assist them in arriving at a just conclusion in the best interest of the disabled man by presenting all the pertinent facts in our possession which are acquired not only through more intimate contacts with the man himself and his employers, but with his family, his neighbors, his church, and his friends. Without these contacts you can not do an effective rehabilitation job. Through them you can frequently present to the industrial commission, if you will, matters of prime import which will be the determining factor in reaching a just conclusion.

Without exception I may state that any constructive rehabilitation program which you have mapped out for a crippled person will be the determining factor in awarding or disallowing a lump sum application by the industrial commission if they but know of your plans. It is our duty to keep them advised. On the other hand, there will be lump-sum applications filed by injured people before you receive a report of such injury. Invariably this is a potential rehabilitation case, except in cases of widows and orphans. If you are advised by your compensation bureau of the filing of this application you can establish contact with the applicant, alter his plans in conformance with the dictates of your broader experience, make available for him many of the liberal provisions of your rehabilitation law, and almost without exception establish him on a more fundamentally sound basis than would be the case if your interest were not enlisted.

Because lump-sum settlements are justified only under exceptional circumstances; because all lump-sum applications (excepting always widows and orphans) result from injuries so serious as to cause the applicant to be a potential rehabilitation case; because this money (lump sum) so often enters into any constructive rehabilitation program; because your rehabilitation job gives you access to channels of information not ordinarily available to the industrial

commission; because the ultimate object of the industrial commission and your bureau, in their broader aspects, are identical, safeguarding the future and protecting the interests of the State and the worker, you should submit a report of your findings, either verbal or written, to the industrial commission in advance of formal hearings on all lump-sum cases, emphasizing especially the relationship of this lump sum to your rehabilitation program.

We have been doing this during the past 18 months in western New York State. Formal reports have been submitted to the industrial commission in about 240 cases. Actually we have made more than 500 investigations. The latest reports compiled cover 202 recommendations over a 15 months' period as follows.

We recommended lump sums be disapproved in 102 cases; that award be granted in 100 cases for following purposes:

The gross awards involved totaled $430,177.12 of which $221,880.10 was disallowed and $208,297.02 awarded and paid in accordance with our recommendations for purposes described. A satisfying feature in connection with this work has been the complete harmony in thought and action between representatives of our respective bureaus during all this period. Another feature which argues well for the arrangement is the fact that not a single appeal has been taken from one of these 202 decisions by either claimant or carrier. Thus far our little experiment seems to have met with the unqualified approval of all thoughtful and intelligent people who have interested themselves in this complex problem. This arrangement is no panacea. We have had a few failures but infinitely fewer than under any plan yet devised of which I have knowledge. We are following our cases up closely enough to know when they have apparently been successful and when they have failed. Among all our rehabilitated cases during this period of time those cases wherein lump sums have been involved have been relatively more successful on any basis of computation than those wherein lump sums were not involved.

Realizing our own limitations, we have interested every large bank in Buffalo and banks in many of the smaller communities in our

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problems. As a civic duty they have agreed to and are appraising homes, farms, stores, etc., for our crippled clients every week, almost every day. Their reports are incorporated in our recommendations to the industrial commission.

We spare no energy, shirk no responsibility in efforts to prevent the physically handicapped from obtaining a lump sum when the money and the man would not seem to be adequately protected. Where lump-sum awards are recommended every conceivable safeguard within the province of our rehabilitation efforts is being thrown about our crippled clients.

This is a rehabilitation effort well worth your while.

Chairman FOSTER. Mr. Edward I. Benson, Cleveland, will talk to us on" Artificial appliances." Mr. Benson.

ARTIFICIAL APPLIANCES

EDWARD I. BENSON, District Supervisor of Rehabilitation,
Cleveland, Ohio

My experience in dealing with handicapped persons leads me to believe that the supplying of artificial appliances is one of the most important features of the rehabilitation service. I am sure that the service could never have attained the success it now enjoys without the aid of the modern up-to-date appliances.

I am not going to speak on the legal expenditure of funds for appliances, as you are all familiar with this phase of the law, but am going to talk of my experience in the purchase of limbs, what is demanded from the limb maker, what I consider the ideal stump, and the method used in getting suitable service.

Everyone doubtless has had the same experience in having some artificial limb manufacturers who thought this service was created for the purpose of supplying them with business and who undertook to appoint themselves as volunteer agents and proceeded to go out and beat the bushes for the purpose of locating all the old cases who could not purchase appliances and referring them for the sole idea of getting an order.

After a year of this method, it was concluded that the only possible way of handling this correctly would be to dictate suitable terms, and with this in mind a prominent limb maker was called and conditions under which orders would be placed were explained.

First, measurements should be taken at the limb shop, and the man who took the measurement should make the limb from the foot to the enamel. Second, no measurement should be taken until the stump was properly reduced. Third, I must be present at the final fitting to see that the amputee is properly instructed to walk; that he receives assurance that any repairs necessary to any part of the

limb or harness will be made free of charge the first year. This also includes a reliner if necessary during the first year. The amputee is instructed to return to the limb shop every day for the first week, and after that as soon as he finds it necessary to wear two stockings. Under these conditions, we in Cleveland have ceased to worry over what was once the most disagreeable part of our work.

I believe a description of certain appliances used for different amputations would be of interest. The so-called Chopart is for the partial foot amputation. This is made by fitting a form made of aluminum filled with cork and padded with soft leather or felt to the amputated part with a soft leather boot laced around the ankle to insure adherence to the stump. The Symes appliance is made for the amputation at or near the ankle joint, and the stump is fitted with a heavy leather laced boot extending to the knee and laced up the front, the stump taking the bearing upon the end. The ankle is stiff, and, all in all, an unsightly appliance is the result.

The Chopart and the Symes appliances have proven very unsatisfactory, and a much better result may be obtained by recommending a reamputation at the middle third, leaving the stump not less than 6 inches long. For this amputation you have the below the knee limb, and an ideal appliance consists of wood with a leather socket at the knee, felt foot with ankle movement, and a corset of suitable length, weighing not to exceed 6 pounds.

The knee-bearing limb is similar to the Symes in that the bearing is taken at the disarticulated part. The lower part is wood with the upper corset of leather and laced down the back. This, like the Symes, is unsatisfactory, due to the extra weight and the tendency to irritate because of insufficient padding on the end. It is wise here to recommend a reamputation above the knee, leaving a 9-inch stump.

The above-the-knee limb is made of wood below and above the knee, with knee and ankle movement. The 9-inch stump allows the limb maker to taper the socket and make a neat, practical limb. Below the 9-inch mark the knee would have a tendency to protrude beyond the other member when seated. For thigh amputations, where the client has learned to walk with one crutch, the use of an artificial appliance should be discouraged.

For amputations below the elbow there is no need for me to say that the artificial arm with the Dorrance hook is the most practical and simple appliance at our disposal to-day, although I prefer the leather socket in place of the wooden, as it will stand more abuse. I like the simplicity of the Dorrance hook and am in accord with a leading authority on arms that the more complicated the appliance with levers and springs and moving parts the more useless it is.

I can see no practical use for appliances above the elbow with the exception of use for a weight for paper or holding down other objects.

For partial hands I prefer a hook built into heavy molded leather with a cuff attached to the wrist or forearm.

To conclude, I want to add that the success of any appliance depends a great deal upon the amount of soap and water used on the stump.

Chairman FOSTER. Mr. H. C. Givens, of Arkansas, will talk on "Maintenance." Mr. Givens.

MAINTENANCE

H. C. GIVENS, Rehabilitation Agent, Arkansas

Mr. Chairman, ladies, and gentlemen: In speaking of maintenance in connection with compensation, I am handicapped because, as Mr. Andrews told you, Arkansas has no compensation law. There are, however, some States which through their compensation acts, secure funds for maintenance under certain conditions. There is this to be said in regard to maintenance funds secured in this way, it limits the rehabilitation worker in regard to the people for whom such funds may be used. For example, in Pennsylvania maintenance from this fund can be used only for industrial accident cases. New York State is more fortunate. They have, in addition to their compensation fund, a fund from another source which they can use for other than compensation cases.

I think none of us are interested in the problem of a large maintenance fund. The question is that of securing a fund sufficient to take care of the indigent cases which come to us.

In analyzing the various sources of revenue for this purpose we find four distinct types of legislation: First, the one I have already mentioned, through compensation; second, a direct maintenance appropriation created by the State legislature; third, a rehabilitation act in which is included, among the duties of the board in charge of rehabilitation, a clause which provides for the maintenance of certain people, under certain conditions, and usually for a limited amount: fourth, a rehabilitation act so worded that the State board in charge of the rehabilitation work can authorize the expenditure of part of its appropriation for maintenance purposes.

Those of us who have no maintenance provision are obliged to solicit funds, not only for maintenance in certain cases, but incidentally for physical reconstruction work which does not come under Federal aid. We may, through the cooperation of the county commissioners, secure county funds. I know of a number of States. where this is done, particularly for the maintenance of indigent