BY DOUGLAS C. McMURTRIE. NEW YORK. - for nt 'CrS e p d ,^ ati0 Edit of Sclavs REPRINTED FROM THE MEDICAL RECORD October 26, 1918 WILLIAM WOOD & COMPANY NEW YORK. SOCIAL RESPONSIBILITIES IN THE RE- HABILITATION OF DISABLED SOL- DIERS AND SAILORS. By DOUGLAS C. McMURTRIE, NEW YORK. DIRECTOR RED CROSS INSTITUTE FOR CRIPPLED AND DISABLED MEN ; PRESIDENT. FEDERATION' OF ASSOCIATIONS FOR CRIPPLES ; EDITOR, "AMERICAN JOURNAL OF CARE FOR CRIPPLES." There are distinct social responsibilities in the rehabilitation for civilian life of disabled soldiers and sailors. In the restoration of the man to self- support, although the medical treatment be thor- ough and efficient, though reeducational provision be excellent, and though the will and spirit of the men under training may be of the best, yet the complete success of the program will depend upon whether the attitude of the public acts as a help or a hindrance — upon whether the influence on the individual ex-soldier of his family, his employer, and the community at large is constructive or de- moralizing. What, then, is the public duty toward the dis- abled soldier? For it is certain that the require- ments need only to be understood to be fulfilled. The first responsibility on the part of the family of the injured man is to learn the meaning of dis- L opynght, \\ llliani Wood & Company. 1 ability and see the hopeful rather than the de- Pressmg aspect. Just recently in the suburb of a large Pennsylvania city a woman in a swoon was found on the steps of the local postoffice She had just opened a letter from her son at the front which told of a gunshot injury necess bating am putation of his left arm below the elbow Imme- diately there rose before her eyes the terrifying prospect of a life of idleness and possible pauperism. One can imagine what her next letter would be like: saying she knows what the amputation means and sympathizes most tenderly on account of what must be faced in the future. If it were only a leg it would not be so bad, for then he might be able to take care of himself and get some kind ot a job but with an arm off, he could not expect to do that But she and father have saved up some, and with uncle's help they will take care of him till the end of his days. Picture the influence of this message in comparison with another which might be sent in the light of a fuller understanding of what is possible: "1 have just heard of your aim amputation and sympathize most lovingly in your loss. But I know you will not lose your courage, even at this sacrifice for your country. Even now, the national authorities are making plans to make up so far as possible for such losses, as you doubtless already well know. One-armed men can be trained for skilled jobs, especially men with native ability such a? yours, and the training is already under way in the city near us. The employers also here are becoming tremendously in- terested in the subject, and are finding jobs specially suited to men who have lost arms or legs and have promised these jobs to the fellows who return from the front disabled. And you can count on our stand- e ing behind you at every step and helping in every way we can. This is really a fine future to look ahead to for if you make good here at home with your handicap of honor, you and we will have true reason to be proud. And of course you will suc- ceed if you go at this obstacle with the same spirit and nerve as have gone toward your work in the army. Your mother will look forward to your return home wearing the uniform of Uncle Sam and flying the colors of a soldier who can't be beaten." It is greatly to be desired that the families of men going to the front should know of the possi- bilities of reeducation and reemployment and of the provision being made for the disabled, for it would mitigate not only a great deal of mental suffering over actual injuries but over prospective disabili- ties as well. It is well known that the greatest fear regarding service in the trenches is not the loss of life but the prospect of returning crippled. As one writer has well put it : "To die for one's country: if one could only be sure of dying!" In coming down in the elevator of a large New York djpartment store recently, the day following the publication in its pictorial section by a great daily newspaper of the photograph of the first American amputation cases in France, the follow- ing remark was overheard: "Did you see those horrible pictures in the paper yesterday? I do hope that Jack will not come home that way: I would rather he be killed." Yet the picture showed only foot amputations and to one familiar with cripples and their potential accomplishments such a disability seems a real inconvenience but nothing more. The woman quoted was suffering unduly in her apprehension. It is not here intended to minimize the serious- ness of the total disabilities but these occur in but one case in a hundred thousand. The point is that many injuries that might be regarded as terrible under unintelligent handling in the past no longer remain so. The second responsibility of the family is to understand the importance to the disabled soldier of the proffered training for self-support, and to oncourp^e him in every possible way to undertake it. The family must do more than avoid opposition to the soldier's plan for reeducation; they must do more than give it lukewarm assent — they must *> - et behind it with every influence at their command. Failure to have the family understand and sup- port the program for the future of the disabled man may have disastrous results. In France the mother occupies an unusual place of authority in the family economy. A son may grow up to be twenty, thirty, or forty years old, but mother is still a chief to whom obedience is unquestionably paid. In dealing with the poilu, therefore, one must count in his maternal parent as well. At one French center of hospital care and reeducation it was found that, as a man would approach the point of his medical recovery and approach the time of entry on vocational training, his mother was liable to descend upon the hospital office, beat her umbrella on the table, inquire why they were keep- ing her son so long away from home, and demand his immediate discharge in order that she might take him away "to care for the poor crippled boy for the rest of his life." In vain were explanations and arguments regarding the efficacy of further treatment and training. She had come there de- termined to take her son away, and the scene would continue until her end was accomplished. And in most instances there was nothing to do but accede to the mother's demand. But a better way was found of dealing with the families of men deemed likely to benefit by re- education. Under this procedure when the soldier was nearing the end of his hospital care the director of the institution would summon the mother to come in and advise regarding her son's future. She would then be addressed something in this wise: "Your son's medical treatment will, in another week or two, be practically complete, and we thought you might like to know so that, if you desired, you could make plans to take him home. But you know he is permanently disabled and will not be able to go back to his old job of telegraph lineman. We know that you expect to care for him, but he will outlive you, and later, since the government pension is small indeed, he will be reduced to a miserable situation. You remember the cripples from the War of 1870, how they begged or sold trinkets about the streets — and you would not want your son to be in that fix. Luckily, however, he will not have to be for we have something else to suggest. Across the street is a school where the men are taught various skilled trades. If your son cares to stay for five or six months, and you ap- prove, we will teach him to be a telegrapher and he can go back to his home town and get a good job with the government telegraphs. As a skilled worker still he will be doubly respected in the com- munity, he will be a burden on no one, his future will be assured, and you will be very, very proud of him. What do you think wise under the cir- cumstances?" The whole situation is changed. Mother greets her boy with: "Son, have you heard what they are going to do for you?" And as the son has already been talked to regarding the program, the joint decision is assured. This illustrates the difference between a family for or a family against the proposal of reeducation. The third duty of the family is to stand behind the man during his course of training and try in every way to encourage rather than dishearten him. Letters from home which recite all the troubles of life and none of the joys will not help the enterprise. The family reaction should rather be: "Stick to it; we are getting along all right and want to see you finish the job up right, now that you are at it." In other words it is necessary to maintain the morale of the family in the same way as when the man is at the front. This is largely contributed to by home visitors such as those of the Canadian Patriotic Fund or the American Red Cross. The fourth family responsibility toward the dis- abled man is to make the home influence as sensible and as truly helpful as possible after his return from hospital or school. The first and very natural impulse when son or husband comes home crippled or blind is to pet him and wait on him hand and foot. Yet the best interests of the family as well as of the man himself demand his being encouraged to do for himself everything he can, with the aim of stimulating that self-dependence which has been the object of his whole course of training. Within the limits imposed by affection the family should endeavor to carry along the spirit of that training. In the readjustment of the crippled soldier to civilian life the employer has a very definite re- sponsibility. But this duty is not entirely obvious. It is, on the contrary, almost diametrically opposite 6 to what one might superficially infer it to be. The duty is not to "take care of," from patriotic motives, a given number of disabled men, finding for them any odd jobs which are available, and putting the ex-soldiers in them without much regard to whether they can earn the wages paid or not. Yet this method is all too common. A local com- mittee of employers will deliberate about as fol- lows: "Here are a dozen crippled soldiers for whom we must find jobs. Jones, you have a large factory: you should be able to take care of six of them. Brown, can you not find places for four of them in your warehouse? And Smith, you ought to place at least a couple in your store." Such a procedure cannot have other than perni- cious results. In the first years of war the spirit of patriotism runs high, but experience has shown that men placed on this basis alone find themselves out of a job after the war has been over several years, or, in fact, after it has been in progress for a considerable period of time. A second weakness in this method is that a man who is patronized by giving him a charity job comes to expect as a right such semi-gratuitous support. Such a situation breaks down rather than builds up character, and makes the man progressively a weaker rather than a stronger member of the com- munity. The third difficulty is that such a system does not take into account the man's future. Casual placement means employment either in a makeshift job as watchman or elevator operator such as we should certainly not offer our disabled men except as a last resort — or in a job beyond the man, one in which, on the cold-blooded considerations of product and wages, he cannot hold his own. Jobs 7 of the first type have for the worker a future of monotony and discouragement. Jobs of the second type are frequently disastrous, for in them a man, instead of becoming steadily more competent and building up confidence in himself, stands still as regards improvement and loses confidence every day. When he is dropped or goes to some other employ- ment, the job will have had for him no permanent benefit. Twelve men sent to twelve jobs may all be seri- ously misplaced, while the same twelve placed with thought and wisdom and differently assigned to the same twelve jobs may be ideally located. If normal workers require expert and careful placement, crippled candidates for employment reouire it even more. The positive desideratum is to find for the dis- abled man a constructive job which he can hold on the basis of competence alone. In such a job he can be self-respecting, be happy, and look forward to a future. This is a duty not so easy of execution as telling a superintendent to take care of four men but there is infinitely more satisfaction to the employer in the results, and infinitely greater ad- vantage to the employee. And it is entirely prac- tical even in dealing with seriously disabled men lhousands of cripples are now holding important jobs in the industrial world. But they are men of exceptional character and initiative and have in general, made their way in spite of employers rather than because of them. Too many employers are ready to give the cripple alms, but notSg expend the thought necessary to place him hi a suitable job. This attitude has helped to ma™ many cripples dependent. With new responsibilities to the disabled soldier,, the point of view must eer- 8 tainly be changed. What some cripples have done, other cripples can do — if only given a chance. This, then, constitutes the charge of patriotic duty upon the employer: To study the jobs under his jurisdiction to de- termine what ones might be satisfactorily held by cripples. To give the cripples preference for these jobs. To consider thoughtfully the applications of disabled men for employment, bearing in mind the importance of utilizing to as great an extent as possible labor which would otherwise be unpro- ductive. To do the returned soldier the honor of offering him real employment, rather than proffer- ing him the ignominy of a charity job. The responsibility to the disabled soldier on the part of the community at large is much more com- plex, since the contact exists at a multitude of points and is at none highly intimate. The first reaction of the public to the returning man is hero-worship of the most empty type — described coldly it usually consists in making a fool of the man and entertaining him in inappropriate and hurtful ways. One form of this is society lionization — and for but the proverbial six days indeed. To a large Canadian city there returned a disab'ed soldier after two years' absence at the front. His wife and children had been looking forward expectantly to having him with them, but after his arrival saw but little of the head of the house. As a national holi- day was approaching they were counting on his accompanying them to the park, and had exacted a tentative promise that he would do so. But as the morning arrived and mother was dressing the children to start, father made no move to get ready. Almost tearfully mother asked if he was not going 9 with them. "Oh, no," he answered, "I am going for an automobile ride this morning and this after- noon to a sing-song at the — (naming a fashionable hotel)." Thus was the community showing kind- ness to the returned soldier and helping to put him back on his feet. The man on the street thinks the greatest service to the disabled fighter, particularly when he is dis- charged from the army and no longer under the partial protection of the khaki, to consist in buying him at the corner saloon as many drinks as he can hold. From one small American city a social worker reported inability to distinguish as to whether certain discharged men were suffering from shell shock or intoxication, so hearty was the hos- pitality of the citizens. Such "kindness" requires no comment. Fortunately the war-time measure regarding the liquor trade will soon make this im- possible, and will guard the ex-soldier from one pitfall. It may be noted in passing that this will be a boon to the returned men in more ways than one. In Canada at a time when most of the prov- inces had prohibition and one or two others limited license, the placement of disabled men in employ- ment was many times simpler in the dry territory than the wet. In the latter many men lost jobs again and again by reason of intoxication, not only injuring themselves but weakening the standing of their fellows as well in the eyes of the employers. Finally there is the great general public prejudice against the disabled, the incredulity as to possible usefulness, the apparent will to pauperize, and the reluctance through usual channels of opportunity to give the handicapped man a chance. Successful crippled and blind men unanimously testify that the handicap of public opinion is a greater obstacle 10 than amputation of limb or loss of sight. And this unenlightened attitude is manifest in every social relation of the disabled — with family, with employer, with the community as a whole. It becomes clear, therefore, that a necessary fea- ture of any program for restoring the disabled soldier to self-respect and self-support is a campaign of public education to convert the general attitude toward the crippled and handicapped. This need was recognized most clearly among our enemies by Germany and among our allies by Can- ada. There was signal failure to appreciate the value of public education in France, Great Britain, and Italy. There is no need of it yet in Belgium as all the disabled men are retained in the army and provided not only with training but with em- ployment as well, and there is no family problem as the men cannot return home. Within a few months of the opening of the war, the secretary of the German national federation for the aid of cripples made a tour of the leading cities of the Fatherland speaking to meetings of public officials, social workers, and the like, with the aim of disseminating intelligence regarding modern principles and methods of dealing with the disabled. The same authority prepared several pamphlets of popular character which were distributed in editions of over a hundred thousand. There was in ex- istence at the outbreak of the war an excellent monthly journal on work for cripples, and this devoted its columns to the subject of provision for the war disabled. Some other special publications in the same field immediately sprang up. One of these has the interesting title of "From War to Industry." There has been issued under the title of "The 11 Will Prevails" a volume of biographies of cripples who have overcome their handicaps— from Tam- burlaine down to men disabled in the present war. The book is intended for circulation in hospitals and for general reading. Exhibitions illustrating m a practical way the possibilities of the war crip- ple constitute another vehicle of public education, and have been held in the leading centers of the empire. Moving pictures and lantern slides are also being utilized for propaganda to stimulate in- terest on the part of the people and to arouse ambi- tion and courage on the part of the disabled them- selves. In Canada a real and very intelligent effort has been made to acquaint the people with the aim and practice of reeducation. A well-known poster, printed in red and black, entitled "What Every Disabled Soldier Should Know," is widely in evi- dence throughout the Dominion. It is really ad- dressed as much to the public as to the returned soldier. The text of the poster is as follows : Th tionary" e ^ " SUCh W01 ' d aS " im P°ssible>» in his dic- ^fulnned"^ 11 ™ 1 ambiti ° n t0 C>ain a " ood livin 8' be T ane h vv ° f « ****** That the whole object of doctors, nurses, and instruc tors is to help him in doing that very thine nStrUC " That he must help them to help him 5 g ' i vLf } 1UVe to ' have the most ireful and effectual treatment known to science enectual lhat interesting and useful occupations form a mm* duty for him with the Canadfa"? forces „ verLL" l'?' 12 That his strength and earning capacity will be restored there to the highest degree possible, through the Invalided Soldiers' Commission. That if he requires an artificial limb or kindred appli- ance it will be supplied free. That every man di-abled by service will receive a pen- sion or gratuity in proportion to his disability. That if his disability prevents him from returning to his old work he will receive free training for a new occupation. That full consideration is given to his own capacity and desires when a new occupation has to be chosen. That his own will-power and determination will enable him to succeed, both in the training and in the occu- pation afterward. That his maintenance and that of his family will be paid for during the training he may receive after dis- charge, and for a month longer. That neither his treatment nor his training will cost him a cent. That his home Province has a special commission to assist him in finding employment on discharge. That hundreds of towns and villages have committees, associations, and clubs, to welcome him on arrival, and to help in securing a position for him. That the Dominion and provincial Governments, the municipal authorities, and all t:orts of employers, give the returned soldier preference in filling vacant posi- tions. That the returned soldier wishing to take up land and farm it will be helped to do so, under Federal and other settlement schemes. That the Invalided Soldiers' Commission exists to carry out his restoration and training in Canada. That the Board of Pension Commissioners exists to dis- tribute the pensions provided by his country for him and his dependents. That the Invalided Soldiers' Commission and the Board of Pension Commissioners are in the position of trus- tees, appointed for his benefit, and representing the whole people of Canada. That, therefore, he should write direct to the Commis- sion or the Board if he needs advice or help. Canadians are unanimously resolved that every re- turned soldier shall have a full opportunity to suc- 13 reed. When thai opportunity is put within his reach, his success will depend on his own good sense in seiz- ing and using it. Another poster of pictorial character shows a one-armed man fitted with an artificial appliance at work on a drill press. The daily press has been supplied with material descriptive of the success of men who have com- pleted training and made good. Some stories have carried with them a little preachment as to the sound attitude toward the disabled soldiers. One concludes with this statement: "Every man doing steady work suited to his capacity is a gain to him- self and his country. Every man left idle, or per- forming some trifling task beneath his capacity, or trying to do work he is unfit for, is wasted. And Canada cannot afford to waste a man." A remarkable moving picture film in ten reels has been prepared by the government authorities to illustrate the progress of the disabled soldier after his return from overseas. It shows reception at the debarkation depot, transportation in a hos- pital train, various forms of treatment at military hospitals, recreation, vocational training, and, final- ly, reemployment in industry. The message of the series of reels is "that injury does not mean pau- perism : that every man is given a chance to make good." Where the man does not try to help him- self, however, there is shown the opposite eventual- ity of vagrancy. The film is for exhibition in Canadian military hospitals in England and for showing to the public of the Dominion. In the United States there has been as keen if not a keener realization of the fundamental im- portance of public education to the cause of the disabled as in any other country, and as might 14 probably be expected actual work on such a cam- paign began at an early date. The Surgeon Gen- eral of the Army issued in October, 1917, a clear statement of the modern policy and spirit of deal- ing with the disabled soldier, under the title of "The Passing of the Cripple." Later the same office made an excellent contribution to the cause in the preparation of moving picture films of five success- ful American cripples who were seriously handi- capped, yet had overcome their obstacles. This series of reels was entitled "The Way Out," and was intended for showing to the general public and in hospitals overseas to men who have just met with disabling injury. The set is one item in a "cheer- up campaign," another projected feature of which is the issue of a volume of biographies of disabled Americans who have beaten their handicaps. Still another factor in this work is the issue by the Surgeon General, in cooperation with the American Red Cross, of an inspirational magazine, by name "Carry On," which aims to convey to members of the army medical corps, to army nurses, to Red Cross home service workers, and to the public at large some conception of the new spirit in dealing with wounds, of more kinds than one, which are sustained at the front. This magazine has already a monthly circulation of over a hundred thousand. An unofficial campaign in the interest of the dis- abled was early initiated by the Red Cross In- stitute for Crippled and Disabled Men. One of the most familiar items in this campaign was a small folder of which over seven million copies were distributed, largely through the courtesy of tele- phone, gas, electric, and other public service cor- porations. It was titled, "Your Duty to the War Cripple" and its text— which epitomizes the gospel preached in the campaign — read as follows : 15 When the crippled soldier returns from the front, the government will provide for him, in addition to medi- cal care, special training for self-support. But whether this will really put him back on his feet depends on what the public does to help or hinder, on whether the community morally backs up the national program to put the disabled soldier beyond the need of charity. In the past, the attitude of the public has been a greater handicap to the cripple than his physical disability. People have assumed him to be helpless, and have, only too often, persuaded him to become so. For the disabled soldier there has been "hero-worship": for the civilian cripple there has been a futile kind of sympathy. Both do a man more harm than good. All the cripple needs is the kind of job he is fitted for, and training in pieparation for it. There are hun- dreds of seriously crippled men now holding down jobs of importance. Other cripples can do likewise, if given the chance. In the bght of results already attained abroad in the training of disabled soldiers, the complete elimination of the dependent cripple has become a constructive and inspiring possibility. Idleness is the great calamity. Your service to the crippled man, therefore, is to find for him a good busy job, and encourage him to tackle it. Demand of the cripple that he get back in the work of the world, and you will find him only too ready to do so. For the cripple who is occupied is, in truth, no longer handicapped. Can the crippled soldier — or the industrial cripple as well — count on you as a true and sensible friend? The assistance of chambers of commerce and man- ufacturers' associations was enlisted to secure transmittal to their members, with a special note of indorsement by the organization, of a circular call- ing to the attention of employers their responsibility to the disabled soldier. Over two hundred thousand employers were reached direct in this manner and the statement was reprinted in scores of trade journals. IB A speakers' bureau was organized, a film and pic- ture service instituted, and the daily press and magazines supplied with informative articles on the work being accomplished abroad in the reconstruc- tion of crippled men. One of the most interesting features of the work was the preparation for indi- vidual trade journals of articles on re-education in the particular trade covered by each journal or on employment opportunities for the disabled in that trade. This material proved of very direct interest to both editors and readers of the journals. Another feature of the campaign was the issue of a booklet in ten foreign languages: Yiddish, Italian, French, German, Hungarian, Polish, Greek, Spanish, Danish, and Swedish. These were distributed to pastors of foreign-speaking congregations and to physicians and social workers in the foreign com- munities. The text of the booklets was also re printed by almost every foreign language news- paper in the country. The work of public education in the interest of the cripple has just begun. It must be continued until the "man in the street" is thoroughly familiar with his responsibilities to the disabled — until the community is converted from its present attitude. .'ill Fourth Avenue. IT A COMPOSITE FAC-SIMILE MEDICAL RECORD A Weekly Journal of Medicine and Surgery ) COMPANY Pul S5.00 Per Annum. Published at New York Every Saturday Sinfele Copies, 15c ORIGINAL ARTICLES The Occupational NturoiM. A C Irul ;;tual DIiumi Ptn«or. Print Evldanca. rrath Air in Schooli and Hospllai* EDITORIAL NOTES. Nephrotyphua — Atntsta* and Long NEWS OF TMB WEEK. dc n l«-4iiN[e r y * ' U nd c r"* Wfflcu 1 1 SVa -N« 'I^PfTI Help ^ Tub^rculosie Hri,^-Hr B titnAilon of Pl»lf— ChaHtobl^ Ollta— New Hoi- |V(-^'|l«"*T" y Kou*d bU Uyml— Rn- dvivmtnl Fund for Hom*(,paihy- Am»rlfjn v Medical ^Ediiofi* ( A«0« CORRESPONDENCE. >m the Philippines OP MEDICAL SCIENCE. Ctv. Inf. rhato— AneMhuila In Tonsil Er . I ■ ^ r l v ■ ■ — \ hilly pholfl, Vacr.naMoi Fev«r Propnyltutta — ... INSURANCE MEDICINE. Buw.ll Mi.lt -itv- . Chrc BOOK REVICWA. M.D. Albert H Bvck, M.D- pletf In El«ht Volumea Profusely illustrated. Volume VJ1I. ........ . surgery of '^.'J^ ' ^ e j^ ^ with 37J cncravlnci SOCIETY REPORTS. Connecticut Slate Medical Sodet] MEDICOLEGAL NOTES. Malpractice,— Responsibility for Privileged Coin- ipe of Privlleced vices— Expert Evidence In Murter C*i* STATE MEDICAL LICENSING BOARDS. INSTRUMENTS. NATIONAL AND JUST PUBLISHED URGENT SURGERY Volume Two-»-The I By FELIX LEJARS > 20 Full-pant Plitei and v9« IlluMr.it, on nu-.lin. Ill 01. hull 1