The Crippled and the Disabled: Rehabilitation of the Physically Handicapped in the United States 9780231892858

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THE

CRIPPLED AND

THE

DISABLED

THE CRIPPLED AND

THE DISABLED R E H A B I L I T A T I O N O F T H E PHYSICALLY HANDICAPPED IN T H E U N I T E D STATES

BY

H E N R Y H. KESSLER

COLUMBIA U N I V E R S I T Y PRESS 1

93 5

COPYRIGHT

1935

COLUMBIA UNIVERSITY PUBLISHED

PRESS

1935

P R I N T E D I N T H E U N I T E D S T A T E S OF A M E R I C A BY T H E H A M I L T O N P R I N T I N G CO., A L B A N Y , N . Y .

TO

JOSEPH SPITZ HUMANITARIAN

PREFACE IN these troublesome times of abrupt social change, of serious economic and political maladjustment, when some national governments are taking on even revolutionary aspects, when unemployment is so widespread, it is peculiarly appropriate to call attention to the problem of the disabled and to advance their claims f o r recognition, and their need f o r a more definite economic and social status than they have h a d in the past. T h o u g h the question of rehabilitation of the disabled is not new, changing economic, political and social conditions require a restatement of the problem. Before recent economic disturbances, a good deal h a d already been done to fit such persons into the existing order. However, present economic and social events have intensified their problems. W i t h the cries of the unemployed more effective in directing attention to themselves, the cause of the disabled may be temporarily neglected, but it is certain that it will not be completely abandoned. T h e twentieth century has seen a changing social attitude toward poverty and dependency. T h e interpretation of the causes of dependency has changed f r o m moral stigma to economic maladjustment. Although progress has been made in a changed attitude toward dependent classes, the disabled person is still appraised morally. Somehow the concept of lack of social planning, resulting in economic waste and inefficiency, which is applied to the poor and destitute, does not seem to be applied to the problems of the person handicapped by a crippling deformity. T h e struggle of the disabled f o r economic and vocational status appears to have been solved in Soviet Russia by the absorption of the disabled into the industrial economy. T h i s has been achieved by a revolutionary political concept of the status of each individual, rather than by a changed attitude toward a class.

viii

PREFACE

T h e question is raised, therefore, as to the feasibility of a similar achievement in a democratic and capitalistic society like the United States. In order to answer this question it is advisable to postulate the needs of the disabled and to determine how f a r these needs are met by practice and intent. Since the prevailing attitudes, desires and customs of people are usually crystallized in legislation, it is desirable that we examine this legislation to see how f a r the needs of the disabled are met and how f a r such efforts fall short of desired objectives. M o r e specifically, we wish to discover what role legislation has played in reducing the social and economic differential between the disabled and the nondisabled, what the achievements of this legislation have been and what trends are discernible in recent legislation. Our purpose, therefore, is to study legislation in the United States as it affects the vocational adjustment of disabled persons. Such legislation is found scattered according to its specific purpose and character, such as education, treatment, compensation and rehabilitation. It may, therefore, be of value to bring together the various legislative experiments so as to facilitate examination, to ascertain their g o o d and b a d points, to find out to what extent their purpose has been fulfilled, or has fallen short of achievement. F r o m such an examination we may extract legislative principles which can be embodied in an adequate and comprehensive p r o g r a m which will facilitate the vocational adjustment of the disabled person. In the following p a g e s the disabled person is first defined. T h e extent of the problem presented by this group is then described by references to the available statistical material. F o r convenience of treatment the disabled as a group of vocationally maladjusted persons are subdivided into the child cripple, the industrially disabled, the military disabled, the chronically disabled, the blind, deaf and dumb. Specific and general legislation for these classes is then examined. In some instances it will be found that adequate legislation has been effectively developed, but, because of administrative defects

PREFACE

ix

and legal difficulties, full benefits h a v e not been obtained. In many cases we h a v e to d e a l with legislation b e a r i n g only indirectly on the vocational a d j u s t m e n t of physically handicapped p e r s o n s . A p p l i c a t i o n of s o m e of the provisions of these laws, or extension o f them, m a y be helpful in i m p r o v i n g the economic position of the disabled. N o a t t e m p t h a s been made to study exhaustively all of the legislation b e a r i n g on their p r o b l e m s . S o m e f o r e i g n legislation has been included f o r comparative p u r p o s e s , because remedies and m e t h o d s are suggested that a r e not f o u n d in A m e r i c a n legislation. L e g i s l a t i o n in the U n i t e d S t a t e s and in the f o r e i g n countries studied includes w o r k m e n ' s compensation, rehabilitation, child w e l f a r e , minimum w a g e , national recovery, unemployment relief, v e t e r a n s ' pensions and relief, social insurance, education a n d m o t h e r s ' aid. In addition to the examination or many s t a t u t e s a n d their a m e n d m e n t s c o m m e n t a r i e s h a v e also been used. T h e annual reports, studies and publications of the F e d e r a l B o a r d o f V o c a t i o n a l E d u c a t i o n h a v e been examined, as well as similar r e p o r t s of S t a t e Rehabilitation Commissions, V e t e r a n s ' A d m i n i s t r a t i o n , Industrial Commissions, A s s o c i a t i o n s (in s e v e r a l countries) of C r i p p l e d and D i s abled, a n d publications including particularly the L e g i s l a t i v e Series of the International L a b o r Office. F i r s t - h a n d i n f o r m a tion has also been obtained t h r o u g h questionnaires, correspondence a n d interviews. In addition, the author h a s d r a w n on his own field experience as medical a d v i s e r to the N e w J e r sey W o r k m e n ' s C o m p e n s a t i o n B u r e a u a n d Rehabilitation Commission. V i s i t s of inspection to vocational training and rehabilitation schools, hospitals and industrial establishments, both in the U n i t e d S t a t e s a n d a b r o a d , h a v e been h e l p f u l in u n d e r s t a n d i n g a n d interpreting i m p o r t a n t social trends in recent y e a r s . T h e a u t h o r wishes to t a k e this opportunity to express his appreciation to P r o f e s s o r S a m u e l M c C u n e L i n d s a y f o r his inspiration and guidance as well as practical assistance, and also to P r o f e s s o r R o b e r t E . C h a d d o c k f o r his m a n y valuable suggestions. I a m indebted to G e n e r a l F r a n k T . H i n e s ,

X

PREFACE

Administrator of Veterans' Affairs, for the privilege of utilizing the facilities of the Veterans' Administration. I wish to express my appreciation f o r the assistance and cooperation of D r . Fred H . Albee, chairman of the N e w Jersey Rehabilitation Commission; Commissioner John T . Toohey, Jr., director of the N e w Jersey Rehabilitation Commission and Commissioner of the State Department of L a b o r ; and M r . Joseph G . Buch, chairman of the Crippled Children's Commission of the State of New Jersey. H . H . K. New York November 15, 1934

CONTENTS PART

I

GENERAL CONSIDERATIONS I. I N T R O D U C T I O N

3

I I . SOCIAL A T T I T U D E

TOWARD T H E

DISABLED

III. T H E P R O B L E M O F T H E D I S A B L E D

PART

.

.

13

.

32

II

THE CHILD CRIPPLE IV. G E N E R A L CONSIDERATIONS C O N C E R N I N G T H E C H I L D C R I P P L E V. H O W A R E T H E N E E D S OF T H E C R I P P L E D C H I L D M E T ? . VI. FOREIGN LEGISLATION

FOR C R I P P L E D C H I L D R E N

PART

.

.

. .

51

.

56

.

67

III

THE INDUSTRIALLY DISABLED V I I . G E N E R A L CONSIDERATIONS C O N C E R N I N G T H E

INDUSTRIALLY

DISABLED

77

V I I I . H O W T H E N E E D S OF T H E I N D U S T R I A L L Y D I S A B L E D ARE M E T

94

I X . L E G I S L A T I V E M E A S U R E S FOR T H E I N D U S T R I A L L Y DISABLED .

IO3

X . FOREIGN

LEGISLATION

FOR T H E

.

134

X I . G E N E R A L CONSIDERATIONS C O N C E R N I N G T H E W A R - D I S A B L E D .

145

PART

INDUSTRIALLY

DISABLED

IV

THE WAR-DISABLED X I I . H O W T H E N E E D S OF T H E W A R - D I S A B L E D W E R E M E T .

.

.

X I I I . L E G I S L A T I V E M E A S U R E S FOR T H E W A R - D I S A B L E D : P E N S I O N S . X I V . M E D I C A L AND H O S P I T A L CARE FOR T H E W A R - D I S A B L E D . X V . VOCATIONAL T R A I N I N G XVI. E M P L O Y M E N T

SCHEMES

FOR T H E FOR T H E

WAR-DISABLED WAR-DISABLED

. .

. .

157 .173

. .

152

.177 .

l88

PART V THE CHRONICALLY DISABLED X V I I . G E N E R A L CONSIDERATIONS C O N C E R N I N G T H E DISABLED

CHRONICALLY 199

xii

CONTEXTS

XVIII. THE NEEDS OF THE CHRONICALLY DISABLED

206

XIX. HOW ARE THE NEEDS OF THE CHRONICALLY DISABLED M E T ? 2 1 7

P A R T VI THOSE XX. BLIND,

DISABLED BY DEAF,

D E F E C T S OF S P E C I A L

SENSES

DEAF-MUTES

XXI. NEEDS OF THE

239

BLIND

243

XXII. THOSE WITH LOW VISION, HEARING OR SPEECH DEFECTS .

. 248

PART VII SUMMARY XXIII. SUMMARY

255 APPENDICES

I. COMPENSATION

PROVISIONS

FOR SECOND MAJOR

INJURIES

IN THOSE STATES NOT HAVING SECOND-INJURY FUNDS . 2 6 9 II. SUMMARY OF VOCATIONAL REHABII.ITATION LEGISLATION BY STATES III. LEGISLATION

278 FOR T H E

BLIND

295

BIBLIOGRAPH Y

3O5

INDEX

325

TABLES I. N U M B E R

OF

ACCORDING AND

CRIPPLED TO

PERSONS

FINDINGS

PER

OF

1,000

VARIOUS

INHABITANTS

STATE,

COUNTY

LOCAL SURVEYS

37

II. CAUSES OF DISABILITY ACCORDING TO SURVEYS III. COMPARISON O F T H E SAVING I N

ESTIMATED COST A N D T H E

4O ECONOMIC

A GROUP OF DISABILITIES TREATED

SUCCESS-

FULLY IV. P R I N C I P A L

44 F E A T U R E S OF LAWS R E L A T I N G TO T H E

EDUCA-

TION OF CRIPPLED C H I L D R E N

62

V. RESULT OF R E H A B I L I T A T I O N , EDUCATION AND P L A C E M E N T . VI. MEDICAL SERVICES L I M I T E D AS TO T I M E AND A M O U N T . VII. S U M M A R Y OF R E H A B I L I T A T I O N THE

YEARS

WORK CARRIED ON

65 .

106

DURING

1922-32

128

VIII. A M O U N T O F F U N D S EXPENDED FOR R E H A B I L I T A T I O N D U R I N G THE

YEARS

1922-32

129

IX. U N I T E D STATES WORLD WAR VETERANS RECEIVING

COMPEN-

SATION ON J U N E 3 0 , 1 9 3 3 , FOR VARIOUS DISABILITIES.

.

I47

X. S C H E D U L E OF DISABILITY RATES FOR T H E GERMAN WAR-DISABLED XI. POSTWAR

l66 SHIFTS

IN

INDUSTRIAL

STATUS OF G E R M A N

EX-

SERVICE M E N W H O HAVE LOST O N E ARM XII. TYPES

OF

TRAINING

XIII. TYPES OF

INDUSTRY

XIV. EDUCATIONAL

QUALIFICATIONS

179 184 184

OF TRAINEES

185

XV. EDUCATIONAL Q U A L I F I C A T I O N S A N D E A R N I N G S BEFORE A N D AFTER

REHABILITATION

XVI. COMPARISON OF SALARY RANGE BEFORE A N D AFTER

l86 TRAIN-

ING

187

XVII. D E A F - M U T E S IN G E R M A N Y , I 9 2 5 , FOR EACH 1 0 , 0 0 0 P O P U L A TION

242

PART ONE GENERAL CONSIDERATIONS

I INTRODUCTION IN the welfare work which has become so conspicuous an activity of modern society, the object of all help, according to the philosopher Paulsen, 1 is to make help superfluous. If we reflect on this ideal of social service as it may be applied to the crippled and disabled, many difficulties appear in the way of achievement. Frequently the nature of a disability may be such as to f o r m an insurmountable barrier to any means of selfsupport. On the other hand, there are those whose disabilities do not interfere with their vocational adjustment, but who are unable, nevertheless, to secure employment because of social prejudices and legal restrictions. In addition, there is the enormous group of disabled persons with varying disabilities who struggle under the burden of an imperfect adjustment between physical incapacity and opportunities to earn a livelihood. T h e man in the street is familiar with the individual who has reached his goal by a fight against overwhelming odds. H e is not aware, however, of the larger number who, because of social attitudes, are unable to make their adjustments. T h o u g h many disabled persons display qualities of character t h a t reach an heroic level, their efforts are largely futile. Society is uninformed of the productive possibilities of crippled and disabled persons and how under proper limitations they are capable of wide and prolonged usefulness. As a result of false concepts of capacity to work, as well as of psychological prejudices, there have developed social attitudes and legal limitations which seriously handicap the crippled and disabled in their efforts to earn a livelihood. Instead of being interested in seeing their capacity for work become productive, society makes feeble attempts to secure economic independence f o r 1

Paulsen, Friedrich, Introduction

to Philosophy,

N e w Y o r k , 1893, 429 pp.

4

INTRODUCTION

these individuals since it is difficult to find a place f o r them in industry. T h e economic choice, t h e r e f o r e , is one of considering either the whole g r o u p as a burden f o r which asylum and care must be p r o v i d e d , o r that of rehabilitating them in occupations and industries f o r which they a r e suited. T h e s e social prejudices h a v e been emphasized because they a r e so important in explaining the difficulties experienced by disabled persons in earning a livelihood. T h e main purpose of this study is to show how these prejudices and b a r r i e r s are g r a d u a l l y being mitigated by social legislation, both directly and indirectly improving the chances of the individual to make a social adjustment. DEFINITION In this study the term " d i s a b l e d " is used to designate several g r o u p s of persons w h o are definitely handicapped in their effort to m a k e a living because of physical disabilities of one sort o r another. A t the outset, h o w e v e r , it is desirable to dispel s e v e r a l f a l s e notions concerning the so-called disabled person. T h e r e is no such entity as a normal person, and many persons w h o are looked upon as disabled a r e by no means less capable of meeting the economic and social requirements of l i f e than many apparently healthy persons. OUR CONCEPT OF A NORMAL INDIVIDUAL On the basis of physical standards, it is v i r t u a l l y impossible to find a completely normal individual. T h i s point is e m p h a s i z e d in examinations made by the A r m y d r a f t 2 and by the L i f e E x t e n s i o n Institute, 3 as well as in those c a r r i e d out in studies of school children, 4 and in p r e e m p l o y m e n t 5 and mass 2

L o v e , A l b e r t G . and Charles B . Davenport, Physical Examination of the First Million Draft Recruits, U. S. Surgeon General's Office, Bulletin n , W a s h ington, D. C., 1 9 1 9 , 521 pp. 8 Fisk, Eugene, L . : "Periodic Examination of Supposedly W e l l Persons," L i f e Extension Institute Studies, N e w Y o r k , 1 9 1 5 , p. 1+. 4 M i l b a n k M e m o r i a l Fund, " P h y s i c a l Impairments A m o n g M a l e s of D i f f e r e n t Occupational Classes," Quarterly Bulletin V I I I , 57-68 ( N e w Y o r k ) , J u l y , »930. e Britten, Rollo H., A Health Study of Ten Thousand Male Industrial Workers' U. S. Public Health Bulletin No. 162, Washington, D. C. 1926, p. 149.

INTRODUCTION X-ray examinations

5

in l a r g e g r o u p s of w o r k e r s .

I t is w e l l k n o w n t h a t the absence of s y m p t o m s does not necessarily indicate a h e a l t h y o r g a n i s m . I n a study 7 m a d e by the w r i t e r of 6 , 5 6 5 m a l e a n d f e m a l e w o r k e r s e x a m i n e d in f o r t y f a c t o r i e s , only 7 p e r c e n t w e r e f o u n d to be f r e e f r o m gross d e f e c t s detectable by p h y s i c a l e x a m i n a t i o n s ; 7 0 percent had m i n o r d e f e c t s ; 1 6 p e r c e n t h a d a d v a n c e d m i n o r d e f e c t s and 7 percent h a d m a j o r d e f e c t s . A u t o p s y r e p o r t s f r e q u e n t l y establish the f a c t that m a n y i n d i v i d u a l s w h o h a v e n e v e r s u f f e r e d any subjective s y m p t o m s o r p h y s i c a l signs of disease, have definite evidence of c a r d i o - v a s c u l a r disease, a d v a n c e d tuberculosis o r o t h e r definite changes in the p h y s i c a l structure. W e must, t h e r e f o r e , be m o r e c a r e f u l in a s s u m i n g a healthy state even w h e n the i n d i v i d u a l r e p o r t s t h a t he is f r e e from symptoms. T h e r e a r e s e v e r a l points o f v i e w r e l a t i n g to the condition of the h u m a n b o d y which a r e a s s u m e d in defining g o o d health. A n ideal v i e w is t h a t b a s e d on the possibility of p h y s i c a l perfection, f o r which t h e r e is little w a r r a n t . T h e p a t h o l o g i c a l view is t h a t which a s s u m e s t h a t a p e r s o n is n o r m a l if he has no disability serious e n o u g h to cause him to be c o n s i d e r e d morbid. N o r m a l vision, f r o m this point of v i e w , is vision that is not seriously i m p a i r e d in the ability to s e e ; the n o r m a l stomach is a s s u m e d to be one that is not d i s e a s e d . Still a n o t h e r approach to the subject of g o o d h e a l t h a n d disablement eliminates the bias that d o m i n a t e s b o t h the ideal v i e w and the p a t h o l o g i c a l v i e w . T h e statistical v i e w in m a k i n g a count considers an a b s t r a c t n o r m a l i n d i v i d u a l w h o is a s s u m e d to b e without s y m p t o m s of illness o r p h y s i c a l d e f e c t . N o n e of these v i e w s a r e s a t i s f a c t o r y . D e s p i t e its a t t e m p t at objectivity, the statistical v i e w , as w e l l as the ideal and the p a t h o l o g i c a l v i e w s , use social j u d g m e n t s as criteria o r standards. T h e use of the t e r m n o r m a l implies a j u d g m e n t in which 6 B a r n a r d , M . W . , " X - R a y M a s s Procedure Applicable f o r the Discovery of Early Tuberculosis in Industrial G r o u p s , " Am. Jour. Pub. Health, XXIV, 8-17, J a n . , 1934. 7 M a d e under the auspices of the Essex County Tuberculosis L e a g u e , N e w a r k , N. J . , 1927-34. Unpublished data.

6

INTRODUCTION

we, w h o consider ourselves n o r m a l , use ourselves as the s t a n d a r d and the subject of o u r attention as the deviation f r o m that s t a n d a r d . W h a t is a b n o r m a l is that which v a r i e s f r o m this s t a n d a r d . E v e r y one is different physically and psychologically, as it is impossible f o r the o r g a n i z a t i o n of physical and mental traits of any t w o people to coincide completely. T h e concept of the n o r m a l being is a social judgment and represents a series of physical and psychological traits not inconsistent with social prejudices and attitudes. LIMITATION OF FUNCTIONAL CAPACITY It is o f t e n f a l s e l y assumed that a physical defect causes limitations of functional activity and hence limitation of industrial usefulness. T h o u g h apparently true in some cases, it is f a l s e in the m a j o r i t y of instances. E v e n in the presence of a physical d e f e c t there m a y remain sufficient function to c a r r y on required industrial activity. T h a t is, the remaining functions o v e r and a b o v e the disability or lack of function due to the d e f e c t m a y be sufficient to s a t i s f y all the personal needs of the individual, as well as sufficient to enable him to a d a p t himself to his industrial environment. A n d e r s o n ' s study 8 shows the f a l l a c y of thinking that because a man is physically handicapped he is vocationally handicapped. T h e records of the vocational accomplishments of the men he studied constitute a challenge to the conception generally held that in assisting physically handicapped men to find w o r k , the emphasis must be fixed on the disability. A new conception of guidance and placement f o r the handicapped is i n d i c a t e d — a conception that places the emphasis on the positive r a t h e r than on the negative abilities of the individual, on his d e m o n s t r a t e d versatility rather than on his supposed limitations. In 1 9 2 9 the W e s t e r n E l e c t r i c C o m p a n y put into effect a new set of medical requirements f o r employees which included n o r m a l health but admitted persons with certain defects which 8

Anderson, Roy N., The Disabled York, 1932, 103 pp.

Man and His Vocational

Adjustment,

New

INTRODUCTION

7

h a d been f o r m e r l y rejected as undesirable.® D u r i n g the period 1 9 2 9 - 1 9 3 1 , 685 men and women with d e f e c t s were employed by the company. A c a r e f u l check-up of them in comparison with non-handicapped w o r k e r s during this period showed the following results: (1) Sickness Sixty percent of the non-handicapped w e r e absent during some of the time, losing an average of 4 . 2 days per employee, while only 5 3 percent of the handicapped were absent at some time, with an a v e r a g e of 4.5 days per employee. (2) Accidents Thirty-nine and one-tenth percent of non-handicapped w o r k e r s were injured at some time during that period while only 2 3 . 5 percent of the handicapped were injured. (3) Personal Absence F i f t y - e i g h t and three-tenths percent of the non-handicapped w e r e absent at some time f o r personal reasons with an a v e r a g e of 2.6 days per employee, while 67.8 percent of the handicapped were absent f o r personal reasons at some time, with an average of 2.7 days per employee. (4) Income O f the employees on a weekly rate, the non-handicapped showed an increase of 4 percent in total w a g e s during the period while the handicapped showed an increase of 4.6 percent. O f the employees on an hourly basis the non-handicapped showed an increase of 9.9 percent, while the handicapped showed an increase of 8 percent. 1 0 T h e conclusion which the company reached as the result of this experiment was that these handicapped workers proved f u l l y as desirable as the other workers. T h e report g a v e the following reasons f o r the policy of employing handicapped w o r k e r s : " I t constitutes the acceptance, by industry, of a proper sociological responsibility; it augments the good will towards industry of the local popula•Odencrantz, Louise C., "Experience in the Employment of the Handicapped," Rehab. Rev., VI, 225-37. 10 Ibid., p. 228.

8

INTRODUCTION

tion; it increases the labor supply and it admits to industry a group of workers which is characterized by slightly greater stability and a slightly lower rate of turnover than normal workers." 11 T h e work of the company is now so organized that on each job specification sheet the disabilities permissible on a particular job are noted, and an additional list gives all of the non-supervisory occupations with the permissible defects noted opposite. T h e system is based upon a complete job analysis. It is very difficult to determine what the term "unfit" means. One who is physically weak or deformed may nevertheless become a potent factor in society. President Roosevelt is crippled in both legs as the result of infantile paralysis. H e cannot walk or stand freely, and is only able to get about with the aid of braces on both legs. T h e r e are many cases in which physically handicapped men have become outstanding in various fields : literature, art, politics, etc. H a n s W u r t z , 1 2 a German who spent many years studying various aspects of the cripple problem, collected 4 7 2 cases of crippled persons who became famous in one field or another during various periods of history. H e discovered representatives of various professional groups, and of many nations, among the disabled who achieved fame. A m o n g thinkers and educators who were physically handicapped were included Immanuel Kant, Leibnitz, Mendelssohn, Nietzsche, Pittakos, Plato, Schopenhauer, Socrates, and K a r l Julius Weber. Scientists numbered many, including Guizot, H e r m a n von Reichenau, Johannes Keppler, Erich von Salzmann, and August Forel. Other outstanding persons in the fields of religion, art, music, and several divisions of the arts and sciences included Pope Gregory V I I , Ignatius von L o y o l a , Aesop, Balzac, Byron, Cervantes, Conrad, Dickens, Heine, H u g o , Ibsen, Keats, Pope, Scott, Leonardo da Vinci, van Leyden, Beethoven, Chopin, Gounod, Grieg, Handel, M o z a r t , Schubert, Straus, Wagner, Sarah Bernhardt, D a v i d 11 12

Ibid., p. 236. Würtz, Hans, Zerbrecht

die Krücken,

Leipzig, 1932, 392 pp.

INTRODUCTION

9

Garrick, J o s e p h Grimaldi, Steinmetz, Cromwell, A l e x a n d e r the G r e a t , V a s c o da G a m a , Q u e e n E l i z a b e t h , R i c h a r d I I I , Philip S n o w d e n , a n d the last K a i s e r of G e r m a n y . T h e list easily illustrates the point t h a t a d i s a b l e d p e r s o n may not only be n o r m a l l y p r o d u c t i v e but m a y a c t u a l l y excel in a chosen field. H e h a s a r i g h t to his chance in the w o r l d the same as any o t h e r i n d i v i d u a l . W e shall see that even at the present time he has not been g i v e n his r i g h t f u l o p p o r t u n i t y . Despite all t h a t has been done f o r the d i s a b l e d p e r s o n , his place in the g e n e r a l scheme of things is a s m a l l one. H e is still more o r less o s t r a c i z e d by society a n d a f e e l i n g of i n f e r i o r i t y on his p a r t is o f t e n a n a t u r a l consequence. Safety

Factor

I f w e inquire h o w the d i s a b l e d m a n a g e to m a k e their p h y s i o l o g i c a l a d j u s t m e n t s , w e find the a n s w e r in h u m a n s a f e t y f a c t o r s . T h a t the b o d y can a c c o m m o d a t e itself to unusual d e m a n d s despite d i s e a s e a n d congenital o r acquired defects is due to its p h y s i o l o g i c a l resistance b a s e d on f a c t o r s of s a f e t y in its o w n structure. I n the p r e s e n c e of disease the body must m a i n t a i n its n o r m a l f u n c t i o n o r it dies. I t continues to o p e r a t e by calling u p o n e x t r a r e s o u r c e s both in structure and in f u n c t i o n . F o r e x a m p l e , a " m i n i m a l " m a n can get a l o n g with o n e - q u a r t e r of his l u n g c a p a c i t y , 1 3 t h a t is, w i t h h e a l t h y tissue in a h a l f of one lung. A p e r s o n can get a l o n g w i t h onethird of a k i d n e y , o n e - q u a r t e r of a l i v e r , w i t h o u t a s t o m a c h , without a l a r g e intestine, with one-tenth of the p a n c r e a s , w i t h one-third o f the t h y r o i d , w i t h o n e - f o u r t h of the p a r a t h y r o i d , with one-tenth of a s u p r a r e n a l , w i t h one-tenth o f an o v a r y , with one-half of the t o t a l v o l u m e of b l o o d and w i t h 2 0 . 0 percent h e m a g l o b i n . T h e f a c t o r of s a f e t y is f u r t h e r exemplified by the excessive a m o u n t of f e r m e n t s in the d i g e s t i v e t r a c t (three p r o t e o l y t i c f e r m e n t s in the d i g e s t i v e tract, t w o a m y lolytic and one l i p a s e ) . T h e r e is also a f a c t o r of s a f e t y in the ability to substitute one f o o d stuff f o r a n o t h e r . M o r e o v e r , 13 Meltzer, Henry, "Factors of Safety in Prostatic Surgery," Netu York Jour., C X , 942-44, 1919.

Med.

IO

INTRODUCTION

t h e r e is a limit to the a m o u n t of f o o d t h a t can be absorbed. T h e kidney can eliminate much m o r e w a t e r than it is usually called upon to do. F o r example, in diabetes insipidus the kidney can pass the weight of the body in urine. T h e muscles are capable of m o r e w o r k t h a n they are ordinarily called upon to do. T h r o u g h self-repair, regeneration, h y p e r t r o p h y , adaptation to new conditions, vicariousness of function, or substitution of one structure f o r another, such as the skin f o r the kidney, the body is able to combat its environment and fight off h a r m f u l influences. T h i s role of a d a p t a t i o n in the rehabilitation of the physically handicapped is an i m p o r t a n t one. I t is a biological and n a t u r a l process. I t consists in the continuous a d j u s t m e n t of internal to external conditions. Personality

Factor

Personality m a l a d j u s t m e n t o f t e n plays a m o r e i m p o r t a n t role in the causation of incapacity to w o r k t h a n the physical defect. Psychological r e a c t i o n 1 4 following d e f o r m i t y may assume m a n y f o r m s . In a g r e a t number of soldiers mutilated by w a r , a defense reaction never develops, while the retraction of the ego, the n a r r o w i n g of the environment, the feeling of the negative self, do m a t u r e and can only be eliminated by a positive self-feeling t h r o u g h removal of the defect by plastic or reconstruction surgery. T h e result of a retraction of the ego almost inevitably gives rise to suspicion, and suspiciousness long h a r b o r e d is the very m a t r i x out of which is crystallized a p a r a n o i d delusion. Long-continued apprehension, negative self-feeling, preoccupation with self and suspicion of one's environment as being alien, constitute the s a t u r a t e d solution which, when shaken by some minor agitation, produces the crystallization of a full-blown delusion. Simple depression untinctured by delusion or by p a r a n o i a is a very common result. Some of the s h o r t cuts to compensation are t h r o u g h alcohol and drugs. 1 5 14 K a t z , D a v i d , Zur Psychologic des Amputierten und Seiner Prothese, Leipzig, 1 9 2 1 , 1 1 8 pp. 15 Kennedy, Foster, " T h e Psychiatric Aspect in the Practice of Plastic S u r g e r y , "

INTRODUCTION

Conversely, the organic defect may act as a stimulus to overcompensation, so as practically to eliminate the physical defect f r o m consideration. 1 6 T h e majority of us, according to Adler, are equipped with the materials but have not developed them fully. Yet with this imperfect development good performances are turned out, just as our ancestors produced great works with imperfect tools. It is probable that a man equipped with defective organs, i.e., with inadequate tools, will actually develop a better or more ingenious technique to combat the rigors of his environment. H e will pay a great deal of attention to detail, devise more unerring short cuts and will undergo a more intensive training. T h i s accounts f o r the fact that great and really worthwhile accomplishments have been achieved by individuals whose physical equipment was poor. T h i s statement has already been substantiated by mention of names of persons prominent in various fields who have been physically imperfect. T h e r e is a fundamental reason f o r this. If we reflect on the status of the normal person we find that, equipped as he is with normal organs, he approaches the task of life with less concern and with greater ease than the handicapped individual. H e feels assured that he is capable of meeting the needs of his environment. T h e tension of a man who cannot see well, or of a left-handed individual who is bound to work with his weaker hand, is alien to him. H e does not have to exert himself physically or mentally to accomplish his ordinary task in life. W h e t h e r or not Adler is correct in his conclusion that it is one of the greatest advantages to be born with defective organs, 1 7 it is nevertheless true that the physically handicapped person o f t e n has an urge to get things done which may more than compensate him f o r the inherited or acquired disability, and lead him on to a degree of success which he would never have reached otherwise because of his handicap. paper presented before the New York Society of Plastic Surgery, Oct., 1933. Adler, A l f r e d , Understanding Human Nature, New York, 1928, pp. 34-35. "Ibid., pp. 34-35-

18

12

INTRODUCTION SUMMARY

Organic defects have often been over-emphasized and their effect on working capacity wrongly interpreted. An organic disability becomes an actual disability only when the individual senses a defect and feels a consciousness of that defect reflected by his environment.

II SOCIAL A T T I T U D E T O W A R D T H E

DISABLED

T H E disabled person is merely a psychosocial concept, which has developed as the result of deeply r o o t e d h u m a n prejudices and economic necessity. I n o r d e r to u n d e r s t a n d the problem c o n f r o n t i n g the disabled, it is necessary to analyze the social a t t i t u d e t o w a r d such persons. T h i s can best be achieved t h r o u g h an historical survey. T h e social a t t i t u d e s t h a t have complicated t h e problems of the handicapped, t h a t h a v e m a d e self-expression and adjustment m o r e difficult t h a n they would otherwise have been, are essentially t w o : psychosocial prejudice and economic prejudice. PSYCHOSOCIAL PREJUDICE

Psychosocial prejudice is expressed as an aversion t o w a r d the crippled, d e f o r m e d a n d disabled. T h i s aversion may be traced back to primitive attitudes t o w a r d t h e disabled. As a result of these a t t i t u d e s t h e disabled person finds himself limited in his o p p o r t u n i t i e s f o r self-expression and in his ability to a d a p t and a d j u s t himself to his environment. In addition to his actual physical limitation he bears the f u r t h e r burden of social restrictions which m a k e the task of maintaining himself difficult, if not impossible. Primitive

Attitude

F r o m the earliest times the lot of the disabled person has been a h a r d one. In primitive societies life is generally a continuous struggle f o r existence, with war waged either against the elements or o t h e r primitive groups. T h e p r e s e r v a t i o n of the g r o u p is t h e principal aim of society u n d e r such conditions. T h e interest of the individual in the disabled must be subo r d i n a t e d to considerations of the whole group. T h e m a t e r i a l basis upon which the existence and safety of the g r o u p rests

14

SOCIAL ATTITUDE

is the self-sufficiency of each member. T h e individual has the right to live within the group only so long as he is a useful member of society, and does not endanger the existence of the whole group. In such a social o r d e r the individuals who are disabled in any w a y — t h e crippled, the blind, the old and infirm and the ill are generally too g r e a t a burden and handicap to be borne by the group. T h e y are, therefore, frequently put to death, or abandoned to perish of hunger and exposure. T h e E s k i m o and the Dene tribes of N o r t h A m e r i c a , as well as several of the Siberian peoples, are accustomed to put their aged and otherwise disabled members to death. L i f e in the A r c t i c means a continual struggle with the elements, and a disabled member of the group endangers the s a f e t y of the whole tribe. 1 Some of the hunting peoples of N o r t h A m e r i c a were also accustomed to abandon their afflicted, when necessary. T h e y o f t e n found it impossible to carry such persons around with them in their migrations f r o m place to place in pursuit of game. 2 T h e Chiriguan of South A m e r i c a , the C a r i b tribes of the Antilles, various Pacific tribes of A u s t r a l i a and H a w a i i , as well as some of the N e g r o peoples of A f r i c a , have also been known to abandon disabled members of their group. 3 A m o n g some primitive peoples the crippled o r otherwise afflicted person is destroyed because of superstitious reasons. A n y departure f r o m the normal which presents an enigma to the primitive mind and f o r which the cause cannot readily be discerned is attributed to the w o r k of the gods or of the evil spirit. T h e Salivas are an example. T h e y are accustomed to destroy d e f o r m e d children, because they attribute their d e f o r m i t y to the influence of the evil spirit. 4 It should not be taken f o r granted, however, that the action of these primitive groups is the outcome of cruelty, irresponsibility o r lack of consideration f o r the infirm. I t is simply that the survival of the group is placed foremost. Individual 1

Wissler, Clark, The American Indian, New York, 1922, p. 187. Ibid., p. 187. 8 McMurtrie, Douglas C., "Notes on the Early History and Care for Cripples," Amer. J. of Care for Cripples, I, 27. *Ibid., p. 28. 2

SOCIAL ATTITUDE

15

members of the group are sacrificed to that purpose if necessary, while dread of the unusual, and blind fear of the unknown, add the more intense, the more organized hostility of superstition. Examples of apparent cruelty, or killing, or abandoning the disabled can be offset by examples of extreme solicitousness f o r the w e l f a r e of the weak and the ailing. In many primitive groups altruism is developed to a great extent, and a strong consideration f o r the disabled is exhibited. Wissler notes that in the case of the B l a c k f o o t Indians, infanticide, even in the case of marked deformity, is unknown, and that the ill or otherwise afflicted are always cared f o r by their family, even if sacrifice of the best interests of the rest of the family is necessary. 5 T h e Andamanese also show a great consideration f o r the weak and helpless, and f o r the old and infirm, providing special care f o r them. Members of this group who are disabled in any way are generally better provided f o r than the normal members of the group. T h e Bushmen of A f r i c a also exhibit a marked consideration f o r the disabled. T h e y care f o r such persons as long as it is possible, and if they are forced to abandon them, in order to save the rest of the group, they always do all that they can f o r them by way of leaving f o o d and water, shelter against the elements, and fire to keep away the beasts of the jungle. 6 These attitudes show that even among primitive peoples the fundamental qualities of sympathy and consideration f o r the less fortunate members of the group exist. T h e Inca Indians, whom we can by no means consider as a primitive group, had a rather elaborate age schedule, according to which its male members were divided into groups, each group having certain privileges and duties. 7 s W i s s l e r , C l a r k , "Social Organization and Ritualistic Ceremonies of the B l a c k foot Indians," Anthrop. Papers of the Amer. Museum of Natural History, VI, 186, ( N e w Y o r k ) , 1 9 1 2 . • O b e r m a i e r , Hugo, Der Mensch alter Zeiten, Regensburg, 1924, I, 185. 7 ( 1 ) Punuc rucu (old man sleeping), 60 y e a r s and upwards, no w o r k ; (2) Chaupi rucu (half o l d ) , 50-60 years, doing light w o r k ; (3) P u r i c (able bodied), 2 5 - 5 0 years, tribute payers and head of f a m i l y ; (4) Y m a h u a y m a

i6

SOCIAL ATTITUDE

T h e A z t e c s appear to have had a similar scheme, but they, too, possessed a high f o r m o f civilization, so that it is not surprising t h a t they protected their children and their aged. Some o f the plains tribes o f both N o r t h and South America, who were hunting peoples primarily, also had such systems.

Attitude

in Ancient

Times

T h e attitudes shown by primitive man toward the disabled a r e not peculiar to him alone. T h e y have been the dominant ones through thousands o f years o f human history. T h e unwritten law o f primitive society t h a t the disabled were to be sacrificed to the good o f the group was carried over into the written law o f the ancients and determined the course o f the treatment o f disabled persons f o r many centuries. 8 Until relatively recent times the disabled person has met with ostracism f r o m society. O f t e n death was his lot and he was deliberately sacrificed f o r the good o f society, or because o f superstitious reasons. Some ancient oriental peoples turned their cripples out to wander in the wilderness; in ancient India they were cast into the Ganges. 9 According to Daniel, 1 0 the Babylonians did not admit any persons with physical blemishes to the court. 1 1 Imperfection in nature is always more or less abhorrent t o the human mind. T h e human figure, when normal, is regarded as beautiful, and appeals to all o f man's senses. W h e n it is abnormal the repulsion is generally equally strong. T h i s attitude is undoubtedly based upon the primitive one of f e a r and dread o f the inexplicable. Such an attitude was highly developed among the H e b r e w s . T h e y did not permit a crippled (almost a youth), 10-25 years, worker; (5) Coca polla (coca picker), 16-20 years, works; (6) Puellac huamra, 8-18 years, light w o r k ; (7) Planta raquizic (bread receiver), 6-8 y e a r s ; (8) Macta puric, under 6 years; (9) Saya huamroc, able to stand; (10) Moroc copario, babe in arms. 8 Perl, O., Kruppeltum und Gescllsc'naft im tVandel der Zeit, Gotha, 1926, pp. 2-3. 9 Horwitz, H., " T h e Cripples' Place in Society throughout the Ages," The Nation's Health, Aug., 1923, p. 512. 10 McMurtrie, Douglas C., op. cit., p. 4. 11 Dan. 1 ¡4.

SOCIAL ATTITUDE

17

or deformed Levite or priest to officiate in the temple, though there was no element of superstition entering into their attitude. J e h o v a h was simply regarded as the King of Kings, possessed of some human characteristics, and since the H e b r e w himself felt repulsed by the imperfect and would not send a deformed ambassador to a mortal king, he believed that he should by no means send one to the supreme King of all Kings. 12 On the other hand the attitude toward the cripple as a member of society was one of consideration. T h i s is shown in the laws of Moses, which note that a cripple was not to be destroyed. Crippled priests were not permitted to officiate in the temple, but they were given their share of the holy things. 13 Among the disabilities which prevented H e b r e w s f r o m entering the priesthood were lameness, too great length of one limb, broken leg or arm, crooked back, or d w a r f e d stature. 1 4 T h e early Greeks were accustomed to destroy their imperfect citizens in order to maintain their physical superiority. Their attitude was based upon eugenic grounds. It was an ideal, seeking the elimination of the unfit, and aimed at bodily perfection f o r the whole of their society. T h e Athenians allowed their crippled children to die of cold and neglect, while the Spartans took theirs to the hill-tops and killed them. 15 Nevertheless, the destruction of infants which were deformed or diseased was not universally permitted. In Thebes such offenses were punished by death. 1 6 Infanticide among the Romans was apparently never common until the corrupt days of the Empire. Even then legislators condemned it and laws indirectly discouraged it. A distinction was made between infanticide and exposure. 17 A m o n g the early Romans the f a t h e r had the right to destroy a d e f o r m e d child if he first exhibited it to five neighbors and obtained their consent. T h e attitude of Roman society toward the cripple even found expression in the f o r m of law, f o r the Twelve Tables, which were pro12

Perl, O., op. cit., p. 3. 1 3 Ibid., p. 4. 1 4 Lev. 2 1 ; 1 8 - 1 9 . Watson, Frederick, Civilization and the Cripple, London, 1930, p. 2. 16 Lecky, W m . E., History of European Morals from Constantin to Charlemagne, New York, 1890, I, 25. " Lecky, Wm. E., Ibid., p. 28.

15

18

SOCIAL ATTITUDE

mulgated in 5 4 1 - 5 4 0 B.C., extended the authority of the f a t h e r so that he, individually, could destroy a crippled child immediately a f t e r its birth. 1 8 In many instances such children w e r e not destroyed but w e r e cast out into the streets or exposed in deserts, in the woods, or upon the banks of the T i b e r . Some of them did not die of exposure, but were rescued and became slaves of the person who g a v e them a home. T h e y were then f o r c e d to wander about exhibiting their d e f o r m e d members and in many cases were even f u r t h e r mutilated and d e f o r m e d intentionally. T r a d e in slave d w a r f s became extensive among the R o m a n s . I t was v e r y profitable and the merchants even took entirely normal children and d e f o r m e d them by binding them in artificial bandages to stunt their growth. 1 9 In the f o u r t h century b e f o r e Christ, Hippocrates w a s already laying down the principles of modern orthopedic surgery. H e was a pioneer, however, and a f t e r his death the treatment of deformities lapsed, and his teachings were forgotten. T h e r e w a s no f u r t h e r progress in the field f o r o v e r two thousand years. T h e advent of Christianity struck a new note in the attitude t o w a r d the crippled and disabled. T h e destruction of l i f e was declared to be sinful. Abortion and infanticide were condemned as murder. On the whole, the social right to abandon the disabled was brought into question. Sympathy began to be shown to such persons, whereas ostracism had been meted out b e f o r e . T h i s attitude did not dominate the early Christians f o r long, however, and did not permeate the Church until later in its development. T h e old customs continued in many cases. U n d e r the influence of the O l d T e s t a m e n t the evil of the w o r l d was considered an open enemy to be endured, but in no case to be a cause f o r pity. 20 Crippling effects of any sort were considered a p a r t of the burden which the individual must bear. In many cases it was looked upon as the result of evil action. 18

McMurtrie, D. C., Amer. Jour. Care for Cripples, op. cit., p. 5. Ibid., p. 5 ; Gauvain, H., and E. Holmes, " T h e Evolution of Schools," The Lancet, April, 13, 1929, p. 789. 20 Lecky, Wra. E., op. cit., p. 20. 19

Hospital

SOCIAL ATTITUDE

Attitude

in the Middle

19 Ages

During the M i d d l e Ages the cripple sometimes found a place as jester at court, where he was usually regarded with ridicule and contempt. Such a situation naturally excluded the development of a general attitude of consideration. But ridicule and contempt were more or less harmless in comparison to the wave of superstition which developed toward the latter part of the Middle Ages. Ignorance and prejudice among poor and wealthy alike caused the d e f o r m e d to be looked upon as works of the devil, or bodies in league with the devil, or as victims of the w r a t h of God. Such an attitude excluded all consideration f o r their care. 21 T h e cripple was generally coupled in men's minds with malignity. It was assumed that the crippled in body were crippled in mind as well. Because of this widely diffused public attitude, the cripple o f t e n came to regard himself in the same manner, and as a result of brooding, loneliness and ill treatment, actually became mentally as well as physically unstable. 22 During the R e f o r m a t i o n the same attitude toward the cripple predominated. D e f o r m i t y was considered the handiwork of Satan. T h e cripple was often examined f o r the fatal sign of witchcraft, and was continually suspected and persecuted.23 Even L u t h e r shared the belief in the theory of the changeling, according to which it was believed that at the birth of an undesirable child some diabolic mother had stolen away the rightful child and substituted one of her own offspring. The idea was that if the child was sufficiently maltreated its mother would fetch it and leave the rightful child in its place. Also, L u t h e r regarded misformed children as mere masses of flesh and considered that the killing of them was a work well pleasing to God. 2 4 Despite the predominance of such attitudes there have been innumerable instances throughout history where cripples, 21

McMurtrie, D. C., Amer. Jour. Care for Cripples, op. cit., pp. 7-8. Gauvain, H., and E. Holmes, op. cit., p. 789. Perl, O., op. cit., pp. 4-6. 24 McMurtrie, D. C., Amer. Jour. Care for Cripples, op. cit., p. 8.

22 23

20

SOCIAL ATTITUDE

despite their physical disability, h a v e achieved distinction and exercised important influence. 25 W e can easily imagine, however, the f o r c e of character needed f o r such achievement in the face of popular opinion. Between the time of the promulgation of the T w e l v e T a b l e s in R o m e and the eleventh century, only one instance of public provision f o r the crippled has been traced. T h i s w a s in 5 9 0 A.D., when P o p e G r e g o r y included the crippled in his classification of the infirm and the destitute, to be supported f r o m public funds. 2 8 I t was not until the sixteenth century that any legislative provision w a s made f o r the disabled. In 1 5 3 0 the twentysecond statute of H e n r y V I I I (cap. 1 2 ) , concerned itself with the punishment of b e g g a r s and vagabonds. 2 7 T h i s law made a distinction between "impotent and ableb o d i e d , " sending both classes back to the place of their birth, allowing the impotent, but not the able-bodied, to beg. N o provision w a s made, however, f o r sustaining the weak or helping the strong to find w o r k . T h e twenty-seventh statute of H e n r y V I I I (cap. 2 5 ) , in 1535—36, w a s cjevised to remedy lack of provision of relief and employment f o r the f o r m e r . It ordered " t h a t the mayors, bailiffs, constables, and other head officers of cities, towns, and parishes shall most charitably receive such p o o r creatures and shall succour, relieve and keep such people by w a y of voluntary charitable alms, in such wise that none of them shall be compelled to wander and go openly b e g g i n g . " In 1 5 5 1 - 5 2 , the fifth and sixth statute of E d w a r d V I (cap. 2 ) , were passed to provide f o r " t h e impotent, feeble, and lame . . . which are p o o r in v e r y d e e d , " and directed the collection of alms by commissions. Despite these provisions, the metropolis of L o n d o n appeared to have been o v e r c r o w d e d with poor. In 1 5 6 9 an order w a s given to apprehend all beg25

Wiirtz, Hans, op. cit. Abt, H. E., The Care, Cure and Education of the Crippled Child, New York, 1924, p. 8. 27 Nicholls, Sir George, A History of the English Poor Law, Westminster 1854, I, 1 1 5 . 26

SOCIAL ATTITUDE

21

gars and idle persons. T h e aged, impotent, sick, sore, lame or blind were to be taken to St. B a r t h o l o m e w ' s or St. T h o m a s ' s Hospitals. 2 8 T h e P o o r Relief A c t of E l i z a b e t h in 1 6 0 1 consolidated the provisions of previous poor laws and provided f o r custody of cripples. 29

Attitude in Later

Period

T h e earliest organized social interest shown f o r the disabled was in the eighteenth century. E v e n then progress w a s very slow, f o r the defectives were merely cast upon the pity and the mercy of their f e l l o w men. T h e goal w a s to confine them—to get them off the streets. M o n a s t e r i e s w e r e thrown open and converted into asylums. T h e assumption of the place of a f a t h e r on a l a r g e scale to the unfortunate and defective was at least a distinct change in attitude, a m a r k of more solicitous attention. A l l the provisions m a d e during the eighteenth century, however, merely offered asylum to the disabled, and made no provision f o r their proper care or education. 80 In the nineteenth century attention w a s called to child welfare through the poor laws and the f a c t o r y laws. Public interest in the disabled w a s thus increased. But even then, at first, they were still r e g a r d e d primarily as objects of pity. Charles Dickens effectively depicted the attitude of the public toward the disabled and that of the disabled person t o w a r d himself; it was one of no thought or hope of cure. I t w a s generally taken f o r granted that, if a disabled child survived, his deformity would render him useless as a citizen. H e w a s a burden to society which, however, h a d to be borne. Cripples were gathered together in homes and workhouses f o r incurables, or hidden in their own homes, while occasionally they were aided and cared f o r by some philanthropic w o r k e r . 3 1 T h e significant change in attitude t o w a r d them has come in the last seventy-five years. 28 Ibid., p. 177. 2 9 Gauvain, H., and E. Holmes, op. cit., p. 790. 3°Bick, Edgar M., History and Source Book of Orthopedic Surgery, 1933, p. 102. 31 Gauvain, H., and E. Holmes, op. cit., p. 789.

New York,

22

SOCIAL ATTITUDE

Social and Private Endeavor Social and private efforts f o r the care of cripples made r a p i d progress with the growth of medical science. A distinct advance in attitude and treatment resulted. T h e rise of the science of orthopedics provided the first step t o w a r d the adequate management of the problem. T h e power to improve the d e f e c t i v e physically, the insistence upon change and remolding r a t h e r than the f o r m e r submission to the inevitable or the pious acceptance of an unfortunate condition, characterize all subsequent endeavor. W i t h the development of actual experience in orthopedics, more efficient means were found to change the social attitude, as well as to ameliorate the physical deformities of the cripple. H o w e v e r , the repugnance and distaste with which the cripple has been regarded throughout history still prevail. A l t h o u g h modern society has become humane to the extent of feeling called upon to provide care and even education f o r all of its disabled members, it has not yet progressed so f a r as to overcome entirely a reaction of repulsion to all departures f r o m the normal of human kind. T h i s attitude of the general public t o w a r d anyone disabled naturally reacts upon that person himself, and is the cause of one of the most difficult problems with which the w o r k e r in this field has to deal. T h e social aversion to the cripple must be overcome and the disabled person must be brought out of his timidity and retreat. T h e disabled man must not only be cared f o r and educated so that he may be able to fill an independent place in the social and economic life of society, but the attitude of the general public — o f children, parents, workers, employers—must be changed, so that the afflicted person will be accepted by them as a natural unit of the common society to which all belong. ATTITUDE OF EMPLOYERS T h e transactions of the W h i t e H o u s e Conference on C h i l d H e a l t h and Protection illustrate how difficult is this problem

SOCIAL ATTITUDE of educating the g e n e r a l p u b l i c — e s p e c i a l l y

23

employers. 3 2

I n the f i n a l analysis, the u l t i m a t e s o l u t i o n of t h e p r o b l e m of social and economic a d j u s t m e n t f o r t h e h a n d i c a p p e d lies l a r g e l y in t h e h a n d s of commerce a n d i n d u s t r y , because t h e m a j o r i t y of e m p l o y m e n t o p p o r t u nities f o r the h a n d i c a p p e d w i l l be f o u n d in these fields. I n o r d e r t o s e c u r e an expression of t h e a t t i t u d e a n d opinion w h i c h c o m m e r c e a n d i n d u s t r y held t o w a r d t h e e m p l o y m e n t of p h y s i c a l l y h a n d i c a p p e d , t h e c o m m i t t e e sent a q u e s t i o n n a i r e to 600 of the l a r g e s t e m p l o y e r s of t h e c o u n t r y . T h e analysis of the replies t o this q u e s t i o n n a i r e s h o w s t h a t e m p l o y e r s in respect to their a t t i t u d e s t o w a r d the h a n d i c a p p e d , f a l l into t h r e e g r o u p s : 1. T h o s e w h o w i l l not consider t h e e m p l o y m e n t of t h e p h y s i c a l l y handicapped u n d e r any c o n d i t i o n s . 2. T h o s e w h o w i l l not e m p l o y p h y s i c a l l y h a n d i c a p p e d persons c o m ing f r o m t h e o u t s i d e b u t w h o do p r o v i d e f o r e m p l o y m e n t f o r those injured in t h e i r service. 3. T h o s e w h o as a m a t t e r of p o l i c y do n o t d i s c r i m i n a t e b e t w e e n t h e normal and the p h y s i c a l l y h a n d i c a p p e d , p l a c i n g t h e w o r k e r at a j o b w h i c h his m e n t a l a n d p h y s i c a l a b i l i t y w i l l p e r m i t h i m t o p e r f o r m . 3 3

T h e study reveals that 50.0 percent o f those r e p l y i n g to the questionnaire b e l o n g e d to the first g r o u p — t h o s e w h o d o not hire the disabled in any capacity. T h e s e e m p l o y e r s g a v e two main reasons f o r their a t t i t u d e : ( 1 ) T h e nature of the work in their establishment is not suited to the e m p l o y m e n t of the handicapped, and ( 2 ) u n f a v o r a b l e p r o v i s i o n s of the w o r k man's compensation l a w s render the e m p l o y m e n t of disabled persons financially h a z a r d o u s . O n l y 25.0 percent of those responding b e l o n g e d to the t h i r d g r o u p , i.e., those w h o d o n o t discriminate b e t w e e n n o r m a l and physically disabled w o r k e r s . F o l l o w i n g are some o f the replies, w h i c h illustrate attitudes expressed b y e m p l o y e r s of the first c l a s s : [ S m a l l Steel P r o d u c t s ]

We

the

n a t u r a l l y do n o t e m p l o y the afflicted

w h e n w e h a v e s o u n d m a t e r i a l at h a n d . T a k e n as a w h o l e , even w h e n fitted t o t h e j o b , t h e y a r e a p t t o p r o v e less s a t i s f a c t o r y , d u e t o an a c c o m p a n y i n g m e n t a l state of depression or n e r v o u s n e s s o f t e n to be o b s e r v e d . 3 4 32 Frankel, Emil, " T h e Vocational Adjustment of Physically and of Mentally Handicapped Children," Special Report of the White House Conference on Child Health and Protection, Section IV B, Physically and Mentally Handicapped, Washington, D. C., 1928, pp. 10-12. 33 Ibid., p. 13. 3i Ibid., p. 12.

SOCIAL

24

ATTITUDE

[Steel] W i t h the present very stringent liability provisions under which a manufacturer must w o r k , w e can see no possibility of any extended program in our line of manufacture for the physically handicapped child of working age. 85 [ R u b b e r ] T h e r e should be no closed doors against the physically handicapped persons of working age. H o w e v e r , we feel that the employer should not be held responsible for accidents that can be charged directly to a physical ailment. T o best serve the interest of the handicapped persons, of industry and society, the State should assume the responsibility for injuries resulting from a physical disability to handicapped persons. 38 [ M a c h i n e r y ] W h e n carefully selected, certain defectives can safely be assigned sheltered jobs. It is a mistake to install handicapped children otherwise, unfair to them, to their fellow employees, and their employer. Providing employment and its acceptance are still voluntary acts; there is nothing paternal nor filial in its essence, and it is erroneous to proceed on the theory that there is. A n employer should fill his requirements from the best available supply, and not handicap the business and its able-bodied employees by attempting to invade the fields of established institutions and agencies engaged in education or salvage work. 3 7 T h e s e attitudes s h o w that even a m o n g the m o r e

liberal-

minded employers the feeling of repulsion t o w a r d the disabled s t i l l e x i s t s . H e n r y F o r d is q u o t e d a s s a y i n g t h a t s o c i e t y is p e r f e c t l y a b l e t o a b s o r b all o f its h a n d i c a p p e d m e m b e r s , a n d them

full

wages

without

being

charitable!

pay

A l l t h a t is n e c e s s a r y

is t h a t t h e p r e j u d i c e o f e m p l o y e r s a n d f e l l o w w o r k e r s

should

be o v e r c o m e . A n efficient j o b analysis o f the processes i n v o l v e d in F o r d ' s o w n p l a n t s i n d i c a t e d t h a t h e c o u l d u s e a b o u t men with

only one leg, as many more with

several men

without

legs,

several

only

more without

1,400

one

arm,

arms,

and

t h o u s a n d s o f feeble-minded men, p a y t h e m $6 a day, and h a v e t h e m e a r n it. F o r d o n c e p u t a b l i n d m a n to w o r k c o u n t i n g n u t s a n d bolts, and he did the w o r k which t w o n o r m a l men been doing before.38

had

I f F o r d h a s f o u n d t h i s t o b e t r u e in h i s

p l a n t it m a y b e a s s u m e d t h a t t h e g e n e r a l a t t i t u d e o f e m p l o y e r s is t h e r e s u l t o f t h e n a t u r a l p r e j u d i c e w h i c h t h e n o r m a l feels t o w a r d the a b n o r m a l . 85

Ibid.,

p. 13. "Ibid.,

p. I j .

87

man

I f F o r d finds it p r o f i t a b l e t o h i r e

Ibid.,

p. 14.

38

The Crippled

Child, V I , p. i 7 o .

SOCIAL ATTITUDE

25

handicapped persons, other industrial leaders could do the same. H e has hired disabled persons because they are as productive as normal workers, or even more so. T h e attitudes reflected by the W h i t e H o u s e Conference study may be considered representative of employers throughout the country. T h e r e is no doubt that there is a growing recognition of the need of offering employment opportunities to the disabled, but the prejudice of employers, fellow workers, and the general public is still a problem which must be solved. Of what use are physical rehabilitation, education and training, if the cripple is to meet with prejudice and exclusion on every side? T h e prejudice is fundamentally an economic one. It is based on three premises: first, that physical disability means reduced productivity; second, that a disabled person, because of his limited m o t o r activity, is more prone to accident; and third, that if he is injured the employer will have to bear not only the cost of the injuries sustained in this accident but also the additional cost of the aggravation of the preexistent disability. These basic premises are considered in detail below. Disability

as Reduced

Efficiency

Undervaluation of the individual's capacity to work is an error committed not only by laymen but by physicians as well. While it is in p a r t true that the disability limits the number of opportunities open to the disabled person, it is nevertheless incorrect to assume that physical disability means incapacity for work. I t is apparent that the same type of disability does not have the same consequences in all individuals. This applies not only to their vocational or professional capabilities but also to the basic use of the p a r t affected. W e know that the amputation of the tip of the index finger would seriously handicap a jeweler, a typist, or a violinist. Yet the same injury would be insignificant to a longshoreman, a janitor, or a chauffeur. But aside f r o m the vocational handicap, two workers in the same vocation, as f o r instance, machinists, with the same injury and

26

SOCIAL ATTITUDE

end-result a f t e r a f r a c t u r e d f e m u r are affected differently. T h e mental make-up, the social environment, the education and the economic status all play important roles in the effect of the disability on the individual's future. In other words, every man is a law unto himself, and no two are alike. W h i l e one would be depressed as a result of his disability, lose his nerve and suffer marked loss of earnings, another would be stimulated to try h a r d e r and, in such a case, his earnings might even be increased. T h e case histories of 4 , 4 0 4 men with orthopedic handicaps, and covering a period of thirteen years, were examined by A n d e r s o n 39 and the actual jobs they had held f o r a considerable period of time were listed. T h e findings indicated that among 1 0 , 1 7 6 jobs held by these men there were 635 different types of work, representing 7 0 . 0 percent of the 5 5 7 occupations and occupational groups listed in the U n i t e d States census f o r 1 9 3 0 . T h e s e figures give striking evidence of the versatility of these handicapped men. In 1 9 2 5 the F e d e r a l B o a r d of Vocational Education made a study of the occupations in which 6,097 disabled persons were employed, a f t e r having been rehabilitated. T h e study showed that there was a remarkable diversity of jobs at which these persons were employed, there having been no less than 628 different classifications. 40 In one instance an Italian day laborer, aged twenty-one years, lost the last three fingers of his right hand. H e had been earning $ 2 5 . 0 0 per week. A f t e r his claim had been adjusted, he w a s taken in charge by the N e w J e r s e y Rehabilitation Commission and trained as an acetylene welder. A t the end of three months a position w a s secured f o r him in which he began at $ 2 5 . 0 0 a week. A t the end of the y e a r he w a s earning over $ 4 5 . 0 0 a week, and had saved $ 8 0 0 . 0 0 In the examination of over 60,000 cases of accidental injuries f o r the N e w J e r s e y W o r k m e n ' s Compensation Bureau, the author's experience reveals that only in disabilities of a v e r y m a j o r character, such as amputations, o r ankylosis of 39 40

Anderson, Roy N., op. cit., pp. 5-8. Fed. Board for Voc. Ed., Bull. No. 96, Washington, 1925.

SOCIAL ATTITUDE

27

major joints, the elbow, knee or shoulder, at unfavorable angles, was a change in vocation necessary. M o r e o v e r , in certain cases where as much as a 7 5 . 0 percent loss of efficiency of the body f o r routine pursuits of life had been estimated, the disabled person, with courage and perseverance, was still able to pursue his former calling, though at a reduced earning capacity. Physicians have no methods which make it possible to determine the extent of the economic incapacity of a person who has suffered a fractured spine, a musculospiral paralysis or an ankylosed joint. N o t only does the clinical examination allow no scientific determination of work capacity, but it does not show the type of work f o r which the injured man is fitted or unfitted. A t what points in the work does the greatest fatigue take place? W h e r e are the physical strains in a particular type of w o r k ? Such data are not available, and it would be impossible to answer these questions purely f r o m the physiological point of view. Developments in the field of psychotechnique, such as the testing of mental and physical traits, dexterity, mechanical ability, fatiguability and steadiness, which at first seemed encouraging, have not measured up to expectations. T h e r e can be little doubt that a large percentage of decisions by physicians concerning disability must be entirely false in an objective sense. T h e capacity f o r work which is frequently evaluated in industrial accident cases is a concept that has no uniform interpretation. Proneness

to

Accidents

Proneness to accident and increased compensation costs are two arguments frequently advanced by employers to explain their reluctance to hire physically defective workers. T h e r e have been many studies 41 showing some measure of correlation between accidents and working conditions. T h e s e include such matters as lighting, temperature, ventilation, means of protection, machinery, tools, climate, seasons, days of the week, 41 Carozzi, L., and A . Stacker, " M e d i c a l Aspects Archiv fur Geioerbepathologie und Gewerbehygiene,

of Industrial Accidents," Berlin, Oct., 1932.

28

SOCIAL ATTITUDE

hours of the day, scientific management, wages, labor turnover, etc. Accidents, however, cannot be entirely explained on a mechanical basis. Various important studies indicate that a biological factor, namely that of rhythm and fatigue, plays a definite part. T h e worker is not merely a human machine, but each individual reacts in a different manner to different stimuli. It is a difficult matter to fix the dividing line between the technical factor and the human factor in industrial accidents. Nevertheless, there is agreement 4 2 that the human factor is responsible f o r 60—90 percent of industrial accidents. According to Chambers, the graph f o r accident frequency takes the f o r m of a curve resembling the capital letter J. 4 3 H e interprets this phenomenon to be the result of the influence of the human factor. H i s studies further indicate that 70.0 percent of the accidents which occur affect only 25.0 percent of the total workers under observation. English studies 44 also indicate that certain persons are accident-prone while others are seemingly immune. P e r l 4 5 has reported nine men with a work history of fifty years without an accident. T h i s variation in accident risk depends upon biological and social factors, such as racial influence, nationality, age, sex, constitution, etc. A m o n g the reasons given, poor health should be included as an alleged cause of industrial accidents. T h e H o o v e r Committee f o r the Elimination of W a s t e in Industry 46 reported that an imperfect state of health may constitute a cause of fatigue which in turn may stimulate a tendency to, or even directly give rise to, accidents. Although no reliable studies are available, it is assumed that accident possibilities are increased among those suffering f r o m glandular disturbances, e.g., an intensively secreting thyroid gland may make the worker overactive and unstable; a disturbance of function of the pituitary gland may make the 42 Bowers, Edison L., Is it Safe to Work? Pub. of Pollak Foundation for Economic Research, No. 12, New York, 1930, pp. 12-20. 43 Chambers, E. G., "Personal Qualities in Accident Causation," J. Ind. Hyg., 1930, No. 6, pp. 223-32. 44 Industrial Fatigue Research Board, No. 34, p. 74, London, 1926. 45 Industrial Fatigue Research Board, No. 55, London, 1929. 46 Carozzi, L., and A . Stacker, op. cit., p. 34.

SOCIAL ATTITUDE

29

individual t o r p i d o r s l u g g i s h ; w h i l e a l i m p i d o r l a n g u i d individual, s u f f e r i n g f r o m a t h y m u s that is not n o r m a l l y r e g u l a t e d , may be especially p r o n e to f a t a l i t y f r o m electric shock. A s thenic i n d i v i d u a l s m a y s u f f e r f r o m an insufficiency of a d r e n a l i n secretion. I t is f u r t h e r a s s u m e d by m a n y t h a t d e f e c t s o r d e r a n g e ment of the o r g a n s o f special sense, such as sight, h e a r i n g and smell, m a y g i v e rise to accidents. L i k e w i s e n e a r s i g h t e d n e s s , nystagmus, inability to h e a r a w a r n i n g bell o r the o r d e r of a f o r e m a n , o r to smell the o d o r of deleterious f u m e s , m a y contribute to accident p r o n e n e s s . T h e a b n o r m a l f u n c t i o n i n g of the v a r i o u s systems, such as h e a r t , k i d n e y s , lungs, central nervous s y s t e m and a b d o m i n a l o r g a n s , a r e l i k e w i s e a s s u m e d to be contributory causes of accidents. T h e p a t h o l o g i c a l f r a c t u r e occurring in a p e r s o n with c a r c i n o m a , the sudden occurrence of h e m o p t y s i s in a tuberculous i n d i v i d u a l , the fit o f an epileptic, are significant f a c t o r s in the causation of accidents. N o r e l i a b l e statistics exist, h o w e v e r , to indicate a h i g h incidence of accidents in those s u f f e r i n g f r o m p o o r h e a l t h . T h e only a v a i l a b l e evidence a p p l i e s to ill-health a m o n g those w h o have s u f f e r e d f a t a l accidents. F r o i s , 4 7 in a series of 4 3 f a t a l i ties, f o u n d 1 5 h a d been in ill h e a l t h sufficient to w a r r a n t their exclusion f r o m the j o b s which they h a d held, their d e f e c t s including v e r t i g o , h e a r t d i s e a s e , d e a f n e s s , o r d e f e c t i v e sight. A n d e r s o n ' s 48 studies o f 4 , 4 0 4 p h y s i c a l l y h a n d i c a p p e d persons, m o r e o v e r , s h o w e d a l o w e r incidence of accidents w h e n compared to a control g r o u p . In this study of p h y s i c a l l y handicapped w o r k e r s , only 8 men w e r e r e p o r t e d to h a v e i n c u r r e d second injuries. I n Connecticut m o r e t h a n 8 , 0 0 0 w o r k e r s w i t h physical d e f e c t s h a v e been at w o r k . T h e s e men h a v e s i g n e d w a i v e r s to c o m p e n s a t i o n in the event of an accident a r i s i n g as a result of their p a r t i c u l a r defects. 4 9 W e s t e r n E l e c t r i c C o m pany studies 50 confirm A n d e r s o n ' s results. O f 3 , 7 3 6 cases in the w r i t e r ' s series, o n l y 1 2 h a v e h a d second accidents. T h e number of claims f o r second injuries i n v o l v i n g h a n d i c a p p e d " Carozzi, L., op. cit., p. 35. 4 8 Anderson, R . N., op. cit., pp. 32, 94, 95. Personal communication. 5 0 See p. 7.

49

3°

SOCIAL ATTITUDE

persons is negligible, despite the f a c t that up special funds f o r this group. T w o conclusions may, then, be arrived tion of accidents may be traced to technical in which the latter predominate; ( 2 ) poor element among the human factors, has not tically or biologically. Second Injury and

1 3 states have set a t : ( 1 ) the causaand human factors, health, as a specific been p r o v e d statis-

Compensation

T h e employment of the physically handicapped w o r k m a n must be looked at f r o m two points of view. T h e workman's interest is in the effect of his disability upon his opportunity to secure employment. T h e employer is interested in keeping down costs, and accordingly is hesitant to employ the physically handicapped if he thinks doing so will increase his compensation costs. W h e t h e r the employment of the physically handicapped does increase compensation costs depends upon the liability to accidents of the person with a physical disability; upon the relative seriousness of the effects of an accident to the physically disabled and the physically able; and upon the liability of the employer, under the compensation law of his state, f o r an injury which resulted f r o m a previous disability rather than f r o m an industrial accident. I t has already been shown that there is no proof that the handicapped person is more prone to accidents than the nondisabled. ATTITUDE OF THE GOVERNMENT In a field in which the disabled person could be easily assimilated, by lifting physical restrictions and affording extra credits, as was p r o v e d by the absorption of disabled w a r veterans, we find the disabled civilian discriminated against. Inv a r i a b l y the qualifications f o r governmental positions include such provisions as " f r e e d o m f r o m disabling affects," despite the sedentary or nonmanual character of the w o r k . W h e n it is realized that almost 4 5 0 , 0 0 0 s 1 positions are available in national governmental agencies and a similar if S1

F r a n k e l , Emil, op. cit., p. 15.

SOCIAL ATTITUDE

31

not larger number in municipal and state governmental agencies, it becomes apparent that a most fertile field is closed to disabled persons by statutory restrictions. T h e Civil Service Commissions are entirely in sympathy with the plan to assist physically handicapped people and in a number of cases have been glad to cooperate in placing such persons. 52 Since, according to statute, a physical condition free from disabling effects is rated 1 0 0 percent, an applicant with a rating below 70.0 percent is automatically barred f r o m examinations of the United States Civil Service Commission. 53 T h e fallacy of setting up arbitrary values of physiological or vocational capacity has already been indicated. T h e governmental agencies have retained this false concept in the determination of vocational fitness. T h e attitude of governmental bodies reflects the same prejudices and false concepts of physical disability and deformity as are found among private employers. Emphasis is placed on the defect and the value of the remaining functional assets is overlooked. SUMMARY

T w o great social barriers to the rehabilitation of the disabled lie in psychosocial and economic prejudice. These prejudices rest on superstition, misunderstanding and false concepts of capacity to work. A s already indicated, it is the purpose of this study to describe how society is gradually reducing its restrictions through legislation designed to eliminate the differential between the normal and the disabled. 62

Personal communication.

53

Personal communication.

ILL

T H E P R O B L E M OF T H E G E N E R A L SOCIAL

DISABLED

PROBLEM

IN this study the term "disabled" is used to designate several groups of persons who are definitely handicapped in their effort to make a living because of physical disabilities. Five groups, which are generally considered separately, are included: ( i ) the child cripple, ( 2 ) the industrially disabled, ( 3 ) the war disabled, ( 4 ) the chronically disabled, ( 5 ) the blind, the deaf and dumb. Each group is composed of persons who, through some physical affliction, find themselves limited in their ability to earn a livelihood. It is therefore logical to consider them as one large group, although in the past they have generally been provided for individually. Sociologically the disabled have, up to the present time, always been considered as a permanently dependent class. Workmen's compensation and the World W a r have helped to change this concept from permanent to temporary dependence. T h e present approach is, therefore, different. It considers the disabled as maladjusted vocationally and seeks a remedy in legislation and changing social attitudes for the maladjustment. The problem of the disabled is on the whole very similar; these persons demand medical care, vocational training and placement, and in many cases pensions. INDIVIDUAL

PROBLEM

The disabled person is an individual problem of vocational adjustment. Discriminated against in the general labor market, his employment opportunities are necessarily restricted. In order to improve his economic status a body of legislation has gradually developed, whose purpose, expressed or implied, is directed toward meeting his needs. From the standpoint of vocational adjustment the disabled

T H E PROBLEM OF THE DISABLED

33

may be divided into several groups. T h e r e is, first of all, the f u l l y productive class, that group of disabled persons who, if adequately treated and t r a i n e d — a n d frequently without these a i d s — w i l l be fit f o r employment under normal industrial conditions. T h e principal needs f o r this group a r e a pension while undergoing treatment and training, the treatment and training necessary to rehabilitation, and an opportunity f o r employment. T h e r e is a second group of disabled persons, the partially productive, who will never be fit f o r employment under normal industrial conditions, but who would be fit f o r w o r k under conditions where their disability is allowed f o r . T h e i r needs are t h e r e f o r e somewhat m o r e difficult to meet than those of the first group. T h e y , too, require treatment and training, as well as a pension f o r a longer period of time while undergoing treatment and training. If their earnings are inadequate a f t e r they h a v e been placed in sheltered workshops, they may require f u r t h e r aid in the f o r m of a small pension to supplement their earnings. A third group consists of persons who are either bedridden or otherwise confined to their homes. T h i s group requires the greatest amount of aid. T h e y may even need constant care and treatment, and the hope of ever rehabilitating them so that they may become self-sufficient members of society m a y be absent. E v e n then, however, they can be given an interest in life and the possibility of at least a share in their own support following instruction in practical h a n d i c r a f t s and some assistance in the disposal of their goods. 1 EXTENT OF THE PROBLEM T h e magnitude of the problem of the disabled in modern society is best discernible through a consideration of the statistics concerning such persons. T h o s e at our disposal are by no means complete, but they suffice, at least, to show that the 1 Chapin, H. D., " T h e Cripple: A Social Problem," Nineteenth 650-56 (New Y o r k ) , 1930.

Century,

CVIII,

34

THE PROBLEM OF THE DISABLED

number of disabled persons is f a r greater than is ordinarily supposed. M o s t countries of the w o r l d have a census of the blind, the deaf and the dumb, and the aged. F o r the crippled, however, comprehensive statistics are available only f o r G e r m a n y , H o l land, N o r w a y and E s t h o n i a . In the United States a number of cities and states have made surveys of their crippled inhabitants, but the data are by no means complete. It is practically impossible to find information relative to the number of chronically ill. In countries having industrial compensation laws there are generally some data available concerning the number of persons disabled in industry each year. T h e r e are also some estimates concerning the numbers of w a r disabled. It is difficult to obtain f r o m these statistics a complete and comprehensive picture of the actual numbers of disabled persons, and any estimate based thereon is apt to run f a r short of the true numbers. Such figures serve, however, to show that the problem of the disabled in modern society is indeed a large one. T h e first official census of crippled persons to be taken was a survey of crippled children, which was carried out in Germany in 1 9 0 5 under the direction of Biesalski, with the help and patronage of the G e r m a n government. 2 In the United States, Massachusetts was the first state to make a census of crippled inhabitants. In 1 9 0 5 the census enumerators of that state were asked to list " t h e lame, maimed, and d e f o r m e d . " T h e term " m a i m e d " was to include the loss of one eye or other defects. 8 F o l l o w i n g closely upon the Massachusetts survey was one which was made in the city of Birmingham, England, in 1 9 1 0 . 4 Since that time there h a v e been several city and state surveys made in various parts of this country. In 1 9 1 5 Cleveland 2

Biesalski, K., Umfang and Art des jugendlichen Kriippeltums, und der Kruppelfursorge in Deutschland, Leipzig, 1919. 3 Massachusetts State Census, 1905. Enumeration of Defective Persons. * Rubinow, I. M., Report of a Special Sub-Committee of Inquiry, concerning Physically Defective Adults and Children," City of Birmingham Education Committee, Oct. 27, 1 9 1 1 .

T H E PROBLEM OF T H E DISABLED

35

5

took a census of its crippled inhabitants. T h i s w a s a house-tohouse survey, combined with a survey and check-up of institutions, schools, etc. I t seems to be the most accurate survey of its kind which has been made in the U n i t e d States. T h e house-to-house survey w a s carried out between October, 1 9 1 5 , and October, 1 9 1 6 , and covered 1 5 0 , 0 0 0 families, comprising a complete study of the city. In 1 9 1 9 N e w Y o r k City f o l l o w e d Cleveland in a survey of its crippled inhabitants. 6 It w a s conducted by carrying out a house-to-house survey in six different districts, then estimating the population of those districts and determining the ratio of crippled inhabitants to each thousand inhabitants. In 1 9 2 3 T o r o n t o 7 m a d e a survey which was, however, more in the nature of an estimate. In 1 9 2 4 a survey of all its crippled children 8 w a s carried out by N e w Y o r k State. On the assumption that all crippled children of school age would be registered in some school, and that those of preschool age would be known to children in school, this survey was carried out exclusively through the schools of the state, public, parochial, and private. In 1 9 2 4 Chicago made a similar survey. 9 It w a s in part a survey of all institutions, and in part a house-to-house canvass of certain typical areas, including thirty-three square blocks in all. T h e only other published report of a survey of this sort in the U n i t e d States is that of N e w J e r s e y , which w a s carried out in 1 9 2 7 . 1 0 T h i s survey is more or less comparable to that m a d e in N e w Y o r k State, f o r it was a census of crippled children known to schools, and to social and medical agencies. 5 Wright, L., and A. Hamburger, Education and Occupations of Cripples, Juvenile and Adult, a Survey of All Cripples in Cleveland, Ohio. Publication of the Red Cross Institute for Crippled and Disabled Men, Ser. II. No. 3, Oct. 15, New York, 1918. 229 pp. 0 Wright, H. C., Survey of Cripples in Neiu York City, New York Committee on After-Care of Infantile Paralysis Cases, New York City, 1920, 104 pp. 7 Child Welfare Council of Toronto, Report of a Survey of Physically Handicapped Children in Toronto, Toronto, 1923, 64 pp. 8 New York State Commission for Survey of Crippled Children, Report, 1924. to 1925, Albany, 1925, 104 pp. 9 Stevenson, J . L., A Community Trust Survey of Crippled Children in Chicago, May-Dec. 1924, Chicago, 1925, $8 pp. 10 New Jersey Temporary Commission for Inquiry relating to the Distribution and Condition of Crippled Children, Report, Jan. 31, 1928, Trenton, N. J .

36

T H E PROBLEM OF T H E DISABLED

A s i d e f r o m those surveys, the W h i t e H o u s e Conference on C h i l d H e a l t h has recently published material which w a s obtained f r o m various sources: unpublished additional information f r o m N e w J e r s e y , the results of a survey in one county in M i c h i g a n , f o u r counties in Pennsylvania, and two counties in M i s s o u r i . 1 1 In 1 9 2 4 the International Society f o r Cripples m a d e an institutional survey which took into consideration 6 , 5 0 7 children in 3 3 institutions in 7 different states. 1 2 A l l of these surveys are alike in that they cannot be considered complete. T h e Cleveland survey is apparently the most complete. T h o s e based only upon school returns are bound to be incomplete, f o r a relatively large proportion of crippled children are not in attendance at school. T h e Cleveland survey, f o r instance, found that 3 2 . 0 percent of its crippled children of school age were not enrolled in any school. 1 3 T h e N e w Y o r k City survey f o u n d that 2 1 . 0 percent of the cripples discovered in its house-to-house survey were not in attendance at school. 1 4 U n t i l recently 2.5 per thousand children was considered the s t a n d a r d ratio. T h e W h i t e H o u s e Conference study attempted to test the feasibility of applying this standard ratio to the country as a whole, as well as to individual states and communities. Inquiries were sent to various sources, bringing in additional information f r o m N e w J e r s e y , Michigan, Pennsylvania and M i s s o u r i . A c c o r d i n g to estimates based upon the so-called standard ratio and the 1 9 2 0 census, there w e r e 2 8 9 , 9 1 9 crippled children in the U n i t e d States at that time. T h e W h i t e H o u s e C o n f e r e n c e Sub-Committee found that, using the same ratio based upon the 1 9 3 0 census, the estimated number w a s 304,5 4 1 , an increase of 1 4 , 6 2 2 . If the 3 . 7 2 ratio were applied " W h i t e House Conference on Child Health and Protection, Comm. on Physically and Mentally Handicapped, The Handicapped Child, New York, 1933, 452 pp. Recent surveys in Michigan, Kentucky, Iowa, and Missouri conducted by the Federal Emergency Relief Administration were not completed or available at time of going to press. 12 Abt, H. E., op. cit., p. 14. 18 Wright, L., and A. Hamburger, op. cit., p. 43. 11 Wright, H. C., op. cit., p. 55.

THE

PROBLEM

OF T H E

TABLE NUMBER

OF C R I P P L E D P E R S O N S

37

DISABLED

I PER

1,000

INHABITANTS

ACCORDING TO F I N D I N G S OF VARIOUS STATE, C O U N T Y A N D LOCAL S U R V E Y S Rates per T h o u s a n d

Survey

Population . Adults Children

Whole Group 0

Massachusetts B i r m i n g h a m , England b Cleveland c New York City Toronto ' N e w York S t a t e / New Jersey B C a m d e n , N. J > Dover, N. J.* Nutley, N. J > T w o Counties in M i c h i g a n *

5-7 5-7

2.9

2-9

2.8 2.8

4-9 3-3

i-3

6.9

6.2

3.6

2.1 1.38 2.68 1.24

1.19 5.10 9.2

11.3 5-45 >•9

Four Counties in P e n n s y l v a n i a * T w o Counties in Missouri *

3.8

Average

6.12

3.72

3-5

" M a s s a c h u s e t t s State Census, 1905. 6 Rubinow, I. M., op. cit. c W r i g h t , L., and A. H a m b u r g e r , op. cit. d W r i g h t , H. C., op. cit. ' Child W e l f a r e Council of T o r o n t o , op. cit. f New York State Commission f o r Survey of Crippled Children, op. cit. 9 New Jersey T e m p o r a r y Commission for Inquiry Relating to the Distribution and Condition of Crippled Children, op. cit. h W h i t e House Conference on Child Health and Protection, 1933, op. cit. t h e r e w o u l d be 4 5 3 , 1 5 7 c r i p p l e d c h i l d r e n in t h e U n i t e d If

the s t a n d a r d of

3.5

per thousand

cepted there would be 4 2 6 , 3 5 8

c r i p p l e d a d u l t s in t h e

States on the basis of the 1 9 3 0

census.

These

States.

adult inhabitants be

United

estimates cannot be looked upon as absolutely

rect, but they p r o v i d e a f a i r l y a c c u r a t e

figure

ac-

cor-

of the number

c r i p p l e d p e r s o n s in t h e U n i t e d S t a t e s a t p r e s e n t .

The

d i f f e r c o n s i d e r a b l y in t h e r a t i o s w h i c h w e r e f o u n d . S u c h

of

surveys varia-

38

THE PROBLEM OF T H E DISABLED

tions a r e partially due to the types of disability which predominate in different parts of the country, and partially to the methods of making the surveys. H o w e v e r , there a r e variations f r o m one community to the other, even where the same methods of study have been used. FOREIGN CRIPPLE CENSUSES Since the W o r l d W a r several E u r o p e a n nations h a v e conducted surveys of crippled children in connection with their regular censuses. Germany made such surveys in 1 9 2 4 , and in 1 9 3 0 1 5 H o l l a n d , 1 8 N o r w a y , 1 7 and Esthonia 18 also conducted cripple surveys in connection with their censuses. A l l census figures of this sort, however, are liable to a large degree of e r r o r because the cripple himself, or his relatives, fill out the questionnaire. In such cases there is always a tendency to try to conceal the plight of the handicapped person. T h e latest G e r m a n census is probably the most complete, as it has several surveys behind it to furnish experience. T h e survey in H o l l a n d p r o v e d to be very inaccurate. A check-up a f t e r the census revealed that only about one-sixth of the crippled inhabitants of H o l l a n d had been enumerated. 1 9 T h e N o r w e g i a n census is probably more nearly complete. 20 It includes all cripples under sixty-five years of age, but only the most seriously crippled children were included. T h e Esthonian study is not v e r y accurate. It was carried out by the D e p a r t m e n t of W e l f a r e , with the aid of government physicians and health officers. Better results were obtained in the urban than in the rural areas, as the parents were supposed to bring their crippled children to the physicians or other health officers to register 15

"Hauptergebnisse der Reichsgebrechlichenzählung," Wirtschaft und StatisJahrbuch Preustik, V I , 31 ( 1 9 2 6 ) ; X , 1 1 6 ( 1 9 3 0 ) , Berlin. Also Statistisches sen, X X I V , 240 ( B e r l i n ) , 1928. 18 Eckhardt, H., " E r g e b n i s s e der Reichsgebrechlichenzählung, 1924-1930," Zeitschr. f . Krüppelfürsorge, X X I , 486 ( L e i p z i g ) , 1 9 3 1 . 17 Rummelhof, J . , " D i e K r ü p p e l f ü r s o r g e in N o r w e g e n , " Zeitschr. f . Krüppelfürsorge, X X , 1 8 - 3 2 ( L e i p z i g ) , 1927. 18 L ü ü s , A., " E r g e b n i s s e der Krüppelkinderstatistik in Cesti ( E s t l a n d ) , " Zeitschr. f . Krüppelfürsorge, X V I , 3-8 ( L e i p z i g ) , 1926. 19 Eckhardt, H., op. cit. Zeitschr. f . Krüppelfürsorge, X X I , 486. 20 Rummelhof, J . , op. cit., p. 19.

THE PROBLEM OF THE DISABLED

39

them and h a v e them examined. On account of severe weather, h o w e v e r , many in the rural regions were prevented f r o m doing so. T h e whole survey w a s carried out in the month of M a r c h , 1922." T h e census of crippled children which was taken in Germany in 1 9 0 5 under the direction of Biesalski found that there were 7 5 , 1 8 3 crippled children in G e r m a n y , not including Bayern, B a d e n o r H e s s e n . T h e 1 9 2 5 census enumerated not only the crippled, but the disabled. It was found that there w e r e 1 1 4 . 3 disabled persons to every 1 0 , 0 0 0 inhabitants, and 68.4 cripples to each 1 0 , 0 0 0 i n h a b i t a n t s — 1 0 0 . 9 m e n 37-9 women. T h e difference in the number of disabled men and women was due f o r the most part to w a r injuries; one-fifth of all disabled were the result of w a r injuries, while one-third of all cripples were the result of the W a r . T h e 1 9 3 0 census in G e r m a n y found approximately the same results as the 1925." In 1 9 2 0 there w e r e 9 , 0 0 0 d e f o r m e d persons under sixtyfive y e a r s of age, o r 3.6 to every 1 , 0 0 0 inhabitants, 23 according to the N o r w e g i a n census. In H o l l a n d the census of 1 9 2 0 found 4 4 , 8 2 2 d e f o r m e d persons, of whom 6 , 3 5 9 were children under fifteen y e a r s of age. A check-up, however, showed that there were at least six times as many crippled persons in the country as indicated by the 1 9 2 0 census. 24 In Esthonia in 1 9 2 2 it w a s found that there were 1 , 2 4 2 crippled children, which would be about 1 . 0 4 f o r each 1 , 0 0 0 inhabitants. F o r E n g l a n d an estimate of 1 0 0 , 0 0 0 cripples has been made. 2 5 T h e s e figures m a y serve to give an idea of the number of cripples in foreign countries. 21

LÜÜS, A . , op. cit., p. 5. Eckhardt, H., " Z a h l e n aus dem Ergebniss der Reichsgebrechlichenzählung 1925 in Deutschland und deren Bedeutung f ü r die K r ü p p e l f ü r s o r g e a r b e i t , " Zeitschr. f . Krüppelfürsorge, X X I V , 204-13 (Leipzig), 1931. 23 Rummelhof, J . , op. cit., pp. 18-37,. 24 Eckhardt, H., op. cit., Zeitschr. f . Krüppelfürsorge, X X I , 486, 1928. 25 Ibid., p. 486. 22

( ) I Q

UeUIISQ

• m

M in

m S

srisu33

O

9[ddiJ3

O

^ fi

O

UEiSaMjo^j

ut

I Â3S13[ M3fJ 3JBJS

tri co «

/ 1

> oí D CO g

«

« J 55 O

55 £ >-H Q oí O O u
U 4 0 -] ,75o 1,750 to 2,OOO 2,000 to 2,250 2,250 to 2,500 2,500 to 2,700 2,750 to 3,000 3,000 to 3.5OO 3,500 to 4,000 4,000 and up

3 - 4 YEARS, H I G H SCHOOL

3-- 4 YEARS, COLLEGE OR U N I V E R S I T Y

Before Rehabili tation, Percent

After Rehabilitation, Percent

Before Rehabilitation, Percent

After Rehabilitation, Percent

26.21 21.70 19.38 13.31 8.30 5.81

14.22 20.31 24.91 18.76

13.62

3.02 6.98 17.58 20.72

5-93 9.67 16.02 11.30

3-7« 4.08 12.16 11.40

>3-53 20.57 7.05 5.29 2.01 1.11 0.85 0.63 0.65

6.64 12.99 4.02

9-34 20.31 7.76 12.16 3.63 5-34 3.11 3.18

2-35 1.44 0.53 0.35 0.33 0.15 0.15

9-25 7.08 1.86 1.30 0.57 0.27 0.37 O.IO 0.30

1953 23.16 14.88 8.62 9.71 3.56 2.98 1.IS 0.88 0.67 0.53 0.51

Before After Rehabili- Rehabilitation, tation, Percent Percent

7-45 2.21 ••43 2.80 4.89 11.65

3-71

the facilities of the Department of L a b o r ' s employment service, and local civic and w e l f a r e agencies throughout the country. T h r o u g h those sources and the individual efforts of training and employment officers, jobs f o r virtually all rehabilitated veterans were furnished. O f the 1 1 8 , 3 5 3 who completed training under the provisions of Section 400, approximately 97 percent were placed in gainful employment. M a n y of the positions held by veterans subsequent to training did not carry remuneration on a salary basis. T h e r e f o r e it is difficult to make a comparison of the p r e w a r and the present w a g e . H o w e v e r , the following table shows a comparison of a group of employees at certain salary ranges b e f o r e and a f t e r retraining: I t will be noted f r o m the above table that the s a l a r y ranges f r o m $ 4 , 0 0 0 up show a slight decrease. T h i s does not necessarily mean that there has been a decrease in those

VOCATIONAL TRAINING TABLE

XVI

COMPARISON OF SALARY RANGE BEFORE AND AFTER RETRAINING Annual Salary Up to $750 $750 to $1,000 1,000 to 1,250 1,250 to 1,500 1,500 to 1 , 7 SO 1,750 to 2,000 2,000 to 2,250 2,250 to 2,500

Before After Training, Training, Percent Percent 20.3+ 20.06 21.42 15.89 8.37 8.05 2.67 2.32

7.56 11.69 21.50 21.51 13.50 13.15 4.28 3.30

Annual Salary $2,500 2,750 3,000 3,500 4,000 4,500 5,000

to $2,750 to 3,000 to 3,500 to 4,000 to 4,500 to 5,000 and up

Before After Training, Training, Percent Percent 0.80 0.62 0.46 0.37 0.09 0.16 0.18

1.14

0.74 0.69 0.46 O.IO

0.15 0.15

...

ranges, since many positions commanding returns equivalent to the ranges indicated are filled on a commission or amountearned basis. T h e W o r l d W a r Veterans' A c t of 1 9 2 4 states: " T h e test of rehabilitation shall be employability." 10 T h e results of retraining, t h e r e f o r e , may be measured by the percentage of veterans trained to g a i n f u l employment. T h e records pertaining to employment of veterans trained under Section 4 0 0 of the act r e f e r r e d to above show that 97.8 percent were employed at the time training was terminated. SUMMARY Vocational training, which has become the keynote of civilian rehabilitation in this country, received considerable support f r o m the wide p r o g r a m s adopted in the U n i t e d States and other countries f o r the war-disabled during and f o l l o w i n g the W o r l d W a r . T h e w o r k done f o r the war-disabled p a v e d the way f o r f u r t h e r w o r k f o r the disabled in general. 10

Public No. 242, 68th Congress.

XVI E M P L O Y M E N T S C H E M E S FOR WAR-DISABLED

THE

COMPULSORY EMPLOYMENT T H E problem of finding employment f o r handicapped men was the most difficult one f o r which to find a satisfactory solution. Several countries provided f o r their disabled men by compulsory employment legislation. T h e object of the legislation was to provide work f o r a group of men who are entitled to compensation. Germany and Austria include in their professions those persons who have been disabled in industry, as well as those disabled in military service. T h e right to work is only one f o r m of the compensation to which these persons are entitled. Without the intervention of the state these men would be at a great disadvantage in the labor market. A German act applies to disabled ex-service men, as well as to persons disabled in industrial accidents, and to other disabled persons, whatever the origin of their disability. 1 T h e groups provided f o r are as f o l l o w s : ( 1 ) Seriously disabled men in receipt of a pension corresponding to at least 50 percent of the maximum pension allowed in accordance with the Act of M a y 1 2 , 1 9 2 0 . These pensions are allowed to persons with a loss of earning capacity of at least 45 percent. ( 2 ) Persons seriously disabled in an industrial accident who are in receipt of an invalidity pension corresponding to at least 50 percent of the maximum pension allowed under the F e d e r a l Accident Insurance Legislation. These are disabled men with a loss of earning capacity of at least 5 0 percent; 1

I. L. O., Series E., No. 2, Compulsory 1921.

Employment

of Disabled

Men, Geneva,

EMPLOYMENT SCHEMES

189

( 3 ) Injured persons who receive more than one invalidity pension, each of which is less than 50 percent of the maximum pension, on condition that the total pension is not less than 5 0 percent of the maximum. ( 4 ) Persons disabled both in w a r and in an industrial accident who are in receipt of a w a r pension or one or more industrial accident pensions, each of which is less than 5 0 percent of the maximum pension on condition that the two pensions added together come to not less than 50 percent of the maximum. T h e preceding four categories are entitled to preference. ( 5 ) Blind men, even if not blinded in w a r or in an industrial accident. ( 6 ) Persons disabled in war, or by an industrial accident, who receive a pension of not less than 3 0 percent but less than 50 percent of the maximum pension. ( 7 ) Disabled persons not disabled in w a r or by an industrial accident, on condition that their earning capacity is reduced by at least 50 percent. Disabled persons of this kind receive no pension either f r o m the government or f r o m accident insurance. On June 29, 1 9 2 1 , Italy passed an act relating to the compulsory employment of disabled men. According to this act those employing more than 1 0 male persons are compelled to have one disabled man f o r every twenty employees or fraction of twenty above ten. T h i s law applies only to disabled ex-service men, however, and not to those disabled in industry. A l l public administrations were compelled under this act to engage war-disabled men f o r all posts which became vacant. Absolute preference is given them over other persons until a certain percentage of disabled to total staff has been reached. It was subsequently found necessary to m o d i f y this act in view of the difficulty of employing seasonal and temporary workers in the ratio required by the act. A regulation of J a n u a r y 29, 1 9 2 2 , provided that those industries shall be subject to the provisions of the act only as regards permanent employees. It was also provided by a decree of the Ministry

190

EMPLOYMENT SCHEMES

of L a b o r and Social W e l f a r e that in exceptional cases undertakings may be exempt f r o m the obligation to employ disabled men. B y an act of M a r c h 1 8 , 1 9 2 1 , Poland required that all employers of labor in agriculture, commerce, industry and transport shall employ one disabled man affected by a serious injury f o r every 5 0 manual or nonmanual workers employed. France adopted a bill concerning the compulsory employment of ex-service men on June 2 1 , 1 9 2 3 . Beneficiaries under this act are all members of the military and naval forces, who are entitled to a final or temporary pension under the Act of March 3 1 , 1 9 1 9 . H u n g a r y has included clauses relating to compulsory employment in legislation concerning assistance f o r disabled men. EMPLOYMENT BY SPECIAL PREFERENCE The United

Kingdom

T h e United Kingdom has sought to encourage the employ« ment of handicapped persons by a different system. In September, 1 9 1 9 , the National Scheme f o r the employment of disabled ex-service men was adopted. According to this plan every employer is encouraged to employ one disabled exservice man f o r every twenty workers, as the relation of disabled men to the number of men in general was one to twenty. T h e Ministry of L a b o r issues a certificate to each employer who cooperates under this plan, and his name is inscribed on the King's National Roll. H e is then entitled to use as a trademark a special device indicating that he is a participant in the national scheme. Preference is also given to such employers in granting government contracts. On February 1 7 , 1 9 2 1 , 2 4 , 2 3 8 employers were inscribed on the King's National Roll, and 269,000 disabled men were employed. Canada Assistance is given returned men seeking employment, through a special branch of the department, which gets about

EMPLOYMENT SCHEMES

191

1 8 , 0 0 0 applications a year and succeeds in placing a fair proportion even in present times. Its labors are lightened by the fact that preference is given veterans by the government itself, in filling civil service posts, and by many private employers. F o r veterans' relief, caring f o r cases not adequately covered by pension regulations, there will be spent this year something like $2,500,000. Vocational training, on which the Dominion spent $ 4 , 3 4 5 , 7 5 9 in the earlier years of postwar rehabilitation, is now a closed chapter. Still another aid f o r the unfortunate veteran is found in the departmental organization known as the W a r Veterans' Allowance Committee, which has allocated $ 1 , 3 0 0 , 0 0 0 this year. Its object is to relieve f r o m necessity the aged or totally incapacitated veteran whose resources or income are insufficient to provide f o r his comfortable maintenance. T h e committee may supplement the income of such a singled man up to $ 3 6 5 a year, and a married man to $ 7 3 0 . Only those come under this fund who are sixty or more, or who are permanently unemployable through physical or mental disability. Old-age pensions are available to war veterans at sixty, while seventy is the civilian age f o r this public relief. T h e scheme f o r settling soldiers on the land, principally in Western Canada, on which great hopes were based directly after the W a r , has achieved a f a i r measure of success, although at high cost. Through government loans 24,491 soldier settlers were established on farms, of whom 1 1 , 6 1 2 remained at the end of last year. M o s t of the reverted soldier farms have been taken over by civilians under a general land settlement plan of the Department of Immigration and Colonization, which administers this project. F o r the current year the estimated expenditure on land settlement is $ 1 , 5 0 0 , 0 0 0 , which is $680,000 less than f o r the preceding twelve months. The United States Because of possible Constitutional objections, as well as the character of our Federal Government and its limited

192

EMPLOYMENT SCHEMES

jurisdiction, no compulsory employment legislation has been adopted in the United States. Recourse has been had to such devices as the absorption of large numbers of the disabled into governmental services by the expedient of using civil service regulations automatically to elevate disabled veterans to the top of the list. 2 In addition to Federal schemes established by statutes, the states have set up parallel statutes assigning civil service 3 2

Veteran P r e f e r e n c e : A c t of Congress, J u l y 1 9 1 9 , " T h a t h e r e a f t e r in making appointments to clerical and other positions in the executive branch of government in the District of Columbia or elsewhere, preference shall be given to honorably disabled soldiers, sailors, or marines, and w i d o w s of such, and to w i v e s of injured soldiers, sailors and marines who themselves are not qualified, but whose w i v e s are qualified to hold such positions." According to the provisions of the Veterans' P r e f e r e n c e Act, veterans are released f r o m ( 1 ) the age limitations except those provided f o r positions of policemen and firemen, in the District of Columbia, and those required by the retirement l a w s ; (2) the height and weight qualifications required except for positions of g a m e w a r d e n , traveling hospital attendant, watchman, guard, policeman, immigration patrol inspector, and the private fire department of the District of C o l u m b i a ; ( 3 ) they m a y be released f r o m the physical requirements, if the applicant is a disabled honorably discharged soldier, sailor, or marine, provided he has completed an appropriate and sufficient rehabilitation course under the United States Veterans' B u r e a u , f o r the duties of the class of positions in which employment is sought. T h e Commission may, in its discretion, w a i v e the physical requirements in the case of a disabled veteran not so trained. (4) Such applicants are required to earn an a v e r a g e percentage of only 65 (only 60 if applicant is a disabled v e t e r a n ) . (5) T o the earned rate of such applicants will be added 5 points ( 1 0 in the case of a disabled v e t e r a n ) . ( 6 ) Certain preference will be given in the reduction of the force. 3

Persons who m a y not be e x a m i n e d : Anyone suffering f r o m the following defects: Bright's disease; malignant tumor, cancer, etc., diabetes; epilepsy; any abnormal hardening of the arteries; transmissible disease, including syphilis, gonorrhea, and chanchroid, also tuberculosis, active or arrested f o r a period of less than one y e a r ; insanity or mental illness sufficiently definite to affect the usefulness of the applicant; seriously defective vision of both eyes, incorrectable by g l a s s e s ; progressive m y o p i a ; progressive or disabling paralys i s ; uncompensated v a l v u l a r disease of the h e a r t ; loss of both arms, both legs, or one arm and one l e g ; hands, arms, feet, legs, or body so injured, crippled or deformed as to affect usefulness seriously (except that the applications of persons who h a v e lost limbs, or part of limbs, but w h o h a v e demonstrated dexterity either with or without the use of artificial substitutes, will be accepted f o r examinations where physical ability is of subordinate importance) ; chronic alcoholism or d r u g addiction. " T h e president has authorized, on the recommendation of the civil service commission, an amendment to the civil service rules which permits the commission to exempt from the physical requirements established for any position a disabled and honorably discharged soldier, sailor or marine upon the certification of the Veterans' B u r e a u that he has been espe-

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preference to veterans. O t h e r auxiliary services, such as exemption from payment o f county licenses for peddling and preference in assignment o f locations for small business enterprises such as news stands ( N e w Y o r k C i t y ) , have been invoked to aid the disabled veteran in his rehabilitation. O t h e r services rendered to the war-disabled by individual states are poll tax e x e m p t i o n ; 4 limited state tax exemption to veterans or their o r g a n i z a t i o n s ; 5 guardianship for v e t e r a n s ; 9 funds for the purchase, reclamation and settlements of veterans on land and h o m e s ; 7 free notary service in connection with veterans' b e n e f i t s ; 8 veterans' relief commission or other aid in prosecuting compensation c a s e s ; 9 a service officer to assist in making U n i t e d States Veterans' Bureau c l a i m s ; 1 0 free recording of army discharges; 11 scholarships or funds for the education of v e t e r a n s ; 1 2 free vending licenses, e t c . ; 1 3 special hospitalization o f consumptive v e t e r a n s ; 1 4 civil service preferance for disabled v e t e r a n s ; 1 5 state veterans' h o m e ; 1 8 adjusted cially trained for and has passed a practical test demonstrating his physical ability to perform the duties of the class of positions in which employment is sought. The president has also autho rized the commission, in its discretion, to waive the physical requirements in case of a disabled veteran not so trained, to permit his examination. In this respect a disabled veteran is defined as a 'veteran whose disability has been incurred, or increased, or aggravated by, or is traceable to his military or naval service.'" * Ala., Conn., Idaho, la., Me., Mass., Neb., N. H., N. J., N. C. 5 Ala., Ariz., Calif., Conn., Ga., Ind., Ia., Me., Mass., Mich., Mont., Nev., N. H., N. J., N. M., N. Y., N. C., N. D., Okla., Ore., S. C., Utah, Wyo. «Ariz., Ark., Calif., Colo., Ga., Idaho, 111., Ind., Ia., Kans., Ky., Me., Md., Mich., Miss., Mo., Neb., Nev., N. J., N. Y., N. C., N. D., O., Ore., Penn., S. D., Tenn., Texas, Utah, V't., W. Va., Wyo. 7 Ariz., Calif., Colo., N. C., Tenn., Wyo. 8 Ky., Minn. 8 Ariz., Calif., Idaho, Ia., Ky., Md., Minn., Neb., N. D., Okla., Ore., Pa., Tenn., Wis. 1« Ala., Ariz., Ark., Fla., Ga., Idaho, La., Miss., Mo., N. J., N. M., N. C., O., Okla., R. I., S. C., S. D., Texas, Utah, Va., W. Va. " Ariz., Calif., 111., Ind., Kan., Me., Md., Mich., Miss., Mont., Neb., Nev., N. M., N. Y., N. C., Okla., Ore., R. I., Tenn., Texas, Utah, Wis. 12 Calif., Colo., III., Ky., Mont., O., Ore., S. C., Wis. 13 Calif., Ga., Ind., Kans., Mich., Minn., N. H., N. J., N. Y., O., Okla., Pa., Wis. " O., S. D. 15 Calif., 111., Ind., Ia., Kans., Mass., Mich., Minn., Nev., N. J., N. Y., O., Ore, Pa., S. D., Wash., Wis. 19 Calif., Conn., Ind., Ia., Kans., Mass., Mich., Minn., Mont., Neb., N. H., N. J., O., Ore., Pa., R. I., S. D., Vt., Wis.

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service loans legalized f o r state b a n k s ; 1 7 f r e e education f o r blind v e t e r a n s ; 1 8 special relief f o r indigent or disabled veterans or dependents; 19 financial aid f o r Legion h o m e s ; 2 0 special hospitalization for insane v e t e r a n s ; 2 1 state b o n u s ; " special private employment service; 2 3 f r e e hunting and fishing licenses; 2 4 waiver of time requirements f o r public school teachers in the case of v e t e r a n s ; 2 5 free oaths and free copies of state documents on compensation m a t t e r s ; 2 6 and special privileges to veterans who are law students. 2 7 In France, aside f r o m the provisions already mentioned, the war-wounded also benefit by other measures. Reduced railway f a r e s and free medical t r e a t m e n t are granted them. In almost every department o r country there is a soldier's home in which "unemployable" men a r e cared f o r . In all of these homes there are recreation rooms and gardens attended by the men themselves and in most of them they do their own cooking and supply their own service. SUMMARY

In appraising the government's efforts in behalf of the wardisabled, consideration must be given to the political pressure of organized minorities in molding administration legislative policy. Because of this influence, the legislative measures have been liberal in providing for the needs of disabled veterans. N o t only have service pensions or compensation been generous in amount, but eligibility for pensions has been very liberally construed. Medical treatment and out-patient or hospital 17

Conn., Minn., N. J. is Conn., N. J., N. M. 18 Conn., 111., Ind., Ia., Kans., Me., Md., Mass., Mich., Minn., Mont., Neb., N. H., N. Y., O., Okla., Ore., R. I., Vt., W. Va., Wis. 20 Miss., Va., Wash. 111., Me., Nev., Wis. 22 111., Ia., Kans., Mass., Mich., Minn., Mo., N. H., N. J., N. Y., N. C., O., Okla., Ore., Pa., R. I., S. D., Texas, Va., W. Va. « 111., Nev., N. H., N. M., Tenn., Wyo. " Ind., Ore. 2» Ind. 28 Ariz., Idaho, Ind., Ia., Kans., Ky., Miss., Ore., Tex., Va. 27 Me., Minn.

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care have been provided on a comprehensive scale for those suffering from disabilities received not only in but also outside of service. T h e problem of rehabilitation, of vital importance for the economic future of the disabled soldier, was given adequate attention by the United States Government by a plan of vocational training and by special preference to veterans in government positions. This special preference bears a direct analogy to foreign compulsory employment legislation. Nevertheless, rehabilitation has assumed a secondary role in the veterans' struggle for monetary compensation. Foreign governments, because of the pressure of large numbers of employed veterans, adopted compulsory employment legislation as a means of absorbing the large number of disabled into industry and commerce.

PART F I V E THE CHRONICALLY DISABLED

XVII GENERAL CONSIDERATIONS CONCERNING THE CHRONICALLY DISABLED CLASSIFICATION

T H E chronically disabled may be classified on the basis of the nature of the disabling condition and on the degree of vocational incapacity. 1 This group is composed of persons ( i ) disabled as a result of disease; ( 2 ) those permanently disabled as a result of traffic and home accidents; and ( 3 ) those suffering from infirmities of old age which implies reduced working efficiency due to degenerative tissue changes. Arteriosclerosis, chronic hypertension or cardiovascular renal disease, are the pathological disturbances underlying the reduced capacity to work. With respect to vocational capacity, such persons may be grouped as follows: ( 1 ) totally productive; ( 2 ) partially productive; and ( 3 ) totally unproductive. T H E CHRONICALLY DISABLED BY DISEASE

It is practically impossible to obtain any statistical material relating to those who are chronically ill. M a n y persons in this group carry on with their burden of physical disability while others soon become dependent or require custodial care. It is very difficult to place chronic invalids in appropriate institutions. T h e y are usually found in almshouses which have no facilities for their care. Some hospitals refuse them admission because they can retain them for only a short period of time and have no place to which to discharge them. Homes for the aged often reject them because they are not equipped 1

Boas, E r n s t P., and N. Michelson, The Challenge of Chronic Disease, N e w Y o r k , 1933, p. 197. Boas defines chronic disease as "illness lasting a period of three months or more, which prevents the patient f r o m f o l l o w i n g his customary d a i l y routine and which necessitates medical or nursing c a r e at home or in an institution."

200

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to care f o r them. T h e problem of the chronic invalid theref o r e is most acute. 2 During the past two hundred years the types of diseases f r o m which man has suffered have undergone a gradual change, with the virtual elimination of certain diseases during the past few decades. A t present there remain many infectious diseases, but with the improvement in the standards of living in Western civilization, and with advances in medicine and sanitation, such diseases have shown a decrease in frequency. T h e mortality rate has likewise dropped and there has been a consequent increase in the average span of life. W i t h this increase, however, chronic diseases have become more frequent. Patients suffering f r o m such ailments need months in which to achieve rehabilitation. Some may be incapable of rehabilitation, and thus be l e f t with a nonprogressive disability, or with a general physical deterioration. According to a survey of chronic diseases made by the research bureau of the W e l f a r e Council of N e w Y o r k City, the dependent chronically ill in N e w Y o r k City 3 number one in every 3 1 0 persons, exclusive of those suffering f r o m tuberculosis, mental diseases, blindness and deafness. T h e report is based on a census of 20,700 persons incapacitated by chronic illness, who were under the care of medical and social agencies, and on a survey of existing facilities f o r their care (provided by 2 1 8 agencies of different types). T h e five boroughs in the city were represented in the census, in the ratio of one chronically ill person under the care of w e l f a r e agencies to 1 7 5 of the population in M a n h a t t a n ; one to 3 2 5 in the B r o n x ; one to 425 in B r o o k l y n ; one to 875 in Queens, and one to 850 in Richmond. T h e diseases found most frequently were epidemic, general and circulatory diseases, and diseases of the nervous system. N e x t come the diagnoses " o l d a g e , " and diseases of 2

Boas, Ernst P., and N. Michelson, op. cit., pp. 193-95. Jarrett, Mary C., Care of the Chronic-Sick in Private Homes for the Aged in and near Nevi York City, New York City Welfare Council Studies, No. 31, p. 67; 1932. 3

T H E CHRONICALLY

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201

the bones and joints. One-tenth of all the patients suffered f r o m some mental abnormality. M o r e than 20,000 persons in N e w J e r s e y are estimated to be chronically ill, according to a report of the Department of Institutions and Agencies. 4 Of a group of 2 , 1 8 7 patients studied, more than half had been under the care of health and social agencies f o r more than a y e a r ; 3 7 4 had been under care f o r f r o m one to 5 years, and about 1 4 percent f o r more than 5 years. T h e age of these patients varied widely; 8.5 percent were under 16, and 1 0 percent ranged f r o m 1 6 to 3 0 years of age. Social and economic factors of chronic illness are becoming increasingly important with shifts in the age groups. In 1 8 8 0 about 2 1 percent of all types in N e w J e r s e y were among people of 60 years and older, while about 40 percent of the deaths were among children under 5 years of age. In 1 9 3 0 , deaths of young children constituted 20 percent of the total; but among persons over 60 many represent deaths f r o m lingering chronic diseases of later life, representing 44 percent of all deaths in the state, or more than twice the figures a half century earlier. Of approximately 3,000,000 people who are estimated to be disabled at almost any given time, over 25 percent are now found in hospitals. 5 A study of the chronic disease situation in Massachusetts f o r m e d the basis f o r an estimate that approximately 500,000 persons, or about 1 0 percent of the entire population of the state, are "sick with chronic disease at any one given time." 6 It was found that among persons under 20 years of age, the 4

Frankel, E., Chronic Diseases in New Jersey, 1932. p. 26. Moore, H a r r y , American Medicine and the People's Health, N e w York, 1927, pp. 376, 647. A consideration of the d a t a in this reference and the growth of the population leads to the conclusion that approximately 3,000,000 persons are disabled at almost any given time on account of sickness. T h e estimate of 25 percent w a s obtained f r o m the a v e r a g e daily number of patients in all hospitals—775,306 (J. A. M. A., J u n e 1 1 , 1932, X C V I I I , p. 2 0 6 7 ) . 6 Lombard, H. I.., " T h e Chronic Disease Problem in Massachusetts," Hospital Social Service, X X I I , 392-97, 1930. 5

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chronic disease sickness rate was 1 7 per 1,000, and among persons 50-54 years of age the rate was 198 per 1 , 0 0 0 . About one-fifth of the sick individuals had more than one disease, and over 8 percent of the sick (including the aged sick) were completely disabled. 7 In 1 9 2 5 the N e w Y o r k J e w i s h Social Service Agency had 3 , 5 4 9 families in its care. In 1 , 1 4 9 those families some member of the family was unemployed. In 3 3 0 families unemployment was due to incapacity to work because of tuberculosis. In 3 1 0 families cardiovascular disease was responsible f o r inability to work. Other chronic diseases made aid necessary in 844 families. M a n y families had more than one such problem. 8 In a sickness survey of the principal cities in Pennsylvania and W e s t Virginia in 1 9 1 7 , Frankel and Dublin 9 found 1 4 perccnt of the white population in Pennsylvania cities, and 1 0 . i percent of the white population in W e s t Virginia cities, disabled on account of chronic disease that had lasted more than 3 years. T h e number of persons to whom rehabilitation services were rendered during 1 9 3 2 by the state rehabilitation commissions show a large preponderance of disabilities which owe their origin to chronic disease. Of the total number, 5,439, disease as the cause of disability was responsible f o r 2 , 1 5 0 compared to 1 , 7 0 0 which were due to employment accident and 1 , 2 8 3 t o public accident. 10 It is apparent that the number of vocationally disabled and maladjusted as a result of disease is large. T h e exact number, however, is not known. Chronically disabled persons who are vocationally maladjusted are composed of two types of handicapped persons: the individual who acquired his disability in childhood and has been transferred f r o m the child 7 Britten, Rollo E., and L . H. Thompson, A Health Study of Ten Thousand Male Industrial Workers, U. S. Public Health Bulletin, No. 162. 8 Leavitt, M . A., Handicapped Wage Earners, as Studied by a Family Welfare Organization, New Y o r k J e w i s h Social Service Assoc., p. 95, 1932. 8 Frankel, E., and L . Dublin, Sickness Sur registration of crippled children, 6 1 ; second inj u r y compensation, 289-90; State W e l f a r e Department, 60 Oklahoma: chronic disability of miners, 2 0 5 ; legislation crippled children, 60; legislation industrial disability, 1 0 6 ; second injury compensation, 274 Oldenburg, Germany, legislation crippled children, 67 Ontario: employment of disabled, 1 3 2 ; Hospital and Charitable Institutions Act, 72 Orbe, Switzerland, institution for crippled children, $6 Oregon: legislation crippled children, 60, 61, 6 3 ; legislation industrially disabled, 106, 108, 1 1 9 , 1 2 1 Owen, Robert, 2 1 9

P Painted Fabrics, Ltd., 154 Papworth, T . B. Settlement, 154 Paralysis, musculospiral, 27 Paranoia, 1 0 Paris, care of crippled children, 69, 70 Pennsylvania: care of crippled children, 6 3 ; census of cripples, 64; examination of crippled children, 64; legislation crippled children, to, 63, 64; legislation industrially disabled, 106, 1 1 2 ; second injury compensation, 275, 290; survey of chronically disabled, 202 Pensions: Australia, 220, 2 2 1 ; Austria, 138, 1 7 1 , 1 7 2 ; Canada, 162-63; Czechoslovakia, 1 7 1 , 1 7 2 ; Denmark, 2 2 0 ; England, 138, 2 2 2 ; France, for war-disabled, 1 6 3 - 6 5 ; France, for old age, 2 2 1 ; Germany, 1 3 7 ; Germany, for war-disabled, 165-67; Great Britain, 1 6 0 - 6 2 ; industrially disabled, 94-96, 137, 138, 1 4 0 ; Italy, 1 6 7 - 7 1 ; Massachusetts Commission on, 204; Mothers' Aid, 2 2 5 - 2 8 ; Poland for war-disabled, 1 7 1 - 7 2 ; South A f r i c a , 220, 224; United States, old age, 2 2 4 - 2 5 ; w a r disability, I49-50, 155. 1 5 7 , «