his objective, surgery for the injured worker, with the purpose and aim of restoring that worker to a job. He is known not only nationally but also internationally, being a member of the International Conference of Industrial Surgeons. I take pleasure in introducing Dr. Fred Albee. Doctor Albee.

MEDICAL ASPECTS OF CIVILIAN REHABILITATION

Dr. FRED ALBEE, New York City

I speak to-day as a surgeon who has been interested in the technical side of reconstructing men, also as the chairman of the Rehabilitation Commission of New Jersey, and as a man who when through the war period, organized one of our large general hospitals, No. 3, having had the privilege of organizing the only hospital organized by a surgeon from civilian life under the auspices of the Surgeon General of the United States Army and of the Red Cross. I have visited Canada and Europe a number of times in studying this problem; in fact, I recently attended the International Congress on Accidental Diseases and Surgical Conditions in Amsterdam, Holland.

I do not believe there is any subject in the realm of medicine and surgery that is as important to the public and to labor as the subject of rehabilitation. Mr. Elton, our chairman, emphasized the clinical' and surgical aspects of the subject, while the speaker following, interested in the social aspect, considered that more important. Before going further I wish to quote from the report of the New Jersey Rehabilitation Commission, that has just been issued, to show the number of injured men and women that come to the State of New Jersey for help, and the service rendered them.

In New Jersey there were 9,752 individuals examined last year who came under the rehabilitation service. Of that number, 8,044 were treated. Of that number, 6,000 were returned to their old jobs, leaving of those treated, something like 2,044 people, to be directly aided to employment by vocational direction. Forty per cent of these cases were under treatment for three months or less.

I don't know whether you are familiar with the organization that has been developed in New Jersey, but we have divided the State into five districts, in each of which a State clinic has been established.

The previous speaker has pointed out that rehabilitation is a recent term. I am certain we very rarely, perhaps never, saw the term. "rehabilitation" before the war. It came very prominently to the fore during the war. As you probably know, the allied nations in calling a conference in Rome in 1919 to present what had been learned by them in this line of work used the term "Rehabilitation

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congress." I had the privilege of representing the Surgeon General at that conference. That, I think, was the very first use of the word "rehabilitation" in the broad sense in which we are thinking of it to-day.

At just about that time I was writing a textbook on this subject, and as an orthopedic surgeon my first inclination was to use the old established term of "orthopedic surgery," but I was so influenced by the work at the time, and by this congress in Rome, that I couldn't refrain from adding the word "rehabilitation," making the title of my book "Orthopedic and Rehabilitation Surgery."

Rehabilitation, I think, is a very good term for our work. I believe it is a very good term for all interests to further. Our old established terms in the surgical profession, naturally, do not cover this work, because it did not exist at the time when those terms were first coined. Whether "orthopedic " will be given up entirely I don't know, but I favor the word "rehabilitation " as covering the whole process, whether it is technical surgical process or whether it is combined, as it most always has to be combined, with organized effort to restore disabled persons to industry.

Now, you have said a great deal when you have said that. It can't be done by individuals. An individual surgeon can't possibly do all of this work. He must be supported by organized effort, and that organized effort must be taken up and carried on by the State. Under our republican form of government it is the duty of the State to take care of the individual.

As I view rehabilitation, it means everything that takes place from the time the man is injured, from the time the man has an incapacitating disease, until he is placed back in industry. Shall we include prevention in that? Of course! Prophylaxis, as we term it, the prevention of disease, is certainly part of our medical and surgical studies. Whether we should consider in rehabilitation the prevention of accidents and the prevention of disease is a question to decide. And just for the moment in discussing the common application of the word "rehabilitation," we shall take it from the time the person is incapacitated to the time of the initial treatment. In New Jersey the initial treatment is chosen usually by the patient, though the insurance carrier always has the privilege of having a consultant on the case. And then, of course, from that time the treatment starts. If this first aid does not put him back into employment or return him to the job, then so-called definite treatment starts. That may mean an extensive surgical operation or it may mean a physiotherapeutic treatment carried on in some clinic. that is organized to do that, or it may mean the surgical operation followed by physiotherapeutic treatment.

Of course, rehabilitation is a great big job and I can't possibly cover the whole field to-day; therefore, I want to emphasize, other than what I shall have to say about reconstruction service, the curative workshop.

In general hospital No. 3, to which I have referred, we had a very extensive curative workshop. We could put a man at most any kind of work, from clay modeling to electrical engineering. The equipment was very extensive and very expensive. It was partly supplied by the United States Government and partly supplied by very generous donors. I was tremendously impressed with the woLK and the benefits resulting from that type of work.

One of the things that struck me most forcefully in the very beginning, was the fact that we had most urgent requests from the boys to have the curative workshop open every day of the week. Originally we had planned to have the shop open only during week days and not on Sunday.

I will never forget the first day we opened the shops. The director said to me, "Colonel, we must have you around with us." Everybody was a little nervous as to whether this thing was going to be a "go" or not. So I devoted a half day to it. I selected a man whom I considered my most efficient ward surgeon and visited his ward. I was much interested in his inability to size up what this workshop was to accomplish because of his method in selecting men for it When we came to a certain man who, in my judgment, needed the service, he passed him by and said, "Oh, he is a grouch."

I motioned to the ward surgeon to come out to the dressing room to discuss this man's case. I said, "Captain, why not let him be the man? I believe he is the best case you have in your ward."

"He is troublesome."

"Yes, but he is worried about himself. If we can get something to occupy his mind and at the same time work out his stiffened arm (his arm was stiff from the shoulder down to the wrist, having had a very severe injury) wouldn't he be possibly the very best case you have? Wouldn't this curative workshop be the best thing for him?" He graciously allowed me to overrule him, and I did rule that this man be sent to the curative workshop. That man's sleepless nights were made restful nights; he was transformed from a troublesome patient to one of the best we had in the hospital. That was an eye opener right in the very beginning.

From the surgical side it has been proven without doubt that active exercise, active motion, with the man's mind occupied, relieves the contrary muscle spasm that always exists. The man is apprehensive of motion. The very moment he gets ready to do something he thinks of the motion that is going to be produced,

say, in his elbow, and his muscles involuntarily go into a state of contraction. And that is certainly in opposition to what we wish. We want involuntary muscle motion without any muscle spasin, and the only way we can get that is to get the man's mind occupied. And if at the end of the week there is a pay envelope, then we have the maximum amount of leverage on the man's mind, especially if it is piecework he has been doing. The increased amount of work he does will be represented in his pay envelope. If we can get a spirit of competition between the man and some of his friends, that also helps. So, if a curative workshop is run as it ought to be run, with a clever, resourceful man at the head, a tremendous influence can be brought to bear upon the disabled.

This idea so impressed me that I recommended immediately the establishment of a curative workshop in New Jersey. We did not have the space for it, however, and I chafed under the leash. Therefore, Mr. Elton and I started an independent workshop in New York City, and I have a few lantern slides of what we have been doing which I am going to show.

Now, we have come to the point of just starting a curative workshop as a part of our rehabilitation service in the State of New Jersey, to be located at Newark. We have a number of cases ready to begin. The first work we will put them at is the making of benches. That is good curative workshop practice. They will make the benches and we shall save the money.

As a surgeon, speaking from a professional standpoint, I believe in this rehabilitation work that we have the greatest leverage upon these workshop cases. Of course, the curative workshop should be supplemented in the early part of the treatment always with physiotherapy. I am speaking of it in the broadest sense. It may be massage, it may be electrotherapy-whatever will be best for that individual. Then the man should be kept busy. That, I find from my experience, and I have a very extensive opportunity to observe these cases, works out very well.

At the present time the established custom in New York City is for the chief medical examiner of the State of New York labor department to send a case to a surgeon who takes him to the hospital, to study him and see what he can do, whether it is possible for him to carry on. I am sure that many think in the labor department that the surgeon has a wonderful opportunity to check up on this man. We take his temperature. We do all that kind of thing to check up on him, to see if he can carry on, but I want to tell you that we are very much handicapped in attempting to determine what he can do vocationally.

I believe that in many of these cases where there is no lesion, no temperature, I would be very much at an advantage in determining the percentage of loss of function, and determining willingness to carry on if I had the man in the curative workshop for observation.

I am now going to show a few slides. The first is that of a woman, a pianist, a rather brilliant surgical case. It has its lesson that I want to convey to you. She had a fracture of the shoulder, and when I first saw her the whole upper end of the humerus, including the head of the humerus, had been removed. About 5 inches of bone were gone at the shoulder. She came to me with great apprehension and wanted to know if I could restore the function to the shoulder so that she could return to the piano. Well, of course, I told her that was asking too much, but I was strong in my belief that whatever she was to do the rest of her life, that bone should be restored. If she had to give up the piano she would have to make the best of it, but that she didn't like because she wanted to use that extremity and it must be restored.

Therefore, I took the upper end of the fibula (the small bone of the leg) and used about 7 inches of it in restoring the loss of bone in the shoulder. I used the head of the fibula for the head of the humerus and put it in the glenoid socket. It all grew in there nicely.

This is another photograph of the same woman that I want to emphasize. With her it was not a case of taking her into the curative workshop. Her own parlor was her curative workshop where the piano was the instrument to bring back function and to develop the necessary graft. The shoulder was stiff and painful and unconscious voluntary motion was the thing above all else to restore function, and just as soon as it was safe for her to use the piano that was the very best thing for her to do. That would take her mind off the shoulder. She was a student of music and earned her livelihood playing in public. This is a photograph I had taken of her when I presented her at the New York Academy of Medicine some three or four years ago. She was playing a piece of classical music. To-day she is playing the piano in public again and is earning her livelihood as formerly.

That is the idea-the thing the individual is most interested in is the thing he should do.

We had a case at the curative workshop of a man who was caught between two heavy objects and his scalp was torn from his head. As a result he may have had intercranial hemorrhage. No doubt he did. The man was stunned, his morale was destroyed. He did not have the courage to walk across the street. He wouldn't go out