Auguste Broca

“ A man whose working capacity is much reduced, and more especially a man who requires re-education, has no place in an ordinary workshop where neither the proprietor nor the foreman nor his fellow-workmen are in truth much inclined to concern themselves about him. Where actual education is necessary this is best supplied in special workshops where the patient will be among comrades handicapped like himself, whose progress he will be able to watch and whose efforts he will imitate, rather than among able-bodied workmen, by comparing himself with whom he is bound to be discouraged. ”

“ As general principles of treatment are established it is found practicable to give effect to them to their full logical extent, and though there are still many obscure points to be elucidated and many methods in use that still call for improvements, it is now safe to say that the position of the art of military medicine and surgery stands upon a sound foundation, and that its future may be regarded with confidence and sanguine expectation. ”

“ At a time when all physicians are dealing, or will shortly have to deal, with the after-effects of wounds received in war, the question of sequelae presents itself, and will present itself more and more. What has become—and what will become—of all those who, in the hospitals at the front or in the rear, have hastily received initial treatment, and what is to be done to complete a treatment often inaugurated under difficult circumstances? ”

“ We have dealt chiefly with the conditions which are suitable for the re-education of a man who has lost an upper limb, or, speaking more generally, is disabled in one arm, for whom resumption of work in a workshop will often be out of the question. The question is easier of solution for the lower limb. Cases of amputation of the leg can work standing, if supplied with an artificial limb, at practically any trade. Cases of amputation of the thigh have numerous manual occupations open to them in which they sit for at least part of the time. ”

“ It would be wrong to conclude from this that a case of amputation at the wrist should be put to sewing.
It must never be forgotten that intelligence and will are factors of the first importance, so that however little intellectual capacity the disabled man may have, he is bound to profit by his passage through the school of re-education in learning to read and write if he is illiterate—this is more frequent than is usually believed—or to improve his knowledge if he has already had some instruction. It is, in fact, by brain work that many learn to replace their physical defect. ”

“ However brilliant the triumphs of surgery may be, and that they have been of surpassing splendour no one will be found to deny, experiences of the war have already produced a mass of facts sufficient to suggest the complete remodelling of our methods of education and research. ”

“ The views of great authorities who derive their knowledge from extensive first-hand practical experience gained in the field, cannot fail to serve as a most valuable asset to the less experienced, and must do much to enable them to derive the utmost value from the experience which will, in time, be theirs. The series covers the whole field of war surgery and medicine, and its predominating note is the exhaustive, practical and up-to-date manner in which it is handled. ”

“ To ascertain whether the limb is built so as to ensure equilibrium, a thread is stretched against its side so as to pass through the axes of the knee and ankle joints, if this cuts the ischial bearing point at its centre the equilibrium of the patient is assured. Equilibrium will be better still if the cord lies entirely behind the ischial bearing point, leaving in front of it the greater part of the thigh piece. The best method of ascertaining if the foot is properly mounted is to hold the limb in front of one by the thigh piece, with the knee bent at a right angle ”

“ It is indeed especially agricultural labourers who should be urged to return to the land, and those mechanics who will be unable to work in a factory for the future should also be encouraged to take up this work. One reason for this is that the workman's arm—especially if it has not been too much elaborated—is useful for the execution of a considerable variety of work on the land. It is unnecessary to speak of cases of amputation below the knee, since their usefulness on the land may be taken for granted.
In the country as a matter of fact a man never dies of hunger ”

“ Working in wood, to hollow out of a log of wood a bucket which fits the stump accurately, is no novelty. Some sixty years ago two Frenchman, Bailly, then Xavier, succeeded in such construction. But these appliances, like the common, cheap unshaped peg leg, split easily and were only made strong when the Americans conceived the idea of covering the outer surface with a layer of raw hide: strong, and therefore practical, for though we may resign ourselves to the frequent renewal of a peg leg at 25 francs, it is another matter with an appliance costing 300 to 400 francs. ”

“ Worker's Arm
If our object is to fit to an arm stump an appliance which will be at the same time strong and flexible, capable of carrying out rough and even vigorous work, we must abandon the attempt to imitate the natural shape of the arm.
The movements and strength of the stump must be transmitted to the object held by means of a rigid rod at the extremity of which the appliance for gripping is fixed. It is possible to fix around this rod a show arm with a hand and a passive spring thumb for wearing on special occasions, in exactly the same way as we fit the show leg round the peg. ”

“ When it has been swung forwards, in taking a step, the limb comes in contact with the ground heel first; then, as the leg becomes vertical the entire sole lies flat on the ground; if the foot is in equinus this position is only possible with the knee hyperextended, or with full extension it may be possible for a very short period. So that it is the weight of the body that locks the limb in the extended position, the sole of the foot sloping obliquely downwards and forwards; and the weight being taken on the toe. ”

“ It has rapidly become evident that there are too many maimed to be supplied with situations as caretakers of public gardens or doorkeepers, and that they will not be able to gain a living by making tricoloured decanter-mats of string or raffia or artificial flowers, when bazaars organised for their benefit by tender-hearted souls have gone out of fashion. ”

“ Both the arm and the forearm may be cut away freely without any resulting inconvenience, provided that the stump is long; but if the stump is short and includes only the upper third of the forearm, it is impossible to cut away the forearm socket sufficiently without depriving the stump of a proper hold in the socket, so that movements are not transmitted to the forearm lever with their proper force. Consequently the socket for the forearm must be cut away very little, and must be carried up to the level of the fold of the elbow when the joint is flexed. ”

“ Whatever advantage it may be thought to possess, in our opinion the artificial leg with free knee joint is only suitable for sedentary occupations; it is not suitable for manual labourers and particularly for agricultural labourers who are obliged to get about on rough ground. Hence it is not uncommon for a patient who has been provided with an American leg to come and ask for a peg leg. In figures 93 to 95 it will be seen that it is a simple matter to transform the limb into an articulated peg. ”

“ When a disabled man has been fitted with an artificial limb he has to learn a trade which will enable him to supplement his pension and provide for himself and his family. In our opinion, which we believe we have expressed more than once in this book, it is nearly always advisable to determine what profession will ultimately be possible before ordering the artificial limb. This principle is perhaps not always thoroughly understood, although there are fitting centres where it is fully recognised (a proof of this may be found in a recent article by Nové-Josserand and Bouget) . ”

“ It is quite a false idea that a disabled man can gain a living at one of these crafts in a village. It is true that he can do so if, working as an agricultural labourer, he can act as a barber in his spare time, and is capable of executing small jobs, especially repairs, which the villagers would readily give to him rather than have to go several miles to get them done. When the disabled man has this additional work in his hands he will gradually be able to ascertain whether the needs of the countryside and his own personal capacity are compatible with its development. ”

“ These appliances can be used to steady a piece of paper upon which the patient is writing, to carry a parcel which is not too heavy with the elbow flexed, to grip an article with the thumb. A workman who is being re-educated for some occupation which is possible for a one-armed man, will usually—unless he is going out for pleasure—leave his artificial arm at home in the cupboard. ”

“ It can never be sufficiently insisted upon in dealing with the maimed that by resuming work, and on account of the functional improvement resulting from doing so, they need have no anxiety that their pension will be reduced, because the amount of this is based on the extent of the injury itself and on the man's rank, and not on his profession before he became a soldier. In the same rank the pension is the same for a surgeon or a lawyer, if both have lost a hand. ”

“ If the thigh piece is curved forwards, and particularly if the limb is built with a very slight flexion of the knee, the stump remains slightly flexed at the hip and the patient feels as if he is sitting in the apparatus. ”

“ The ruthlessness of war must necessarily hamper the work of the medical scientist in almost every direction except in that of providing him with an abundance of material upon which to work. It limits the opportunity for deliberate critical observation and comparison that is so essential to the formation of an accurate estimation of values; it often compels work to be done under such high pressure and such unfavourable conditions that it becomes of little value for [x] educative purposes. ”

“ The Brunet grip is an actual pair of pliers, shaped like these and furnished with a powerful spring. It is opened by a cord like that of the automatic thumb. Figures 158 to 160 explain the mechanism. It is an excellent appliance with which the wearer can carry out the majority of the actions of everyday life. It has, however, the disadvantage that it is not shaped like a hand—a point to which patients attach much importance—and, moreover, it is a part of a patented appliance, for which an interchangeable hand is not manufactured. ”

“ But all these special inventions, the utility of which we should not think of denying, are only of real practical value if the makers have followed out certain general principles in their manufacture. ”

“ It is when he goes to the centre of re-education in agricultural work, first of all to view it and then to work, that the disabled man takes note of what he can or cannot do, and of the work in connection with agriculture which is open to him, such as poultry rearing or bee keeping. ”

“ It is therefore undesirable—although usual—to attach the steels on the arm and forearm to the inner and outer sides of the limb. If this is done, as rotation is impossible, flexion of the forearm at the elbow can only be carried out in the sagittal plane. But this movement is only exceptionally required; the elbow being flexed to the right angle and fixed in this position by a ratchet the limb forms a hook upon which an object may be hung, provided that the forearm lies transversely in contact with the abdomen and not antero-posteriorly. ”

“ Where there is no intelligence education can do little. There are in civil life innumerable "casual labourers" with limbs intact who have never been able to learn a regular trade and who earn a miserable livelihood by doing what "turns up." ”

“ But the great majority of workmen have no notion of such calculations and such organisation as are indispensable when a man runs a business even if he is alone. It follows, therefore, that the education of his mental, and especially his commercial, faculties must be considered, and it must be ascertained whether the man is likely to profit by such education. It is useless to install in a hamlet a shoemaker who is incapable of working except as an assistant, and in the town at the actual factories the prospects are poor. ”