It would seem, therefore, very important at this time to add to the various methods used in reporting cases an extensive program to educate all employers and their employees in the value of the service and also in the importance of notifying the civilian rehabilitation service as soon as a disabling accident occurs.

The merits of the methods as given by Mr. Thompson can ouly be measured by the results they bring in the communities in which they are used. Therefore, I believe that any further discussion should come from those States who do not use them or have other methods than those mentioned.

Chairman FOSTER. Mr. J. F. Marsh, of West Virginia, will lead the discussion on "Lump-sum settlements." Mr. Marsh.

LUMP-SUM SETTLEMENTS

J. F. MARSH, Director of Rehabilitation, West Virginia

Mr. Chairman, ladies, and gentlemen: I have nothing to add to the discussion of this subject except to caution those of us engaged in the rehabilitation service that we give no advice about lump-sum settlements unless we feel very sure that we have information that is superior to the information possessed by the compensation department, because we are likely not only to lose our own reputation by giving haphazard advice, but may do injury to the person receiving the compensation.

We have in our State, in very few cases, been able to secure lumpsum settlements to set a man up in a safe business much to his advantage.

I might close by reminding you that the best example of the disaster coming out of lump-sum settlements is recorded in the Bible itself, because you remember a certain man had two sons, and one of these, the younger son, said unto his father, "Give me a lump-sum settlement." And he secured that settlement and went into a far country and fell among thieves and robbers and swine and real estate agents. And he spent his substance in riotous living, and finally got into an automobile smash-up and was crippled, and the rehabilitation agent came to his assistance and took him back to the place from whence he started and advised the old man to get him another job, or to restore him to the original job, and never again to give a lump-sum settlement without a careful survey. So, in general, I am against the principle of lump-sum settlements.

Chairman FOSTER. Mr. Marsh, I think you made a very valuable contribution to the subject.

Mrs. Mary C. Lewis, of Michigan, will lead the discussion on "Artificial appliances." Mrs. Lewis.

ARTIFICIAL APPLIANCES

Mrs. MARY C. LEWIS, Rehabilitation Officer, Detroit, Mich.

Mr. Chairman, ladies, and gentlemen: My method of leading discussion may seem like a prearranged plan to give Mr. Benson more than the five minutes allotted to him, but I feel that his paper calls for the discussion of several questions that arose during his reading. Why have the measurements for artificial appliances been taken at the shop rather than by the salesman at the applicant's home?

Mr. BENSON. The purpose of that is that the man who takes the measurement sees the applicant for a limb, who may be bow-legged, or knock-kneed. It would be a very valuable thing for the man who makes the appliance to know that peculiar thing about him, so that he could apply it when making the appliance. The artificial limb must be made in the form of the original limb. It must be lined up in that same fashion. If it isn't the man may not be properly balanced.

Mrs. LEWIS. Do you consider it an advantage to have the manufacturer or the salesman wear an artificial appliance?

Mr. BENSON. I will answer that by saying that I don't see anv advantage in having the dentist having his own teeth out, or the surgeon in having his leg off. Again, might not the salesman have to have his leg off probably in a dozen places, which wouldn't be possible.

Mrs. LEWIS. Why do you advise the 6-inch stump?

Mr. BENSON. I wouldn't say 6 inches. I say not less than 6 inches, if that is possible. If the surgeon can elect to amputate where he wants, I would say between 6 and 9 inches, because between 6 and 9 inches and the middle third of the lower limb you find the live, meaty flesh which can be properly padded. The bones there can be properly beveled like the end of a broom. But when you get down close to the ankle you have bones down there with no live flesh to pad and the wearing of an artificial appliance means an eventual reamputation.

Mrs. LEWIS. Why do you discourage the use of artificial legs for thigh amputations?

Mr. BENSON. I didn't make that as clear as I should. That paper was confined to five minutes and so I didn't have the time to go into details.

I discourage the use of an artificial limb where a boy is between the ages of 16 and 25. I was reared with two young men from the time they were probably 6 years old, who had 3-inch stumps. Neither one of those men will ever wear an artificial leg. Nobody in our neighborhood could walk or run faster than they could. There

wasn't a better catcher on the baseball team than one of these boys. If you had put an artificial appliance on you would have slowed him up. And in this day of speed he is going along like all of us on that one crutch. He can jump over that table any time.

Mrs. LEWIS. What special appliances do you use for hand amputations?

Mr. BENSON. I never recommend a special appliance for hand amputations, for this particular reason: If the man hasn't enough intelligence and initiative to recommend his own appliance for the thing he is going to do, you or I never could help him do it. Let him give you an idea of the job he is going to do and the appliance that he is going to need, and if it is going to be a successful appliance he must recommend it and you buy it. That is about the only function you have.

Mrs. LEWIS. I noticed that you advise reamputations in certain cases. How do you get to the man to agree to that sort of procedure?

Mr. BENSON. We don't always get it. The majority of the surgeons that I work with in this section of the State amputate during the emergency where they can, and possibly a week or two after they tell the man that they must go in and do a little more work with it and trim it up to suit an artificial appliance.

You will find to-day that the majority of surgeons have in mind this idea in amputating for an artificial appliance. Some of the older surgeons are just amputating, but the modern surgeon amputates for an appliance and he gets that ideal stump, that 9-inch and that 6-inch stump.

Mrs. LEWIS. Since five minutes have expired, I shall, in conclusion, leave this suggestion with you. If you wish to read a book in which you will find vividly depicted the agonizing results of wrong amputations, and also have a portrayal of the happy effects of right amputations, I beseech you to read "Plumes" by Lawrence Stallings.

Chairman FOSTER. Would someone else like to add to this discussion?

Mr. H. L. STANTON, supervisor of rehabilitation, North Carolina. I was very much interested in this subject for four or five years, reading everything I could get on it. I am wondering if Mr. Benson could give us any suggestions as to how we might educate some of our surgeons as to proper amputations for artificial limbs. I think that is really a serious need, especially in the State of North Carolina. I'd like to know if he has made any attempt to do that. Mr. BENSON. I have made some progress in doing that by forgetting all ethics and forgetting the fact that the surgeon is not to be

criticized. I have just "taken the bull by the horns" and criticized the surgeon, and I have come for a lot of criticism for doing that. I don't believe you will be able to do it any other way. The only way you can do it is by just telling him that you don't think the job is right. Embarrass him. Ask him if he will take the case up to Doctor Smith or Doctor Jones, forgetting that he is a doctor, and ask Doctor Jones if he thinks that is a good amputation.

J. R. JEWELL, Supervisor of rehabilitation, Nebraska. Right along the same line, I think there should be in the various medical schools throughout the country, especially in those which are operated upon State funds, or funds obtained by taxation, in the last year of the curricula, which the student surgeon spends in the hospitals, a provision that the surgeon must spend at least 90 days in the fitting room of an artificial appliance factory, because he will get more first-hand information on horrible results obtained from poor amputations, incorrect amputations, some of them almost criminal. He will get more solid information out of that than he can by reading all of the books published on the subject at the present time.

We have several prominent surgeons who have made quite an investigation of that subject, but they can not make an impression on their own field because of the wall of ethics which is built up in the medical and surgical profession. It is something which will have to be attacked by the schools themselves. And it will take a lot of constructive, hard, honest effort on the part of people interested in rehabilitation of persons disabled by amputations to put the thing over.

There is one other phase of the artificial-appliance proposition that I haven't time to touch on, and that is that the results a man obtains from an artificial appliance depend largely on the fit. The fit that a man obtains from an artificial appliance depends on the ability and the experience of the fitter.

A man can not plumb your house, wire your house, or make you a set of false teeth without a license. Why should he be allowed to practice on the American public who have the misfortune to suffer amputations without having first passed some examination under a State board which definitely establishes the fact that he is qualified as an artificial-limb fitter? There are no such regulations that I know of existing in any of the States, but I am firmly convinced that there should be.

Mr. CUMMINGS, member of rehabilitation staff, Federal Board for Vocational Education. I see in the audience Doctor Kessler, of New Jersey, who has had a great deal of experience in physical restoration work and amputations. I suggest that if time permits Doctor Kessler say a word or two.

Doctor KESSLER, rehabilitation staff, New Jersey. I don't think the medical profession needs any apologies or defense. I think what the previous speaker did say about the medical profession at large is true in certain respects.

Wherever you have poor surgery you will have poor amputations.. However, those men who are doing reconstruction work, doing orthopedic surgery, doing physical rehabilitation, are properly qualified both to recommend and to do the type of amputation and to recommend the proper type of appliance to be used.

However, the question resolves itself down to this: That you have a proper medical or physical rehabilitation program in conjunction with your vocational rehabilitation program. This, fortunately, we have in New Jersey, and for that reason perhaps we have not had much difficulty in securing the proper type of surgery and in securing the proper type of artificial limb.

There is one point I wish to make, however. We have always relied on the judgment of the limb maker in fitting the artificial limb. However, there is a critical period in between the time that the limb is amputated and the time it is going to be fitted where proper medical and orthopedic supervision is necessary, and because of the structure of our organization, because of the number of clinics that we have, and the manner of their being outfitted, both as to personnel and appliance, we are able to take the amputee and give him the proper treatment in between the time that the leg is amputated and the time that the artificial appliance has been fitted.

I can agree with Mr. Benson in practically everything he has to say, and for that reason I do not wish to discuss the paper except to say that wherever you do have poor surgery you will have poor amputations. However, it is really a question of medical ethics. It is also a question that the doctors have to fight among themselves. You take the surgeons of the different hospitals; they are angry now because orthopedic men want everything. The orthopedic men want fractures. Surgeons are saying, "There will be nothing for us to do but the navel."

Mr. STANTON. Mr. Benson brought out a new idea to me this morning. I think I understood him to say that he didn't believe that thigh amputations should be fitted with artificial limbs for cases under 25 years of age. Is that correct?

Mr. BENSON. I should make that slightly flexible. That would depend upon the individual entirely. I am talking about a group. Mr. STANTON. We have had some unfortunate experiences with very short thigh stumps. We feel that we have been quite successful in fitting all ages with longer stumps. We have with us, I believe, this morning, a gentleman who has made a very careful and thor