SOME GENERAL PRINCIPLES IN THE RE-EDUCATION OF THE DISABLED

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 unnecessary to repeat that whilst every effort must be made to associate form with function, the latter is bound to take precedence of the former. It is, however, not always easy to impress upon patients, and more especially upon their protectors, that form is for Sundays and holidays, and function is for workdays.

The grave problem of re-education of amputation cases, and in a more general sense of all the maimed, now confronts us. We believe it to be worth while to indicate the general principles so far as they are at present understood.

I

At the outbreak of war the idea of the disabled in general, and particularly of those who had had a limb amputated, was often to give up any really active trade and to seek a "situation" generally as an official with no actual manual labour. It must be confessed that many people, especially the nurses, encouraged them in this, and possibly the latter would not deny having done so.

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.

One of us was present a short while ago at the following little scene:—

In a hospital where there were two amputation cases, one through the lower fourth of the thigh, the other through the middle of the leg, both agricultural labourers, a distinguished man of letters, actuated by the best intentions, asked them what they counted on being able to do after they had been fitted with artificial limbs. The first replied that he hoped to return to agricultural work, the second that he would never be able to do that but would look out for a "situation." Our friend was much surprised to hear us say that he would be ill employed in using his influence to obtain his desire for the second patient, because a man with only one leg could work on the land with almost no diminution of his ordinary capacity, even with the old-fashioned kneeling peg leg.

As Jean Camus has well said in a recent article in the Paris MÉdical, "We are beginning to pass beyond the phase when re-education of the maimed was left to chance. It is felt now that the frivolous efforts of benefactresses who, acting with the best intentions but without reflections, are delighted to be able to transform into a shorthand typist an honest farm labourer who had a strong attachment to the soil and could quite well return to it, must be avoided. Such feats are both culpable and absurd."

These fantastic ideas must be got rid of, and all our efforts must be co-ordinated, the complexity of the conditions to be dealt with being duly weighed.

Given a maimed man the first care should be to educate to the maximum all the uninjured and remaining parts. It is too often forgotten that among the parts remaining the brain plays a leading rÔle, even the chief rÔle, not only because it is the organ of "good will" without which all attempts at re-education are fruitless, but also because good will being given the intelligent man will succeed better and will be able to adapt himself to more delicate work. "Physiotherapy cannot be prescribed," says J. Camus, "as quinine is prescribed. The malarial patient who takes the latter medicine benefits whether he wishes to or not. The wounded man who submits each morning to his mechanotherapeutic treatment does not recover unless he wishes."

It is very difficult to make the layman understand this. He invariably takes for granted the good will of the patient, with all of whose complaints he sympathises, without for a moment realising that they sometimes degenerate into jeremiads, often with an ulterior motive. An examination by a doctor—and an experienced doctor—is therefore necessary in order to determine under what physical and mental conditions an amputation case can be re-educated; so that he may understand that it is entirely to his interest to work as quickly and as well as possible, that begging is degrading, and above all that private charity is temporary and exhaustible; and that in consequence he must as quickly as possible put himself into a condition to supplement by a salary justly earned the pension or gratuity which is certain to be insufficient for his maintenance.

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.

It is a deep-seated notion, instilled into the minds of injured workmen by the often suspicious folk who advise them, that if they begin work before their case has been settled their pension will be less.

It must be acknowledged on the other hand that the civil expert is often faced with a difficulty. As our law stands—and it is unfair—work cannot be resumed partially with provisional half-pay followed later by whole-time work with permanent salary. This difference is important to our wounded soldiers, who have everything to gain by a rapid and complete re-education and whose duty it is to do whole or part-time work while their legal position is being arranged and before the wound, in legal phraseology, has become "consolidated," that is to say, before the completion of treatment.

It is only fair to add that the patients are not alone to blame and that the administration has for long been guilty of an error against which reaction is growing, viz. delaying re-education until the time when the local condition has become permanent and the patient has been discharged and has received his prosthetic apparatus.

This delay is deplorable, on both medical and social grounds. On medical grounds because in very many cases before treatment is quite complete the addition of carefully graduated and supervised work is an important part of the treatment. On social grounds because it is necessary to fight in every possible way against the common tendency of the patient to fall into habits of laziness and intemperance.

This is now understood, and almost everywhere to-day the wounded soldier can resume work in workshops attached to the centres of physiotherapy, and thus begin his re-education while continuing his treatment.

At a certain stage resumption of work becomes the best therapeutic agent of all.

It is obvious that this resumption of work cannot supply the place of certain special treatments such as electrical treatment during the regeneration of a nerve, balneotherapy, or graduated gymnastic exercises; but is it not true that work with its continual active movement is infinitely superior to passive mobilisation by means of apparatus however ingeniously the latter may be contrived? Morover it is surely a more efficacious course of mechanotherapy when the patient works for half or all the day than is provided by the special course occupying only an hour or two.

The tendency to-day is in this direction, as, for example, at the Grand Palais, thanks to the efforts of J. Camus, and also in the agricultural centre of the XIIIth district under the direction of Belot and Privat. At a given moment all treatment may be suspended and the patient may devote himself exclusively to work with results the excellence of which Nepper and VallÉe have demonstrated.

The workmen are then eligible for work in a town in private workshops, but so far this freedom has more inconveniences than advantages. 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.

The problem has been solved by the Belgians in a remarkable establishment opened at Port-Villerz, and by the Austrians at Vienna under the direction of Spitzy, as NovÉ-Josserand and Bouget inform us, by delaying a maimed soldier's discharge from the army until his re-education is as complete as possible. This method has proved to be to the interest both of the individual and of the State, but we do not seem to have considered this solution, and it is still to be feared that it would accord ill with the independence of our national character. The actual fact, though it has not been brought into prominence, is that our usual system of "watertight compartments" has been applied by adding to the centres of physiotherapy centres of agricultural or industrial re-education, the results obtained in which are dependent upon the efficiency of the director of physiotherapy.

This matter seems to have received very little special attention in connection with amputation cases. It is, however, of great utility to develop the strength and agility of the remaining limbs by suitable gymnastic exercises, to teach a man with only one leg, for example, to jump without an artificial limb and to climb a slippery rope or a ladder; or to train the left hand of a man who has lost his right; to develop the greatest possible strength in the stump by training it in movement combined with the exertion of force. In addition to this, early and provisional equipment with artificial limbs must become general. These temporary limbs are undoubtedly rudimentary contrivances, but they are functionally good and are useful on account of their mere weight.

In this connection the temporary arms used by NovÉ-Josserand and Bouget in their agricultural re-education centre are very interesting models. The great advantage of using a temporary limb is that the time required for the construction of the permanent apparatus, often a considerable period, is not lost in idleness, the mother of all the vices.

II

It was said at the beginning of the last chapter that whenever possible a disabled man should be given a real trade and not one of those frivolous and trifling occupations which were at one time the fashion.

In the choice of a trade the ruling principle is that of aiming to restore as nearly as possible the man's former occupation. This principle should not, however, be carried to an extreme.

As Camus has justly said, by his previous work a man has stored up a mass of ideas, a fact which is too little realised, especially by himself. These include the manner of choosing, holding, and attacking the materials upon which he works, and of appreciating their qualities and faults; knowledge of their market value, of the value of the labour, etc. This should be utilised in his future work even though it be realised, as M. Bourillon has remarked, that the resumption of his trade in its entirety may be impossible.

With the tools that have been described a man who has lost his forearm may be able, for example, to undertake a locksmith's work and to execute correctly all the movements required in plying the trade. Granted; but how long will he take to make one piece, let us say, as well as his neighbour? If he produces little he will not find an employer to give him daily work, while if he does piecework, apart from the fact that it is not in good repute among those who are the actual leaders of the working classes, it will not be remunerative, and to earn 3 frs. a day when a comrade earns 10 or 12 frs. is practically an impossible solution.

The case may be cited of a woman suffering from congenital deficiency of the hand with a very short rudiment of the wrist which is only slightly mobile. By means of contrivances which we need not describe, and with no prosthetic apparatus, she threads her needle and sews as quickly and as well as anybody. This is not an argument, for: (1) it is a congenital lesion and the educability of a child is well known; (2) the woman is extremely intelligent, and unhappily this favourable factor cannot always be counted upon. 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. Let us take, for example, a disabled bricklayer. If he is intelligent and is given a helping hand in the shape of the necessary instruction, he may become a builder on his own account in a small way when he knows how to make plans, work out estimates and keep accounts.

This is not a Utopian fancy. In the small towns and villages there are many owners of businesses such as masons, decorators, joiners, etc., workmen who cannot spell, but who are intelligent, have business minds and a gift for overseeing, who have given up the trowel and will build you a house as well as, or often better than, many "architects." It is with similar aims to these in view that a bricklayer should be re-educated when it is judged that his intellectual capacity is sufficiently great.

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." Their situation becomes serious when they lose some of their physical capacity. They can, however, be rescued, particularly by encouraging them to become agricultural labourers. 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; and this cannot be said of the town. Apart from actual cultivation of the land, which is in part impossible for the maimed, there are numerous and important occupations of which a town dweller would not think. 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.

This applies to other employments than agriculture.

Apart from his actual trade which the workman can no longer ply with a sufficient return for his labour, he may be able to work at one or two of the accessory employments which would not of themselves bring him in a living but which would yield a satisfactory supplementary income.

In certain re-education centres there seems to be a marked predilection for crafts in which the apprenticeship is short and the installation costs little, though these are in fact the characteristics of those trades which give the labourer a poor return, that is to say, time-work in a large or small workshop.

At the beginning of the war an attempt was made to show that there would never be enough tinkers, sabot makers, shoemakers, or saddlers in the country. 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. In that case, however, he will be, in fact, a small proprietor buying his own tools and materials and fixing a retail price. 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.

Moreover, conditions of life in the disabled man's native place must be considered as a matter of importance. A man from the Mediterranean country has no idea beyond the cultivation of meadows, and one from Picardy none beyond the making of cane baskets for packing flowers.

Judgment is difficult, and in order that the choice may be exercised as reasonably as possible, the careful collaboration of the patient, the doctor and the managers of the workshops is essential. We repeat that this is one of the principal objects for which the centres of re-education are useful. There are some efficient men, we know, who without asking anything of anybody find quickly and unerringly the exact work that suits them. There is no need of anxiety in such cases.

A certain metal worker from the invaded area suffering from pseudarthrosis of the shoulder, whose wound we were treating, sent for his wife, and they began to rear geese. We know two cases of amputation of the right arm, an operative at an aeroplane works and a worker in stucco, who during their stay at hospital and before they had been supplied with artificial limbs, had taught themselves, the one technical design the other ornamental design. Both of them, as soon as they were discharged, have been taken on by their former masters, who no doubt were fully conscious that they were thus combining a good deed with good business. To come to a decision of any value, however, cases of this sort must not be taken as a criterion, for they are in fact exceptional. The majority of the men are in need of guidance.

The procedure employed at the Belgian centre of re-education at Port-Villerz consists in allowing the patient to frequent the workshops at will for a few days, during which time he sees what is going on and is not slow to make his choice, which it appears rarely needs to be amended.

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 must be understood, however, that these professions which require skill can, as a rule, only be learnt in well-equipped workshops at the price of a fairly long apprenticeship. Two or three years are necessary to make a good mechanic, a good watchmaker, glass cutter, etc. This should not deter us in the case of fairly young men. The difficulty is to organise special workshops, often with a complicated equipment, where the maimed man can at least pick up the rudiments of the work, for it is not to be thought of that he can remain there during the whole time occupied in a complete training.

In conclusion, we should like to draw attention to the law of 1831, which regulates the distribution of pensions by means of groups classified according as the loss is of two limbs or of one. No distinction is made with regard to the seat of the amputation. But a man who has lost both legs and has been suitably equipped with artificial limbs can earn a fair wage, whereas a man who has lost both arms is completely disabled so that he cannot even wash or dress himself. Among the amputation cases the difference is also considerable in the lower limb, between amputation through the leg and through the thigh, and even more in the upper limb, between an amputation retaining the movements of the elbow and one in which they are lost. There is, moreover, a great difference in the quality of stumps and the consequent utility of the artificial limb. It is of course impossible to allow with mathematical precision for all degrees of disablement, but the several general distinctions which we have enumerated could be taken into consideration without difficulty.