^ og gj 6 i 9 1 I Reeducation and Rehabilitation of Crippled, Maimed and Other- wise Disabled by War S. I. FRANZ, PH.D., M.D., LL.D. * UNIVERSITY of CALIFORNIA LOS ANGELES LIBRARY Reprinted from The Journal of the American Medical Association July 7, 1917, Vol. LXIX, pp. 63 and 64 COPYRIGHT, 1917 AMERICAN MEDICAL ASSOCIATION FIVE HUNDRED AND THIRTY-FIVE NORTH DEARBORN STREET CHICAGO REEDUCATION AND REHABILITATION OF CRIPPLED, MAIMED AND OTHERWISE DISABLED BY WAR SIIKPHERD IVORY FRANZ, Pn.l)., M.D., LL.D Scientific Director, Government Hospital for the Insane WASHINGTON, D. C. The importance of the work looking toward the rehabili- tation of the maimed and crippled, using these two terms to cover the great number of different kinds of defects which have been produced, is being appreciated more and more by the Belgian, English and French governments, and by the special physicians and others who have been compelled to deal with certain of the problems. TJiis is shown both l>y the number of institutions which have been established, and which are being planned, and by the amount of space in the medical journals which is given to the consideration of the various factors involved. More recently there have been numerous expressions of criticism that these matters were neglected at the beginning of the war, and many hopes that more energetic measures would now be taken to deal with this class which had been neglected. As the result of previous wars and of accidents in indus- trial pursuits numerous crippled and maimed have been pro- duced. Except in relatively few cases these individuals have been permitted to bear their infirmities as well as they could, and the burden of their support has fallen on their families, or on the state if they became social parasites, beggars, and the like. In many cases these individuals have gravitated to the poorhouses or to special homes for the crippled, where they have been supported mostly in idleness. Now, however, it is being appreciated that great effort, and as concerted as is possible, must be made to limit the parasitic conditions, and to make these relatively incompetents as competent as possible. For the general welfare of the nation as a whole, for the comfort and the well-being of the individuals, a laissez-faire method of dealing with them cannot, and should not, be tolerated. No matter whether or not pensions will be provided for partial or for complet* support, humanitarian and social interests demand that something more shall be done. Efforts must be made to bring about a functional betterment, for the performance of those operations which will make the individual a useful and a productive member of society. On the side of the individual efforts must be made to prevent the mental attitude of dependence and of woe- fulness, and this attitude or tendency to this attitude must be replaced by one of effort, of pride in accomplishment, and of self-help. 1248N7 I Statistics are not available regarding the number of those who require special treatment of the nature of reeducation. That the number is not a small one, and that in case the war 'continues for any length of time for our troops the number will not be small in these United States, is evi- denced by the efforts which are being made in the countries which have been at war for nearly three years to bring about a medical and public appreciation of the conditions. The several conferences of the allied nations at which the dif- ferent aspects of the general problems (medical, educational, scientific, social, etc.) have been discussed have also shown the need of preparation for many more than are now taken care of. Borne has divided these individuals (and has grouped with them certain others) into three general classes: 1. Those who, with immediate care, can be made almost perfect. (This group includes those who have been operated on, but who have been compelled to remain quiet and almost motionless, and who consequently have also suffered from muscular atrophies and ankyloses. Here also come the ten- don retractions, the defects which are due to adherent bind- ing cicatrices, etc. In some cases it may take as long as six months to get an individual of this class normal, or approach- ing his normal condition. Many of these individuals have been incapacitated in the manner mentioned because of lack of appreciation of the .possibilities of the production of such defects.) 2. Those who are definitely educable, or who are readap- table to work of some kind, but who cannot return to their former occupations on account of the defects which have been produced. (The class includes all those who have lost a part of the body, such as a hand, or foot, or arm, or leg, or even one or more fingers. In these cases after surgical inter- ventions, amputations and the like, it may take only three or four months to make the individual as nearly normal as he can be made. This includes, of course, necessary ortho- pedic appliances.) 3. Those who are so severely and extensively mutilated and infirm that nothing can be done for them. (Relatively few of this class will exist. Some of those now thought to be incapable of training will be found to be amenable to some kind of treatment, and this is one of the problems which will need to be considered. Those who cannot be benefited by treatment of any kind, edupational or otherwise, will probably have to be kept as permanent wards in special institutions or in homes for disabled soldiers.) It has been estimated by Amar that if proper and prompt treatment is available 80 per cent, of the whole number are reeducable. Some of those who are not counted in this classi- fication will probably be dealt with in special institutions where they may also be educated. This is true of the blind and the deaf. Of the total which he considers educable, Amar also counts that at least three quarters may be uncon- ditionally returned to some kind of gainful occupation and to useful social life, after they have been given the training which their conditions warrant. The remaining quarter can he instructed in certain occupations, and can carry them out for such a period of time, that will enable them to be useful although their physical conditions may make them very slow in performance and may prevent their active competition with more normal individuals. For this last class, therefore, special workshops may be required, special positions may need to be sought, and some may need special permanent care. Already in France and in England much work has been done with the maimed and crippled, as has been said, and the kinds of occupations which have been undertaken by these defectives are numerous. Besides farming and horticulture, for which many have special aptitudes and previous special training and for which their infirmities are not prohibitive, the following occupations have been taught, or retaught, to certain individuals: clerical work, stenography and type- writing (with the necessary instruction in writing, drawing, geography, arithmetic, commercial law, important languages besides the native language), carpentry, wood turning and carving, tailoring, brushmaking, basketmaking, shoemaking, hook binding, trussmaking, making orthopedic appliances, locksmithing, making chains, making mats and rugs, making playthings, working in wood and in iron in making articles for ornaments, plastic arts. It will readily be seen, therefore, that a considerable num- ber of occupations are open to those who have been maimed or crippled, and that many more will be found in our indus- trial establishments there is no doubt. In the selection of an occupation there should be considered carefully the tastes and the previous aptitudes of the individuals, their past occu- pations, the degree of education, and great care must be exercised that caprice is not given sway, so that an individual select such an occupation that it is inconsistent with his infirmity and that, if not entirely inconsistent, it is so time- consuming that the cost of reeducation is out of proportion to any expected gains that the individual may make subse- quently. In many cases also it is necessary to limit the kinds of occupations from which selection may be made, for certain occupations may tend to increase an existing infirmity such as a contracture or a laxity of an articulation which cannot be corrected. Rochard has criticized the conduct of the reeducation wo/k in France, because of the lackadaisical methods which were used at the beginning. The corrective apparatus was badly conceived, awkward and not effective for its purpose in many cases, and due regard was not paid to the individual. It is important that each individual be considered as an individual, and that he be treated with that kind of mechanotherapeutic measure that will be best fitted to his particular needs, and at the same time that if any corrective apparatus is needed this should be considered in relation to the occupation that the individual is to undertake as a matter of rehabilitation and also in relation to the defect which is present. Perhaps no better general outline of what is needed can he cited than that of a commission of the Royal Society of Medicine which has recommended as follows : 1. A service of physical treatment, consisting of hydro- therapy, electrotherapy (including roentgenotherapy), mechan- ical treatment, medical gymnastics, and massage should be made available at the earliest possible date for all soldiers needing it who are disabled by war. 2. Centers of physical treatment, comprising all the foregoing methods, should be established throughout the country on an adequate scale, and wherever possible in association with general hospitals, so that other forms of special treatment and diagnosis may be readily available. 3. At such centers there should be a uni- form system of measurements and records. 4. Centers of reeducation and centers of physical treatment should be closely associated. In any consideration of the general matter of reeducation and rehabilitation one matter must be given due attention, viz., the placing of the men after the reeducation has been completed. It would be a waste of time and effort if such individuals were reeducated and they were refused by the public to take advantage of their possibilities. The organiza- tion of the work must deal with these matters, and perhaps with such other things as are being considered in France, like mutual societies, organizations, and cooperative endeavors for the general benefit of the members. And propaganda for the popularization of the work of these men, for their utiliza- tion in a variety of ways, should not be too lightly considered. Dr. A-mar, one of the most noted of the French leaders in the movement for rehabilitation, has protested against the lack of preparation and the failure to provide suitable facili- ties for the proper prosecution of the work when the maimed first came in. He has insisted on the necessity for full preparation and on the necessity for careful, scientific and thorough work. In this regard he has said : "The time has come for organizing the work of the wounded in such a manner that each one may take his true place in the social machine, and contribute according to his ability." And. in like vein, Regnier, after pointing out some of the difficulties of the work at the beginning has emphasized the need of a careful "scientific organization" if the work is to lie con- ducted for the greatest benefit of the country, and of the individuals who have helped their country and who desire to be returned to that condition in which they may be of the greatest help to themselves and to their fellows. 124887 stamped below tr.:--- Y of CALIPOBNU AT ANGELES LIBRARY """'""i mil ill || ill I HI 000 690 887