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Section VII

Contents

SECTION VII

SCOPE OF RECONSTRUCTION; ITS BEARING ON ACHIEVEMENT

It is impossible to evaluate medical or educational service in figures. Benefits oftenest of the highest grade, most lasting, and of vital value to the patients are of such intangible nature as to defy quantitative measurement. The best that can be done here will be to give the number of men reached by the service, and in a few cases, where quantitative measurements were possible, show the individual benefits received. As regards the individual cases, additional references are made to them in chapters dealing with reconstruction as conducted in hospitals.

NUMBER OF MEN REGISTERED

Table 6 gives in detail the new registrants in educational service by months, during the period July, 1918, to December, 1919, in each of the hospitals for which formal reports were made to the Surgeon General. The actual number of men reached by educational service in all hospitals is larger than the 110,638 shown in the table.1 Some men were enrolled in this service before July, 1918: some hospitals failed to report; others maintained some reconstruction service though not officially designated reconstruction centers. On the other hand, though effort was made to exclude duplication, it is probable that some errors have been made, which is only natural in view of the large number of men dealt with, and the widely scattered location of the reconstruction hospitals.

TABLE 6.- Numbers of new individuals enrolled in the educational service, by months, from July, 1918, to December, 1919 1

Table 7 shows the population in United States Army hospitals functioning in physical reconstruction and men in the educational service, by months, for the year 1919. In addition, this table shows the average percent of hospital population enrolled. Thus, it may be seen that the hospital population enrolled in educational work steadily rose from 29 percent in January, 1919, to 48 percent in May, and to 61 percent in November, or an average of 44 percent


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patients enrolled during 1919. At first sight, though the steady increase is encouraging as showing increased efficiency in organization and popularity of the educational service, yet it is at all times surprisingly low. Investigation, however, reveals the fact that of the patients in hospital a large number never were at any time in condition to be benefited by or to engage in educational activities. During the earlier months of 1919, and especially in the spring, large numbers of patients who had been transferred as such from the American Expeditionary Forces were immediately ready for discharge upon their arrival at the hospitals in the United States. Unless a man was likely to be in hospital for more than seven days it was not wise to enroll him as an educational student. The percentage of this class of men was relatively large, especially in the base hospitals, since they automatically gravitated thereto because of their lack of serious disability. Acute medical and surgical cases were ineligible, as a rule. Another class of men ineligible to educational service comprised patients in contagious disease wards, though in some rare instances the service was carried into these wards. 1

TABLE 7.- Population in United States Army hospitals functioning in physical reconstruction; men in educational service, by months, 1919 1

Furloughs were granted very liberally to overseas patients upon their arrival in the United States, approximating 14 percent of a hospital's population during the first half of 1919, varying, of course, from month to month and in different hospitals and depending somewhat upon the character of disability.1 The rule was to offer furloughs initially to men returning from overseas. Officer patients, as a class, were not well represented in the educational service because of the lack of classes in the higher subjects.1

Various studies by different hospitals at different times indicated that the number of men eligible to educational services varied greatly. The assumption is warranted that, for the entire year of 1919, 35 percent of the patients were ineligible. If the monthly percentages of men enrolled be recalculated upon the estimate of 65 percent of population, representing the eligibles, it appears that 67.7 percent of men eligible to the service were reached throughout the months of January to December, 1919, inclusive. In many hospitals the percentage exceeded 90 during what might be termed favorable months that is, after the spring of 1919.1

Chart IV shows the number of individual subject enrollments. The data upon which this chart is based are given in Table 8.


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TABLE 8.- Enrollments in Army hospital schools, by months, from August, 1918, to December 1919 1

It is evident that the men were enrolled in more than one subject each-that is to say there is an average of three subjects for each man. The months

CHART IV.- Enrollments in the educational service in reconstruction hospitals, by months, August, 1918, to December, 1919

from January to December, 1919, when the organization could reasonably be expected to be in full operation, showed each man registered in 1.9 courses.

PERIOD AVAILABLE FOR WORK

The length of time during which patients will be in hospital and available for reconstruction courses will always be of vital importance in planning for work of this type, particularly as regards the educational activities. It will be of less importance in considering the proposed activities of the physiotherapy department and of the curative work-shops, as the completion of these activities usually indicates the completion of treatment and determines the time of the
patient's discharge from hospital. On the other hand, the occupational and educational activities begin as soon after admission as practicable and may continue to the time of discharge. A knowledge of the prospective period of hospitalization for the various types of disabilities is therefore essential in planning educational courses. Chart V furnishes limited information on this subject,


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and emphasizes the wisdom of preparing short courses which are more or less complete in themselves, as exemplified by the unit courses of study previously mentioned. The studies on which this chart is based cover two periods-one during the winter months of 1918-19, before any great number of overseas cases had been received, and the other during the spring of 1919, when many such cases were in the hospitals in this country. Over one-third of all men enrolling for educational work during the first period remained in hospital for not over 10 days, and it must be remembered that only about 65 percent of the patients in a hospital are eligible, for one reason or another. The chart, therefore, furnishes a working basis on which to construct plans for an educational service, with data applicable to both the training and combat periods.

CHART V.- Days spent in hospital schools, and percentage by day groups, of 13,158 patients enrolled in the educational service

TYPES OF CASES

The results which could be attained, in so far as reconstruction is concerned, depended largely on two factors concerning the students--their physical and their mental conditions.

PHYSICAL CONDITION

The types of cases most frequently dealt with are illustrated by Table 9.It may be observed that of the 12 classes of disease and injury included therein 6 are of such a general character as to include many entities, and that, even so, a single pathologic process--pulmonary tuberculosis--occupies second place in frequency of occurrence.


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TABLE 9.- Types of cases registered for educational work 1

MENTAL CAPACITY

If it is considered that the patients in reconstruction hospitals were representatives of the general body of men secured by the draft, then the psychological ratings applicable to the latter must indicate the mental capacity of the prospective students of the educational service. The average mental age of white officers was about 18 years. Table 10 gives the data for enlisted men.

TABLE 10.- Approximate mental ages of recruits, World War Army a

The results of a study of the mental capacity of 1,020 patients are shown in Table 11. Those of this group who were attending the school rated some what higher in the grades A and B of the classifications than those who were not attending school.

TABLE 11.-Intelligence grades of 1,020 patients, United States Army General Hospital No. 29, Fort Snelling, Minn.


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The choice of an educational activity depended not only upon the man's mental capacity but also upon his previous education. The results of an analysis of the records of 12,067 reconstruction patients is given in Table 12. It is probable that in the majority of those in which no schooling was recorded there was none to record, which would raise the percentage of illiteracy to approximately that given for the entire country by the United States Census of 1910--7.7 percent. In this connection it should be borne in mind that for all practicable purposes education which stops with the third grade leaves the person illiterate, if one considers that literacy should mean ability to comprehend readily simple written matter. However, men who had received a third- grade education in their youth and subsequently acquired studious habits should be thoroughly literate at the average age of the soldiers of our World War Army. It should be borne in mind also that men with higher educations could appreciate more readily the advantages to be derived from the educational courses, a higher percentage of them therefore enrolling and thus raising the educational standard of the enrolled group as compared with those who did not enroll. As may be seen from the table referred to, 65.6 percent of the 12,000 men attended school not beyond the eighth grade, 21 percent had a more or less complete high-school education, and 4 percent had attended college for one year or more.

TABLE 12.- Schooling of 12,067 patients enrolled in the educational service 1

A study of the vocations followed by the men prior to their entry into the Army is of interest in view of the fact that much of the work in question had a vocational bearing, both for the men who after discharge from the Army planned to continue training with the Federal Board for Vocational Education and for those who would return to active business. Table 13 gives the results of such a study in a group of 1,270 selected overseas men who were enrolled in the educational service.1


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TABLE 13.- Occupations of 1,270 returned overseas patients, United States Army General Hospital No. 28, Fort Sheridan, Ill.: Comparison of previous occupations with desired occupations 1


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CHOICE OF FUTURE VOCATION

The character of the disability also largely dictated the choice of a future vocation, more especially in certain classes of cases, as in tuberculosis. Among 860 cases of tuberculosis, 27.3 per cent gave farming as their choice. 1

SUMMARY OF WORK ACCOMPLISHED

A summary of the work accomplished is shown by Table 14, and a detailed statement of the enrollment in the various courses during the first six months of 1919 is shown in Table 15. As stated above, the actual number of men reached by the educational services in all hospitals was somewhat larger than the 110,638 accounted for in the table.

TABLE 14.- Summary of enrollments in the educational service in reconstruction hospitals 1


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TABLE 15.- Detailed enrollment in educational service, January to June, 1919 1


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TABLE 15.- Detailed enrollment in educational service, January to June, 1919 1 -Continued


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TABLE 15.- Detailed enrollment in educational service, January to June, 1919 1 -Continued


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A significant point is the concentration of the work during February, March, April, and May, 1919, due to the return of the majority of overseas men during those months. Fifty-three thousand and fifty-six men were enrolled during that time,1 nearly one-half of the enrollment for the entire 18 months' period.

The period represented by Table 14 was less favorable for educational work than a later one, for the average of short stay in hospital was much higher. Nevertheless, the median case remained in hospital for 19.5 days, which is conclusive evidence of the possibility of doing really purposeful and valuable work, not only of a curative but also of an educational and vocational nature. Twenty days devoted seriously to a well organized, practical unit course of instruction will enable an intelligent man to accomplish much, and some of the unit courses were of not more than 10 days' duration. Thousands used this time to their advantage by learning to read and write, to train a new writing hand, to try their abilities in a new vocation; or used it materially to refresh and improve themselves in their previous civil occupation. Capable men can become trained as competent typists, assistant telegraphers, clerks, laboratory technicians, and mechanics' assistants in a period of time not in excess of the time spent by these men in educational activities in Army hospitals. If conservation is one of the duties of a republic, then a conservation of man-power by the utilization of otherwise wasted time in the improvement of the soldiers' qualifications should be a potent reason for maintaining some form of educational service, not only for its curative value but for its value in training men for army activities.

The so-called "Americanization" courses deserve special mention here. Reading, writing, arithmetic, English, penmanship, composition, history, and civics were included under this heading, and were in much greater demand than had been expected. Their popularity led to the development of "citizenship" courses for noncitizens of the United States, which consisted of instruction in the subjects necessary in order to qualify as a citizen, and the arrangement for the conference of citizenship to groups of the students. A study of the records of 12,874 men enrolled in the educational department showed that 1,729 of them were of foreign birth, and that 80 per cent of the 1,729 were enrolled in one or more subjects of the Americanization courses

MENSURATION OF IMPROVEMENT, EDUCATIONAL SERVICE

As stated previously, the results accomplished by reconstruction work, as a general term applying to individuals, are rather difficult to evaluate; however, the progress made by individuals in the academic work can be determined with accuracy from a consideration of their daily records. On the other hand, it must be admitted that the estimation in some of the commercial and technical subjects is more difficult to so standardize as to be readily apparent.

Charts VI, VII, VIII, and IX were devised to give a curve for an average student by plotting from the average markings of classes over a prescribed course.2 A study of the results attained by individuals would yield nothing different from those of ordinary civil schools for individuals of an equal mental equipment, except in so far as the physical handicaps of the soldier patients are concerned.


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CHART VI.- Progress curve in mechanical drawing, average speed and accuracy, 23 students

CHART VII.- Progress curve in telegraphy, average speed, 12 students


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CHART VIII. - Progress Curve in radiotelegraphy, average speed, 16 students

CHART IX. - Progress curve in typewriting, average speed and accuracy, 45 students


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PHYSIOTHERAPY SERVICE

Final statistics from this service are very meager, consequently it has been possible to give only incomplete information as to the number of cases treated. Table 16 indicates the proportion of patients under the treatment who required attention by the various branches.

TABLE 16.- Report of physiotherapeutic activities, General Hospital No. 6, Fort McPherson, Ga., for the year 1919 3

Chart X shows graphically the periods of operation of the physical reconstruction services in each hospital officially designated as a reconstruction hospital, to the end of the year 1919; also, it illustrates the concentration of the work into the first six months of that year.

Progress in improvement of the physical condition with the types of disabilities which came under the jurisdiction of the physiotherapy service was, generally speaking, easy to measure, for the improvement was mechanical as well as physical. Various devices were used to indicate accurately the motion in joints.a The curves of normal improvements could hardly be established for the individual variations in structural conditions are limited only by the number of cases considered. Curves were plotted to record the rate and degree of improvement in individual cases, as in Charts XI, XII, XIII, and XIV.

PHYSIOTHERAPY CASE RECORDS

CASE 1.-S. H. H., Pvt., Co. D, 165th Inf., age 28 years.

Condition requiring physiotherapy.- Contraction of tendons in right leg; atrophy of muscles in left arm, shoulder, and back; adherent scars.
History previous to receiving physiotherapy.- On October 14, 1918, wounded by high-explosive shell, in left leg, left arm, and shoulder. Left leg amputated next day, upper third thigh. Sent to various hospitals in France, had influenza and pneumonia in December. Returned to United States December 24, 1918, with a stump unhealed, discharging sinuses in left upper arm, and three large bed sores. In January the right leg, entirely unaffected by wounds, began to give pain; patient sought to relieve tension by raising knee on pillow. As the tendons continued to contract, it became necessary to support knee at greater height. During this time osteomyelitis was present in left shoulder, and patient was receiving Dakin treatment.


a See Chapter III for illustrations and other charts.-Ed.


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CHART X.- United States Army hospitals functioning in reconstruction, and the periods of operation of physical reconstruction departments, 1918 and 1919


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CHART XI.- Improvement curve during 37 days of typewriting and woodworking after bone graft of ulna and radius for gunshot wound, lower third, right forearm


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CHART XII.- Improvement curve during 61 days of typewriting, manipulation of adding machine, and automechanics prescribed for musculospiral paralysis due to fracture of right ulna


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CHART XIII.- Improvement curve (a) during 55 days of work in wood shop for ankylosis of left knee; (b) during 45 days of work in wood shop for gunshot wound of left foot


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CHART XIV.- Improvement curve during 65 days of work in typewriting for musculospiral paralysis and ankylosis, right elbow


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Condition at beginning of treatment in physiotherapy department.-Treatment began July, 1919. Stump urihealed; large bed sores on back and right hip; sinuses of left arm and shoulder still discharging; left shoulder ankylosed; flexion of elbow impaired by scar on posterior surface. Right leg, uninjured by wound, was by this time badly crippled; the muscles had wasted, and all tendons contracted so that the knee was bent to a right angle; foot pointed downward and toes lifted rigidly. There was marked loss of muscular power everywhere except in right arm, which necessarily had received constant exercise; the patient was unable to raise himself in bed or even to lift the right leg; the combination of unhealed stump and shoulder on left side and bed sores on back and right hip made it impossible for him to lie in any position except on the back. The right arm was the only limb remaining in normal condition.
Course of treatment in physiotherapy.- Beginning in July, 1919, the right leg received daily massage and passive stretching, the supporting pillows being removed one at a time. By October the patient kept the knee straight without discomfort, the tendo Achillis had relaxed somewhat, and the toes, though still in abnormal position, yielded under manipulation

FIG. 85.- This and Figures 86 to 89 illustrate Case 1. Pvt. S. H. H.- Osteomyelitis, left shoulder, following gunshot wound. Lateral view

There was also great improvement in muscular power. In October treatment of the left arm and shoulder was begun. X-ray findings showed the head of the humerus was gone and that there was bony ankylosis between the end of the humerus and the glenoid cavity. The sinuses had nearly healed . Massaged and gentle passive motions were given. The muscles responded rapidly, the movement of the scapula soon became free, and the scar at the elbow stretched sufficiently to allow nearly perfect flexion. As a result the condition of the man changed from that of absolute helplessness, in which the left arm was held rigidly by the side of thle body, to one allowing the patient to dress himself, fasten his necktie, and finally to use a crutch. The bony ankylosis at the shoulder permanently limits the abduction of the arm to the point made possible by movement of the scapula- i. e., the hand can be raised about 2 feet from the side of the body. Of course rotation is prevented. During October the patient underwent an operation on the stump of left leg, and treatment was discontinued for a short time. In November the back, as well as left arm and right leg, received daily massage and exercise. By that time the man's general condition had great improved, but he had so far lost the use of the back muscles that he could not support himself in bed an instant, and when held in sitting position the contraction


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in right leg still compelled a bent position of knee. The back responded quickly to treatment, the patient being literally reeducated to use of the supporting muscles. At the end of three weeks he could sit without props of any kind, with arms folded across chest.
Present condition and inferences.-The patient first stood erect about Christmas, after 14 months in bed. During January he had gradually come to the use of crutches, and can now walk short distances without assistance, using a crutch with his injured arm without much difficulty and lifting his foot from the floor 4 or 5 inches. Systematic massage and passive exercises have restored his left arm to its maximum usefulness, without which it would have been impossible for him to use crutches; the same treatment has restored his right leg to a condition which will soon become normal as he uses it in walking. The patient is to be discharged with "total disability," but his condition has been restored to one enabling him to lead a fairly normal and active life at home. He has been encouraged to use his hands and arms in useful occupations; while in bed he learned basketry and produced creditable work. One point to be observed emphatically in the history of this case is that if proper massage and manipulation of the right leg had been given during the first six months of the man's illness it could in all probability have been saved from any disability whatever.

CASE, 2.-W. R. W., Pvt., Co. B, 9th Inf., age 30 years.

Condition requiring physiotherapy.- Musculospiral nerve injury, right arm.
History.-Wounded by high-explosive shell July, 1918. Comminuted compound fracture of shaft of humerus. Returned to United States in November, 1918, with wounds healed; incomplete union of fracture; complete paralysis of muscles supplied by musculospiral nerve. A splint has been worn constantly since the patient was first put under treatment in France.
Treatment.- In December, 1918, the arm received massage daily. There was little improvement during the winter, the wrist-drop remaining complete.

FIG. 86.- Posterior view, left shoulder

In April a neurological examination showed traumatic neuritis of the musculospiral nerve with coluplete physiological blocking of nerve. An operation, preceded and followed by massage and electrotherapy, was advised. Beginning April 10, interrupted galvanisin was applied daily. On May 6 an operation was performed-excision of the scar and end-to-end neurorrhaphy with sutures through sheath. The arm was kept in abduction splint, and massage and electrotherapy continued. Examination in September showed that the strongest galvanic test failed to cause any contraction in the paralyzed muscles; the only indication of beginning recovery was a slight extension downward of Tinel's sign. On January 17, 1920, examination shows triceps functioning with good strength, extensor carpi radialis and extensor carpi ulnaris contracting voluntarily but weakly. All other muscles supplied by musculospiral are paralyzed. Sensation has improved but little, and there is some limitation of motion in wrist and fingers, due to fibrous changes.
Conclusion.-This case has received physiotherapy constantly during its course of 19 months. The injury to the musculospiral nerve was severe and recovery is slow. The arm


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and hand have been in splint constantly, and without the daily massage and passive movements would probably have become ankylosed. Flexion of wrist and fingers have of course been avoided and consequently there is a decided stiffness in this regard. The muscles of arm and hand, in spite of long disuse and the wasting effects of paralysis, have been kept in good condition.

CASE 3.- Z. J., Pvt., Co. C, 125th Inf., age 30 years.

Condition requiring physiotherapy.- Musculospiral nerve injury, both arms.
History of treatment of right arm.- Gunshot wound received October, 1918, fracturing radius. Operated in March, 1919, excision of sear, division of radius at point of fracture, removal of several bone spurs, and insertion of bone peg. Up to this time there was no apparent nerve injury. The arm was in cast for three months following operation. In May, 1919, when cast was removed the arm had lost pronation and supination, and the muscles supplied by musculospiral nerve were partially paralyzed, causing wrist-drop. The conclusion was drawn that at time of operation in March the musculospiral nerve, below where the branch to the supinator longus is given off, was injured, with resulting traumatic neuritis of musculospiral nerve. Beginning in May, 1919, interrupted galvanic current was applied to the extensors of wrist and fingers daily, and the entire extremity was given a daily massage. X ray taken in September showed a knoblike growth of bone projecting from radius posteriorly and apparently uniting radius and ulna. In October the arm was operated for removal this growth. In November, 1919, the extensor muscles were functioning, but very weakly, and there was a slight improvement in pronation and supination. Electricity, massage, and passive movements have been given daily, and during the present month of January, 1920, there has been a decided improvement in voluntary motion of the wrist and fingers and some improvement in pronation and supination. It seems probable that there will be a complete recovery from the nerve injury. The patient has worn a cockup splint on this arm since cast was removed.

FIG. 87.- Contracture of uninjured right knee after 18 months' confinement to bed

History of treatment of left arm.- Gunshot wound received October 17, 1918, injuring soft tissues of upper arm without injury to bone; followed by paralysis of entire extremity and atrophy of all muscles supplied by the musculospiral nerve. Operated in March, 1919, excision of scars, neurolysis of musculospiral nerve adhesion of median nerve freed. In April, 1919, diagnosis showed traumatic neuritis of musculospiral nerve due to injury on inner side of arm just below axillary space. Beginning in April, 1919, interrupted galvanism and massage were given daily, and by the 1st of May, 1919, the arm had entirely recovered from paralysis, and treatment was discontinued.
Occupational therapy.- In the past few months, since this patient regained use of his hands and arms, he has occupied a large part of his time in learning to make useful articles. He joined a class in jewelry making, and the constant use of the file brought his formerly paralyzed muscles into action. MAuch of his spare time is spent in the carpenter shop, where he has made substantial pieces of furniture. At present he is working with a class in engineering, studying gas engines, and tractors.


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CASE 4.- C. F., Pvt., 27th Co., 7th Bn., 166th Depot Brigade.

Condition requiring physiotherapy.- MusculospiraI paralysis of both arms.
History of treatment.- Gunshot wound left leg, resulting in compound fracture of femur, later developing osteomyelitis requiring removal of 4 inches of hone. Was placed in cast and walked about with crutches which produced paralysis of both arms. On January 29, 1919, was referred to physiotherapy department with following diagnosis: Acute traumatic neuritis of both musculospiral nerves. Patient was given massage with interrupted galvanism and when slight voluntary movement was noticed treatment was changed to allow sinusoidal electricity. Complete recovery of both arms.
Conclusion.- The result is typical of the many cases of 'crutch paralysis' which have been treated successfully.

CASE 5.- W. T. W., Pvt., Co. G, 3,59th Inf., age 27 years.

Condition requiring physiotherapy.- Paralysis of muscles supplied by median and ulnar nerve of right arm.
History of treatment.- Wounded September, 1918, by shrapnel, injuring right brachial plexus. Was admitted to this hospital in December, 1918, with following diagnosis: Atrophy and paralysis of all muscles of hand supplied by median and ulnar nerves, and of inner side of forearm supplied by ulnar. In the same month, December, 1918, an operation suturing the ulnar and median nerves was performed. In January, 1919, the patient was put on daily treatment of massage and interrupted galvanism, which has been continued during the entire year past. In March, 1919, the movement of shoulder and elbow was found to be normal, the small hand muscles were badly atrophied, and the possible motion of hand and wrist very weak. The patient as at this time sent to gymnasium for active exercises on the finger board. By April, the muscles in the median distribution had greatly improved in voluntary contraction, but those under ulnar supply were still paralyzed. By November, 1919, the median paralysis had nearly disappeared and the ulnar ha d slightly improved. The patient is at this date, February,1920, being discharged on his own request, in order that he may enter school. He has not reached his maximum benefit front treatment, but, with intelligent care of his arm, improvement will probably continue.

FIG. 88.- Result of five months' treatment with physiotherapy

Conclusion.- This case is one of typical recovery from nerve injury. Considerable atrophy and weakness has resulted in spite of regular physiotherapy treatment, but in so complete a paralysis, these conditions would have been emphatically worse without treatment. There is no fibrous ankylosis in any of the fingers or wrist joints, and this good condition has been maintained, doubtless, by massage and passive exercises, and also in a large degree by active exercise.
Occupational therapy.- When this patient first regained partial use of his hand, he was set at active exercise on the finger boards in the gymnasium. One of these is a board cushioned with steel springs under leather. By patiently dressing these springs, the flexors of the fingers and the interossei are exercised. The outer device consists of a board with a serrated


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edge, up which the fingers climb, stretching to reach the highest notch possible. This exercises the extensors of the fingers.

Note.- Several months ago the patient was advised to give up these exercises and instead to spend his time learning to use the typewriter. It will be readily seen that in operating a keyboard with four tiers of characters, all the above exercises are accomplished unconsciously. This man has become a proficient typist. He intends to complete his education and without doubt his mastery of the typewriter will be a distinct help to him.

CASE 6.- F. A. V., Sgt., Co. E, 137th Inf., age 28 years.

Condition requiring physiotherapy. - Paralysis of left leg, caused by internal and external popliteal nerves.
History of treatment.- Patient received gunshot wound in popliteal space, September 8, 1918 resulting in a division of external popliteal nerve and a neuromatous degeneration of internal popliteal nerve. In February, 1919, excision of neuroma and end-to-end suture of both nerves was performed. This has been preceded and followed by interrupted galvanic treatment and massage. The first improvement was noted in July (6 months), when the posterior leg muscles contracted voluntarily, showing that the internal popliteal nerve was regenerating. The first improvement in the muscles controlled by external popliteal nerve was noted in October, 1919 (9 months). At that date all the leg muscles were functioning except the flexors of the toes. There were large areas of anesthesia and the skin over the dorsum of foot was then dry and glossy. The patient received regular treatment including massage, exercises, and interrupted galvanism. A foot-drop splint had been worn from the time of injury until October, when it was discarded during the day and worn at night. At the present date recovery is complete except for flexors of toes, extensor longus hallucis being completely paralyzed. The patient does not wear splint and walks without cane.

FIG. 89.- Final result-left shoulder ankylosed, right-knee normal

Conclusion.- Typical foot-drop case in which recovery is slow and in which physiotherapy is of great value in preserving muscle tone and maintaining normal skin condition.

CASE 7.- G. W. S., Pvt.. Hdqs. Co., 120th Inf. age 21 years.

Condition requiring physiotherapy. - Double thigh amputation; both hip joints mobilized under ether, following ankylosis.
History of treatment.-Wounded September, 1918, admitted to this hospital July, 1919, with stumps nearly healed and both hip joints ankylosed. During the same month both stumps were ope)rated on for excisionl of scar and removal of portion of femur, allowing flap to be made. In September a (daily light massage of the stump was given to improve circulation, promote healing, and to aid in drawing flesh down to make flap firm and permanent. In September, the hip joints were mobilized under anesthesia and the physiotherapist then undertook the very important task of preventing a recurrence of ankylosis. This patient


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had also developed bed sores which in healing left large adherent scars on his back. These have been loosened and the back muscles improved by massage. The patient is now ready to be fitted with artificial legs.
Conclusion.-The proper massage treatment for amputation has here been followed with success. It is a case where the ward surgeon in charge fully cooperated with physiotherapy department. Massage of the stump was begun early enough to be of all possible help, and the immediate and regular treatment of passive exercise of the hips prevented a recurrence or ankylosis.

FIG. 90.- Case 9: Nerve readings made (A) before and (B) 13 months after suture of median musculospiral and musculocutaneous nerves

Note.-It has been observed in numerous instances where various stiff joints have been mobilized in the operating room, that the patient has not been recommended to the physiotherapy department until all the potential good of the operation has been lost. Immediate and regular administering of passive exercise is of the utmost importance.

FIG. 91.- Case 10: Nerve readings made (A) before and (B) 12 months after suture of the ulnar nerve

CASE 8.- C. C., Sgt., Co. L, 11th Inf., age 29 years.

Condition requiring physiotherapy.- Paralysis of both lower extremities, caused by gunshot wounds. Injury to left sciatic nerve and right anterior crural nerve.
History of treatment.-1. Left leg-wounded by machine gun bullets, October 14, 1918. Admitted to this hospital in March, 1919, with wounds healed, all muscles of leg paralyzed. Neurological examination in March, 1919, revealed a traumatic neuritis of sciatic nerve, the


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nerve not severed but probably containing neuroma. An operation was performed in March, excision of scar, neurorrhaphy, end-to-end suture of the sciatic nerve at junction of upper and middle third of thigh. In April, 1919, a daily treatment of massage and interrupted galvanism was begun. In June, 1919, the hamstring muscles had regained normal power, and there was a slight voluntary contraction in gastrocnemius

FIG. 92.- Case 11: Nerve readings made (A) before and (B) four months after suture of the musculospiral nerve

in spite of regular treatment there has been considerable atrophy. Treatment is being continued and improvement is still expected. An external popliteal splint has been worn constantly. 2. Right leg-injured at same time as left. Examination in March, 1919, showed a traumatic neuritis of middle branch of anterior crural nerve, the branch being completely severed. Motion was not lost, but sensation was lost in all areas governed, by the nerve. By an operation in March, 1919, the nerve was sutured. Massage and interrupted galvanism were given daily beginning in April, and by June 11 improvement was so marked that treatment was discontinued.
Conclusion.-This case is a typical one of slow recovery from nerve injury, It is now 10 months since the sciatic nerve was sutured; and during this long period of waiting for the nerve to be restored, physiotherapy has done everything possible to keep the muscles in good condition and the joint movement normal.

CASE 9.- Diagnosis.- Gunshot wound left shoulder causing injury to brachial plexus. Figure 90, A. Nerve reading taken before suture of median, musculospiral and musculocutaneous nerve; Paralysis of all muscles of hand, forearm, and arm. This patient received interrupted galvanism, slow sinusoidal electricity, and massage. The above treatment was continued for 13 months.

FIG. 93.- Case 12: Nerve readings made before suture of sciatic spiral, and musculocutaneous nerve; deep pressure sensation absent in shaded area

Figure 90, B, reading taken 13 months after treatment shows all muscles functioning normally except the muscles supplied by the median nerve which are beginning to show slight function, especially the sublimis digitorum.


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CASE 10.- Diagnosis.- Gunshot wound upper arm severing ulnar nervc. Figure 91, A, diagram showing nerve reading just before suture. Figure 91, B, showing nerve reading 12 months after suture. In this interval of 12 months the patient received interrupted galvanic followed by slow sintusoidal electricity, and at intervals electricity was discontinued and contrast whirlpool arm baths were substituted.

CASE 11.- Diagnosis.- Gunshot wound upper arm severing musculospiral nerve. Figure 92, A, nerve reading was made just before suture of the nerve. Figure 92, B, in four months patient had regained sensation and use of muscles supplied by the musculospiral nerve. Recovery complete.

CASE 12.- Diagnosis.- Gunshot wound lower thigh severing sciatic nerve. In Figure 93, the black area shows where deep pressure sensibility is lost. The reading was made just before suture. Paralysis of all muscles supplied by sciatic nerve. This case received electricity and massage and short intervals of contrast whirlpool baths. After six months' treatment the nerve reading, Figure 94, shows a gradual disappearance of the dark area, which mcans that sensibility to deep pressure is returning with normal action of the gastrocnemius muscle. Patient later had complete recovery of sensation and movement of all muscles of the leg.

FIG. 94.- Case 12: Nerve readings made six months after suture of sciatic nerve; deep pressure sensation absent in shaded area

FINAL RESULTS

The following data may be taken as a measure of the final results of reconstruction work in the United States Army hospitals: Of 15,449 men who were discharged from the service on certificate of disability, 0.87 percent were totally disabled, 7 percent required further training in order to resume their old occupations, and 92 percent required no further treatment in order to resume their old occupations 4

REFERENCES

(1) Based on educational service reports sent to the Office of the Surgeon General. On file Record Room, S. G. O., 353.91-1.
(2) Letter from First Lieut. Charles L. Harlan, San. Corps, Education Service, Base Hospital, Camp Dix, N. J., to Maj. Arthur G. Crane, Sant. Corps, June 12, 1919. Subject: Progress Curves in Radiotelegraphy, Wire Telegraphy, and Mechanical Drawing; also attached documents. On file, Historical Division, S. G. O.
(3) Report of the activities of the physiotherapy department, Fort McPherson, Ga., 1920 by Capt. Charles L. Ireland, M. C. On file, Historical Division, S. G. O.
(4) Evans, H. M.: Physical reconstruction in United States Army hospitals. The Military Surgeon, Washington, 1920, xlvi, 33-39.