Rehabilitation of the Physically Handicapped 9780231889421

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Rehabilitation of the Physically Handicapped

Rehabilitation of the Physically Handicapped BY

Henry H. Kessler Revised Edition

COLUMBIA UNIVERSITY PRESS

New York • 1953

C O P Y R I G H T 1953 C O L U M B I A U N I V E R S I T Y PRESS, N E W Y O R K

Published in Great Britain, Canada, India, and Pakistan by Geoffrey Cumberlege: O x f o r d University Press, London, Toronto, Bombay, and Karachi. MANUFACTURED IN THE UNITED STATES OF AMERICA

T o Colonel Robert S. Allen who by his gifts and sacrifices has met the sternest tests of war and peace

PREFACE

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is rapidly becoming an accepted part of our way of life. Originally identified with the needs of the war disabled, it has been gradually extended so that its benefits are now available for the larger requirements of the civilian handicapped. It has evolved from the idea of isolated and fragmentary activity on behalf of the crippled and the disabled to the modern concept of integrated and continuous service. In the United States rehabilitation had its formal beginning as a governmental service in New Jersey, in 1919, with the establishment of the state sponsored Rehabilitation Clinic at Newark, New Jersey. As assistant director from its inception and as medical director up to 1941, I was in a unique position to observe and to participate in the daily drama and evolution of this program. The successes and failures of the service were recorded in 1934 in The Crippled and Disabled. The progress of this movement was further summarized in a lecture delivered before the Hunterian Society in 1935. Interest in rehabilitation had already germinated in England, and added impetus was given to the New Jersey Rehabilitation Clinic in 1936 by visits from British representatives. In 1939 I gave testimony before a parliamentary commission on rehabilitation, about a month before the outbreak of World War II. Apparently the interest in rehabilitation had gone far beyond the initial stage, for a complete and well-designed master plan for the care of the Royal Air Force casualties was revealed with the advent of the blitz, the program to which Sir Watson-Jones contributed so much. This plan in large measure formed the basis of the later United States Army and Air Force program of rehabilitation. Thus was completed the American-British cycle of rehabilitation. The United States Navy's program followed a different course, one inclined to the pattern of civilian rehabilitation. In the days EHABILITATION

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Preface

immediately following Pearl Harbor, very little attention could be paid to this problem. T h e r e were more important things to be done. Nevertheless, the early phases of a program of rehabilitation were made available to the casualties of the Solomon Islands campaign in 1942 at the United States Naval Base Hospital 2, at Efate, New Hebrides. I was then transferred to the United States Naval Hospital, at Mare Island, California, in October, 1943, to conduct a program of rehabilitation for the war disabled evacuated from the South Pacific until the close of the war. Although this hospital was primarily an amputation and psychiatric center, rehabilitation services were made available to all types of disabilities. T h e general methods employed followed those of my experience in civilian rehabilitation. In the development of this program the California Rehabilitation Bureau gave valuable assistance. Since the publication of The Crippled and Disabled, in 1934, dynamic events have taken place. World War II has come and gone. Peace, or the illusion of peace, walks the earth. Nations are concerned with the lethal effects of atomic energy and ignore the biological weapons of physical fitness and high birth rates. In the light of all these changes, the agonies and the triumphs of the crippled and the disabled require reexamination. It is hoped to focus public attention on the physically handicapped as a national and international problem of social, economic and political significance. T h e views here expressed are my own, the culmination of twenty-eight years of continuous participation in the problems of the physically handicapped in war and in peace. Nevertheless, no one can walk this road without feeling the impact of ideas and personalities which have helped to shape this program into an organized and permanent movement. I therefore wish to acknowledge my indebtedness to the following persons, who have contributed so much to civilian and military rehabilitation: Michael Shortley, Director of the Office of Vocational Rehabilitation; Miss Tracy Copp, rounding out a career of twenty-seven years with the Office of Vocational Rehabilitation; J o h n M. Dodd, Supervisor of the California Rehabilitation Bureau; Miss Bell Greve, Director of the Cleveland

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Rehabilitation Center; Colonel J o h n N. Smith, Jr., Director of the Institute for Crippled and Disabled; Joseph Spitz, formerly of the New Jersey Rehabilitation Commission; Dr. Douglas J . Galbraith, of the Ontario W o r k m e n ' s Compensation Board; Dr. Carl Peterson, Secretary of the Council of Industrial Health, of the American Medical Association; Captain H. H. Montgomery, Chief of Navy Rehabilitation during the war; Dr. Howard Rusk, who was responsible for the brilliant Air Force rehabilitation program and has extended his interest to the field of civilian rehabilitation; Captain J o h n Porter, Commanding Officer, Captain William Muller, and Captain W a l t e r Simpson, of the United States Navy Base Hospital, at Efate, New Hebrides; Admiral J . P. Owen, C o m m a n d i n g Officer, Henry Lindgren, Educational Services Officer, Miss Signe Brunnstrom, Physical T h e r a p y Officer, Miss Lucy Gore, Occupational Therapy Officer, Miss Natalie Mogelner Kahn, Psychologist, all of the rehabilitation staff of the United States Naval Hospital, M a r e Island, California; Mrs. Evelyn Garden and W . A. Huggins, whose service to the Mare Island rehabilitation program deserves special mention. I wish to express my appreciation to my colleagues on the New Jersey Rehabilitation Commission and to ChairmanDirector Harry Harper and Program Director Victor Bleecker. T o my British friends, especially Dr. Donald Norris, Medical Director of the Bank of England, and H. E. Griffiths, of the British Council for Rehabilitation, I wish to acknowledge our strong bond of personal and professional relationship. T h e chapter " T h e Disabled V e t e r a n " was written during the reorganization of the Veterans Administration. I have great confidence in the efforts of Administrator Bradley and Medical Director Hawley in carrying out the mandate of Congress and the people to provide first class service for first class men. I am also indebted to David Wechsler for the use of the total range ratio as a measure of determining the limitation of differences in human capacities in the physically handicapped. Finally, grateful acknowledgment is made to M. E. Odoroff, who critically reviewed the statistical data, Miss Doris Soibelman, who assisted in the early phase of the development of the

Preface

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manuscript, and Miss Matilda Berg, who carefully reviewed the manuscript. T o my many friends in both public and private agencies, I am indebted for many fruitful conversations and discussions which have helped me formulate my ideas. HENRY Newark, July,

N.J. 1947

H.

KFSSLER

PREFACE TO THE SECOND EDITION

D

URING the five years since publication of the first edition of Rehabilitation of the Physically Handicapped, advances in rehabilitation medicine have kept pace with the general scientific progress that has characterized the postwar years. While the philosophy upon which rehabilitation is based is changeless, the specific techniques have been refined to permit constantly improving services to increasing numbers of disabled men, women, and children. While it is still true that complete rehabilitation is available to only a small percentage of persons who need this service, the trend toward expansion is clear. It is not too much to believe that the ideal of rehabilitation—total rehabilitation of the total group of disabled—will become reality in the not too distant future. The need has never been greater. With the present emphasis on total utilization of manpower to meet the needs of peace and war, the productive potentialities of the handicapped must be developed to enable this large segment of our population to find its place in the national economy. The handicapped among us are a challenge and a responsibility: a challenge to the best resources of our medical and social sciences, and a responsibility that must be recognized and met in terms of service from public and private agencies. The spread of these principles and practices all over the world has been the most important single development in rehabilitation since the close of the Second World War. International interest in the problems of the disabled is evidenced by the visits made by American and British specialists to assist in the development of rehabilitation facilities in other areas of the world, by students from abroad who are being educated in local institutions, and, especially, by the work of the United Nations and its various branches. No history, however brief, of rehabilitation during the past

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few years would be complete without mention of the International Refugee Organization. Resettling refugees from the wartorn areas of the world is difficult enough; add to this the difficulties of resettling those who are not only displaced but disabled as well, and you have a problem so staggering that it seems to defy solution. T h e work of the I.R.O. for these disabled displaced persons is a tribute to man's refusal to accept the word "impossible." Since the end of the war, I have had the opportunity to travel all over the world on various missions for the United States Army and the United Nations. In Germany, I was deeply impressed with the camps established by the I.R.O. to rehabilitate displaced disabled persons—the blind, the crippled, the tuberculous—and fit them for new jobs and new lives in other countries. Not only in Germany, but in all of Europe, one is profoundly moved by the efforts being made to rehabilitate the ill and injured, not only by the countries themselves but also with the assistance of the United Nations. I was sent to Yugoslavia as an expert consultant to the United Nations, to inspect rehabilitation facilities and make various recommendations as to how the needs of the Yugoslavs might be met. As one of the results of this visit, a group of professional people from Yugoslavia was given an opportunity to study rehabilitation in the United States, and return to their country with the nucleus of what will someday be a comprehensive rehabilitation plan. In the Orient, lack of scientific knowledge and traditional revulsion for physical deviants is giving place to Western science and a modern attitude toward the physically deformed. In Japan, where this traditional revulsion had reached heights unknown in the Western world, there are now societies of and for the handicapped. With large numbers of students in Western universities, and through the establishment of proper facilities, scientific rehabilitation is becoming an actuality. India, home of uncounted millions of sick and disabled, now has her first rehabilitation center and her first physical therapist. Israel, which will accept immigrants regardless of their physical condition, is organizing an excellent program of medical and rehabilitative care for its expanding populace. Siam has a program for educating its blind; Iran is in the process of forming one.

P r e f a c e to t h e S e c o n d

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T h e s e developments not only m e a n more and better care for millions of handicapped persons, but, taken together, reflect the international ideal of service which is the hope of a peaceseeking world. T h e United States has made a great contribution to this work t h r o u g h sharing its skills and knowledge with the rest of the world. T o care for its own citizens, the government has steadily increased the range of services available f r o m the Office of Vocational Rehabilitation and affiliated state agencies, now u n d e r the brilliant direction of Miss Mary Switzer. T h e military services a n d the Veterans Administration have made great strides in the m a n n e r in which they meet their responsibility to inj u r e d servicemen. Private agencies assist those civilians who are n o t eligible for government assistance, a n d prove, again, that g o v e r n m e n t cannot do the job alone. I n the final analysis, however, the work of these specialized agencies depends for its success u p o n the private citizen. T h r o u g h his support of rehabilitation measures and his faith in the handicapped, he can, and will, translate the f u n d a m e n t a l concepts and philosophy of rehabilitation into the everyday life of every citizen. HENRY

Newark, N.J. 1952 November,

H . KESSLER

CONTENTS

PART

I. II.

i. Problems of the Physically Handicapped

G E N E R A L CONSIDERATIONS

3

PROBLEMS OF T H E DISABLED

16

III.

T H E CRIPPLED CHILD

26

IV.

THE INJURED WORKER

43

V.

T H E DISABLED V E T E R A N

56

VI.

T H E C H R O N I C DISABLED

81

PART

VII. VIII.

11. Principles of Rehabilitation

PHYSICAL R E S T O R A T I O N

93

REHABILITATION CENTERS

105

IX.

VOCATIONAL G U I D A N C E

114

X.

VOCATIONAL T R A I N I N G

128

PLACEMENT

140

XI.

PART HI.

XII.

Rehabilitation in Practice

T H E M E N T A L L Y AND E M O T I O N A L L Y DISABLED

151

XIII.

THE ORTHOPEDIC PATIENT

169

XIV.

T H E B L I N D AND T H E DEAF

182

MEDICAL AND S U R G I C A L INVALIDS

196

XV.

PART

XVI. XVII.

IV.

A National Program

LEGISLATION AND ADMINISTRATION

215

A NATIONAL CHALLENGE

233

M A J O R C E N T E R S AND AGENCIES FOR T H E HANDICAPPED

253

INDEX

259

PART I

Problems of the Physically Handicapped

Chapter I GENERAL CONSIDERATIONS

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NE of the deep disappointments of W o r l d W a r II was the discovery of the low state of national physical fitness. It came as a distinct shock to the nation to learn that despite its high standard of living, 40 percent of its selectees for military service were rejected because they could not meet the standard physical requirements. W h a t was more, despite the screening out through Selective Service of those with emotional disorders, the highest rate of discharges from the armed services was for neuropsychiatric causes. T h e first reaction to this discovery was a feeling of frustration. W o u l d we be able to fulfill the requirements of military service with able-bodied men? T h e second reaction was one of selfreproach. W h a t had we failed to do? For years we had boasted arrogantly not only of our huge physical resources, but also of the advantages of our way of life, our dedication to sports and athletics, our low morbidity and mortality rates. W h e n we examined the fruits of our labors we f o u n d them shot through with decay and disease. O u r ability to meet the great national emergency of war by adequate man power was seriously questioned. W e met the problem in our usual pragmatic way by selecting our so-called physically fit for military service, and relegating the unfit, the 4FS, to a position alongside the women (who have always been regarded as physically inferior) and the superannuated, to man the defense factories and carry on the battle of production. T h e record of production achieved by these apparently substandard groups is now history. H o w did they accomplish it in the face of our usual concept of physical fitness? Sober analysis reveals the basic error of our thinking. It is necessary to reexamine the whole concept of physical fitness not as a mere semantic exercise, but as a term of great social significance. It refers not only to the physical fitness of the soldier, sailor, or marine, to perform military service, but the ability of the worker to perform productive and continuous work. It is a

4

General Considerations

term with many political and economic overtones. It is a key word to the correct understanding of the whole problem of the crippled and disabled. False concepts of physical fitness have had an important influence on our civil, industrial, and military life. Vague standards have been created that have condemned those with physical defects as unproductive and socially useless. Excessive import has been given to psychologic and aptitude tests in the determination of physical fitness, while human energy and capacity have in general been largely underestimated. Though the presence of physical defects may imply limitation of capacity to work in some cases, this premise is false in the majority of instances. Even in the presence of serious physical defect, sufficient function may remain to carry out industrial activity. One study of 4,404 physically handicapped persons engaged in 653 different types of work shows the versatility and adaptability of the physically handicapped. Another investigation by a large industrial company covers a group of 685 men and women with physical defects; it shows that they are as fully productive as workers without physical defects, and further shows no greater loss of time for illness, accidents, or for personal reasons. Civil Service records, as well as reports from 300 major industries, also confirm the excellent productive performance and low incidence of accidents among the physically handicapped. T h e production record of more than 11,000 physically handicapped workers at the Ford Motor Company confirms these findings. T h e ability of these individuals to be as fully productive as socalled normal persons, that is, those who are free from obvious physical defects, is largely the result of the safety factor. This factor is demonstrated by the ability of the body to accommodate itself to unusual demands despite disease or congenital or acquired defects. Through self-repair, regeneration, hypertrophy, adaptation to new conditions, vicariousness of function, or substitution of one structure for another (such as the skin for the kidney), the body is able to combat its environment and fight off harmful influences. This safety factor provides a huge reservoir of structure and function upon which the individual can draw. T h e organic defect may even act as a stimulus to overcompensation. While drive or motivation pushes a man to an ordinary level of achieve-

General Considerations

5

ment, an increase in the intensity of that drive propels him far beyond what he thought he could do, and helps him to approach the limits of his capabilities. Adler developed a psychological system based on the idea of organ inferiority. He notes that we are equipped with resources that are not fully developed. Yet with this imperfect development good performances are turned out, just as our ancestors produced great works with imperfect tools. It is possible that a man equipped with defective organs, that is, with inadequate tools, will actually develop a better technique to combat the rigors of his environment. He will pay a great deal of attention to detail, devise more unerring shortcuts, or undergo a more intensive training. One of the factors that seriously affects our evaluations is the failure to view the individual as a whole. T h e individual does not act as a series of separate structural units or functions, but rather as a psychophysical entity. Mind and body cannot be divorced from the need of meeting each problem in an integrated way. It is not enough to say that the physically handicapped person uses his residual normal capacities to solve his specific problems. T h e effective dynamic action is the significant factor, and this is a product of his whole mind-body structure and function. Physical examination can reveal a pathological state (diabetes), or a functional or anatomic defect (amputation), but it has no means of determining the way the whole body meets its physiological and social requirements. Long before the modern trend toward administrative medicine, physicians were called upon to render opinions regarding the personal, social, and economic consequences of accidental injuries and disease. These opinions formed the basis of monetary benefits paid by insurance companies and fraternal societies. By nature these judgments were limited to broad speculative surmise; rarely was an attempt made to study the patient's true adaptability. Estimates of incapacity to work were thus made by intuitive correlation, that is, the quick mobilization of past experience. Because monetary benefits were paid on the basis of these estimates of working capacity and disability evaluation, the physician played an important role in determining an injured man's

6

General Considerations

economic status. Custom and legislation gave the physician a new social power, but the science of medicine has failed to provide him with the means to put this power to use. There is no system of pathology through which the capacity to work can be clearly defined. Pathology determines the nature of illness, but not the extent of the remaining health. A person lives not only with his pathological lesion, but also with his undisturbed organs and functions. A man, lame in both legs, may be fully capable of work, whereas a sound-limbed neurotic may be totally incapacitated. T h e determination of the working capacity of a person who has suffered a fracture of the spine, a paralysis of the main nerves of the arm, a stiff and immovable elbow joint, or chronic lung disease from the inhalation of silica dust, can only be made by arbitrary means. Routine physical examinations provide no means of scientifically determining the general working capacity. Some attempts have been made to define physical efficiency in mechanical terms. But man is not comparable to a machine. For though the human motor is subject to the laws of thermodynamics, its physiologic work (the static energy of the ordinary machine) far outweighs its physical work. Furthermore, human safety factors which permit a large degree of compensation despite physical defect, are ignored in this mechanical evaluation. There is little doubt that many of the judgments rendered by physicians concerning disability evaluation are questionable in an objective sense. It is important that these limitations be stated. It helps to explain the variations in the opinions and estimates rendered in legal controversies, and reflects the enormity of the task before us. How then shall we define physical fitness? Shall we define it subjectively, as a state of being, as normal, healthy, efficient, free from symptoms, free from obvious physical defects, able to withstand physical effort and strain, having the capacity to work? Or shall we define it in terms of its objective (physically fit for what—work, play, industry, military services)? In its common usage, physical fitness is considered as a combined concept, in which subjective and objective elements play a part. In any case it is usually identified with three states: ideal or superior, substandard or inferior, normal or average.

General Considerations

7

T h e wide difference in human performance on all levels, intellectual, mechanical, in the world of sport, business, and military service, is taken for granted by most individuals. Yet there is a tendency to categorize the grades of performance and ascribe to them a special quality and character. Labels or names are given to special or outstanding performances, and automatic scales are used in which the achievements of the genius lie at one end and the deficiencies of the moron at the other. A conspicuously brilliant act may lead most of us to believe that the individual is endowed with some special gift or talent; while on the other hand, a conspicuously stupid one is ascribed to a congenital absence of any such talent. T h e theory of critical differences throws some light in explaining and evaluating the differences in performance. This theory can be better appreciated by an analogy with physical phenomena. If for example we add a grain of salt to an already saturated solution, crystallization will take place. Mercury, which is a solid, will volatilize at certain temperatures. Water changes itself to ice at 32 degrees Fahrenheit and to steam at 220 degrees Fahrenheit. Air at certain temperatures and pressure levels can change its character from that of a gas to a liquid. In other words, dramatic transformations take place in these substances following almost imperceptible changes. When these substances pass certain critical points of temperature, pressure, or chemical composition, certain spectacular changes occur. So, too, in human function, small quantitative variations may give rise to marked qualitative differences. T h e chemical equilibrium of the blood and body tissues permits wide variations without serious disturbance of function. But when the critical point is exceeded, we pass from a normal or healthy state to an abnormal or diseased state. Beyond certain points, even slight differences in efficiency of individual ability may so alter the character of the resulting performance, as to make it appear as an achievement of an entirely different order. T h e lightning calculator and the prestidigitator are examples of this kind. These performances do not represent a special quality or species of ability, but a series of traits which fewer and fewer attain in the distribution of traits and abilities. Out of a thousand individuals of the same age, 998 will present a close similarity in the manifestation of physical and mental

8

General Considerations

capacities, while two will vary so widely from the intermediate group as to represent almost an entirely different species or trait. It is the highest and lowest place on the scale which is given special interpretation as if they belonged to a different category. Superior and inferior states arise from the summation of the quantitative traits of which they are composed. Human abilities, then, acquire new characteristics or configurations when they exceed certain levels of achievement. Deficiency states are qualitative expressions of quantitative changes that have failed to reach certain critical levels. We have said that out of 1,000 individuals of the same age, two will vary so much from the intermediate group as to constitute a different order or species. But what about the intermediate group of 998? How much do they differ from each other? D o these differences, if they exist, obtain for the entire span of human capacities, or are they encountered only in such special fields, as for example, those of mathematical or artistic ability, or the ability to pilot a plane? How much more productive is the most efficient individual than the least efficient in a given occupation? Many of the answers to these queries have been provided by studies which have shown that there are little differences in human capacities in the same age-group. It has been further demonstrated that the relationship between the least productive and the most productive individual as revealed by existing data, is not greater than two to one. For example, in an industrial plant, where discs were being strung, this ratio was two to one. In another operation, namely the speed of inserting bolts, the ratio was two to one. In still another operation, that of card sorting, the ratio was approximately two to one. In the high jump and broad jump, the ratio was two to one. These differences in performance are indeed small. It would seem that, contrary to the popular notion, we are very much alike. T h e idea that we are fundamentally alike is shared by the anthropologists who have explored the myth of specific racial superiority. T h e y have demonstrated the infinite variety of component stocks that comprise the mixture which is called a pure race. We recently learned to our dismay how much we had underestimated the military capacity of the Japanese because of their

General Considerations

9

small stature and apparent near-sightedness. T h e s e were only rationalizations for the prejudices we innately felt toward a competing national group with different physical features. Biologists, too, have stressed the unity of man's physical pattern. W e take for granted the central body axis, the symmetrical pairing of eyes, the fundamental doubleness of both sides of the body, the constant pattern and number of digits of the hands and feet, until we encounter a monstrosity with a Cyclopean eye, a hare-lip, or cleft palate, webbed fingers, or supernumerary fingers. But one does not require scientific data to dispute the validity of the myth of human difference; the evidence is plain enough for the man in the street to comprehend. Perhaps the most significant contemporary evidence was the response of individuals to the war-production effort. Millions of men and women, with apparently no technical background or special aptitude, were engaged in a variety of war occupations which not only required skill but strength and endurance—as in steel mills. In Ford's W i l l o w R u n plant, 38 percent of the workers were women. T h i s was a cruel blow to those industrial psychologists who have supported the thesis of women's physical inferiority. But more to the point was the response and adjustment of men to the demands of military service. N o t only were there the physical and mental demands of combat service and the physiologic demands of adjustment to changes of climate (as in the Aleutians and the South Pacific) but also the more difficult adjustment to technical and administrative tasks for which most of this new military force had had no previous training or experience. T h e story of the war cannot be written without dedicating a glorious chapter to their achievements. Hospital corpsmen, whose only training had been a short course in hospital nursing, established base hospitals in islands in the Pacific. T h e s e men unloaded ships, built roads, constructed Quonset huts, installed water and sanitary facilities, and set u p messing and beddingdown facilities for patients and personnel amid the heat and humidity of the tropics. These men were not the experienced mechanics of construction battalions. T h e y were clerks, millhands, sign painters, bookkeepers, farmers, and insurance salesmen. Many were discovered to have had preexisting physical de-

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General Considerations

fects, such as recurrent dislocation of the shoulder, trick knees from football injuries, old fracture deformities of the elbow, and in several instances, partial hand amputations. One of these men had been a prize fighter, who despite an old deformity of his elbow and a nerve injury, had been both champion in the ring and on the battle field. The alchemy of war does not transmute base metals into great leaders and fighting men—the fundamental stuff is already there. That stuff, during the past war, was not only physical, but spiritual as well. It was epitomized in the response of one Marine, in whom severe gunshot wounds had necessitated amputations of both arms and one leg. T o the question of how he felt after the operation, his poignant reply was, "Gee, you guys certainly show me a lot of attention." It is, nevertheless, difficult to get the average man to accept the notion that we are fundamentally alike because the idea docs not fit in with his experience. He does not have to be shown the tremendous gap that exists between the mind of an Einstein and that of a mental defective. Nor does he have to rely on the circus to be reminded of some of the major physical differences that distinguish men. He just "knows" we are different. He has only to look around him to appreciate the variations in height, form, and color. The explanation for this difficulty is primarily the semantic difficulty in defining the term, likeness. The usual interpretation is that of identity. But no, we are not identical; we are similar. And our similarity is much greater than our differences. This relationship is so close and constant that it takes on the character of a natural law such as gravitation. Of course, the cited two-to-one ratio of the range of human capacities may trouble the reader a little. It may still represent to him a very great disparity. But all relationships must be interpreted relatively. If we review the tremendous differences in the physical and natural world, the two-to-one ratio is no longer impressive. The tree and the blade of grass, the mountain and the plain, the river and the ocean, the ant and the elephant, display far greater differences. Cosmically considered, the ratio fades into insignificance. It was on the ship that brought us to the South Pacific that we received an introduction to the interpretation of cosmic phenomena. During an elementary lecture on celestial

General Considerations navigation, the captain remarked how such a study confirms the most fundamental democratic tenets. He said, "In relation to the vast expanse of the heaven, and the vast concepts of time and space, we are equal—nothing." And then he added, "Here I am, talking to you about millions of light years; and at home, my wife scolds me if I'm fifteen minutes late." How then shall we appraise the normal state? We can, for example, view it as one that is free from all physical defects. But on such a basis it would be virtually impossible to find a completely normal individual. This fact has been determined by physical examinations conducted for Selective Service (in which 40 percent were rejected for major physical defects); by mass preemployment examinations, and studies of school children. In a study of 6,565 male and female workers, only 7 percent were found free from gross physical defects detectable by physical examination without the use of X-ray or laboratory facilities; 70 percent had minor defects; 16 percent had advanced minor defects, and 7 percent had major defects. Nor does absence of symptoms constitute a proper basis for defining the normal person. Autopsy reports frequently established the fact that many individuals who have never suffered subjective symptoms or physical signs of disease, may present evidence of advanced cardiovascular disease, tuberculosis, cancer, or other systemic diseases. No matter what attempts are made to evaluate physical fitness, the appraisals are generally complicated by social judgments. The term normal is not a statistical concept but a personal judgment in which we use ourselves as the standard, and the subject of our attention as the deviation from that standard. It represents, therefore, a series of physical and psychologic traits, the evaluation of which is influenced by social prejudices; and our vocabulary is the vehicle by means of which these prejudices are transmitted. The word cripple, for example, is a term of derision, of contempt, a brand that has come down through the centuries, carrying with it the stigma of repugnance and aversion. It has been a continuous target for the hatred of all ages. Objectively, it has been a mark of identification, of deviation, of alienism. It has also been a mark of social status, an evidence of caste, like the Hindu mark or the Maori tatoo.

12

General Considerations

B u t it has been m o r e than that. Subjectively, for the inhibited, repressed, a n d limited ego it has been the patent medicine, the relief, the resolution of confusion and anxiety f r o m the rigors of day-to-day living. T h e driving force of ego satisfaction requires constant fuel for its fires. Its own storehouse is so bare that it must o b t a i n its fuel vicariously f r o m the superiority it gains t h r o u g h comparison with others. T h e cripple by his deformity, limited f u n c t i o n , or grotesque appearance, provides that satisfaction. T h i s is the basis of the prejudice that forms the f o u n d a t i o n of the social attitudes toward the physically handicapped. It is a poison c o m p o u n d e d of demonology a n d ego need. T h e cripple is, nevertheless, a social p r o b l e m , which, d u r i n g brief interludes of sympathy, sanity, and reason, has attracted the a t t e n t i o n of the public. T h e helplessness of the crippled child has appealed to the sentimental impulses in m a n a n d formed the basis of i n t e r m i t t e n t attempts to help h i m in his struggle against s u p e r i o r odds. Because of the serious emotional resistance that the term cripple evokes, there has been a deliberate a t t e m p t to replace the term in o u r vocabulary by means of word-substitutes. Of these, the most popular is physically handicapped. T h i s term certainly possesses fewer malevolent features than that of cripple. T h a t , in itself, is of great practical value in an educational p r o g r a m a t t e m p t i n g to improve the social a n d economic position of the physically handicapped. T h i s , however, is n o t the most satisfactory term, for it has m a n y meanings and i n t e r p r e t a t i o n s a n d there is n o u n a n i m i t y of o p i n i o n regarding its scope. For example, shall it include those with obvious defects such as amputations or facial disfigurement? O r shall it include mild heart disease, diabetes, or an obscure neurological disease? O n the o t h e r hand, shall it include the mentally a b n o r m a l , the psychotic, the psychoneurotic? Shall it include the social disabilities associated with the racial features of the Semite, or the color features and pigmentation of the Negro and Chinese? For o u r purpose, we shall confine o u r i n t e r p r e t a t i o n of the t e r m to those individuals who have a physical defect, obvious or h i d d e n , which limits their physical capacity to work, or evokes an unfavorable social attitude. T h e social handicaps of race or color are supplementary to, b u t n o t identical with, the physical handicap. T h e presence of a

General Considerations

J

3

physical defect, however, does not constitute disability. Only when the defect causes an actual restriction of activity or arouses a psychosocial prejudice, will it be so defined. T h e definition of physical handicap, then, must be necessarily social and economic rather than medical or anthropologic. It defines the status of the individual in society. T h e basic feature which distinguishes the physically handicapped is the presence of a physical defect. Its influence upon the individual's adjustment will depend on whether the defect is obvious or hidden, sialic or dynamic. T h e terms obvious and hidden have here a social connotation. Amputations, deformities, facial disfigurement, a limp or impaired function, by provoking attention, all fall into the first category. Hidden defects may be of two kinds. Amputations or lost members may be replaced by a substitute or prosthesis; and in this way the defect may be disguised or camouflaged. On the other hand, the very nature of the condition may conceal the defect. Thus it may involve any anatomical system as the central nervous system (brain tumor, epilepsy), the skeletal system (bone cyst, osteoarthritis), the genitourinary system (nephritis, stone in the kidneys), the gastrointestinal system (gastric ulcer, colitis), the pulmonary system (bronchiectasis, tuberculosis), the cardiovascular system (endocarditis, pernicious anemia, hypertension, endarteritis). T h e terms static and dynamic as applied to defects refer to their functional significance. T h e loss of a finger or a leg is a permanent and fixed condition. T h e rehabilitation of an individual with a fixed, permanent, and static defect is facilitated by the knowledge that no further changes are to be expected in the physical makeup. Arrangements can then be made to utilize the remaining mental and physical skills for selective placement of the individual in suitable employment or for training in a vocation consistent with his capacities. On the other hand, the patient with diabetes, tuberculosis, arthritis, or heart disease, is suffering not from a stationary defect, but from a progressive or dynamic one, one so subject to change for better or worse, as to alter his entire capacity for continuous work. Such instability of work-capacity in an industrial world demanding continuity and stability requires exceedingly

14

G e n e r a l Considerations

fine discrimination in the selection of suitable rehabilitation measures. T h e difficulties associated with dynamic defects first prompted the Office of Vocational Rehabilitation of the Federal Security Agency to limit its approval of rehabilitation services rendered by the states to those with static defects. T h e restoration of motion in a stiff joint, the correction of a limp by surgery, the provision of an artificial limb, eye, or arm, are conducive to specific and concrete results. T h e chronic and elusive nature of arthritis, osteomyelitis, and the degenerative neurological diseases like syringomyelia, however, make these conditions difficult to control. However, some liberality is permitted in the practical application of the term static to include slowly progressive conditions as, for example, glaucoma, in which early treatment may prevent its ultimate development with resulting blindness. How can the physically handicapped fit into the social order demanded by the dynamics of events? It is to this question that the term, rehabilitation, attempts to frame an answer. In the military services this has always had a medical or clinical connotation referring to the speeding of cure and convalescence and the return to military duty. T o that end surgical or medical treatment, physical therapy, occupational therapy, athletic exercise, physical and military conditioning, are employed. T h e slogan of the Navy, " T o keep as many men at as many guns as many days as possible" emphasizes this purpose and even the method designed to secure it. Perhaps the professional meaning of the term as a distinct type of service was derived from the thirty-year record of state agencies on behalf of the crippled and disabled. T h e basic aim of these services was to fit the disabled for remunerative employment. In that period approximately 546,000 men and women with various types of disabilities were made employable and given employment. This record was both a victory and a failure. It was a victory over the prejudices and apathy of the public. It was a victory over the confusion, the pessimism and the despair of the physically handicapped. It was a victory in demonstrating, however fragmentarily, the practicability of this social measure for the utilization of man power. It was a failure in that so small a number were rehabilitated;

G e n e r a l Considerations

15

in that it has only broken the strong outer defenses of tradition, cherished infamies, calumnies, and prejudices. It was a failure in its limited objectives. T h e restoration of the crippled and disabled from war and peace has been carried out on a piecemeal basis. T h e potential industrial and military value of the handicapped has been given little consideration. T h e methods employed were cast in the mold of the nineteenth century atmosphere of paternalism. Maximum success was considered achieved when the crippled or the disabled were restored to their former status. This means, in large numbers of cases, returning them to a state of ignorance, illiteracy, and lack of vocational skill. Rehabilitation has acquired new connotations growing out of civilian and military experience. It has come to be regarded as a creative process in which the remaining physical and mental capacities of the physically handicapped are utilized and developed to their highest efficiency. It is an organized and systematic method by which the physical, mental, and vocational powers of the individual are improved to the point where he can compete with equal opportunity with the so-called nonhandicapped.

Chapter II PROBLEMS OF T H E DISABLED E the physically handicapped a major social problem? Do they require organized political and social action? Or should they continue to be the responsibility of the halting, broken efforts, the half-hearted movements of charity relief, and limited government aid? O n e way of answering these questions would be to determine the size of the problem. T h i s might be obtained by a review of available statistics. Unfortunately, the material at our disposal is woefully inadequate and incomplete. Estimates that have been made, however, range from two to twenty-five million physically handicapped persons in the United States. Baldly stated, these figures are, of course, altogether unreliable. T h e y are not only untrustworthy; they are dangerous. In an attempt to dramatize the problem of the physically handicapped, distortion only excites suspicion and distrust. Furthermore, if the size of the problem is distorted to such magnitude, it may create a sense of hopelessness and futility. It is probably true that twenty-five million people have physical defects of one sort or another. But it is not true that the defect is of such a character as to interfere with working capacity. It will be remembered that our criteria of disability were obvious defects, which caused a definite impairment of working capacity, or which excited social prejudice and prevented employment. On this basis, I would favor the smaller estimate of two million physically handicapped adults. A number of cities have made surveys of their crippled inhabitants but the data are incomplete and unreliable. It is difficult to obtain complete information relative to the n u m b e r of the chronically ill. Even industrial accident statistics do not reveal the number of injured workers who are left permanently disabled and unemployed. T h e published figures on the n u m b e r of war disabled with residual economic and physical disabilities are inaccurate, since minor injuries are frequently included with those that produce a vocational handicap.

Problems of the Disabled

>7

Early censuses of crippled persons varied from 2.5 per thousand children to 6.12 per thousand adults and children. More recent censuses reveal a higher ratio, namely 20 per thousand of the population. On the basis of the 1940 census we could then estimate one-half million crippled children in the United States and two million crippled adults. T h u s there would be about 2.5 million disabled persons in the United States exclusive of the war disabled, the chronically ill, the blind, the deaf, and hard of hearing. But numbers alone cannot tell the whole story. T h e story behind the figures is one of spiritual, physical, and economic misery which must be endured by the disabled persons; of the loss to the nation of many productive citizens; of the burden to society in general. T h e social cost is composed of the loss of earning power, the general social and economic ineffectiveness and the actual expenditures for maintenance, care, and relief. Some idea of the loss of earning power can be gained from a study made by the Office of Vocational Rehabilitation. In the fiscal year 1950,59,597 physically handicapped persons were rehabilitated; 71 percent were unemployed when rehabilitation services were begun. Although this figure represents the greatest number of persons rehabilitated by the O.V.R. during any one year of its history, only a fraction of the total number of persons requiring services are receiving them. Thousands of others could be helped if adequate facilities were available. It is very difficult to ascertain the actual cost to society in money for the work done for the disabled. There are no reliable figures concerning the numbers who are dependent upon private or public aid because of physical disability; they are lumped together with all persons receiving aid and relief. Similarly, in compiling statistical data during the depression years of 1929 and after, economists and public officials included the unemployables with the unemployed, placing the total as high as five million. In none of these estimates was there any rational basis for the opinions concerning the nature of the physical condition which produced the state of unemployability. T h e U.S. Department of Labor in 1930, the American Federation of Labor, the U.S. Chamber of Commerce, the Brookings Institute and others constantly referred to "unemployables," but gave no explana-

i8

P r o b l e m s of the Disabled

tion of what constitutes unemployability. It was assumed that the reduction of the labor market had restricted the opportunity for employment of a group of marginal people who (so the presentation ran) were less well equipped to secure and hold jobs because of physical defects. N o attempt was made to analyze this group carefully and to determine the exact cause of unemployability; nothing was done other than to impose on its members the label "social misfits." Had an adequate investigation been made it would have disclosed that the disability played only a minor role in their inability to secure or hold jobs. T h e dominant factors in this maladjustment were the larger intangible ones of national economic conditions and local prejudices. T h e loose interpretation of economic facts by reputable agencies appears ludicrous, particularly in the light of current figures on unemployment. If we have reached the peak of man-power utilization with an irreducible minimum of two million unemployed (due to age and physical incapacity) then we must certainly have been mistaken about the working capacity of the five million unemployables of the depression years. These false estimates resulted in large measure from the need for explaining away the failure of a nation to solve a critical economic and social problem. Since no solution was available it was necessary to invoke a scapegoat, the physically handicapped person. By this device the public could save face. All the physically handicapped have problems to meet as they attempt to adjust their limited physical equipment to the demands of living in a social environment. Many of these problems are internal and physiologic. As we shall see later, through the employment of the safety factor this conflict is resolved with very little difficulty. Many external problems are to be faced as well. Among these, the most difficult is the adjustment to hostile social forces. These attitudes that have made self-expression and adjustment more difficult can be expressed by the term psychosocial prejudice. It is an individual and collective reaction of hostility toward the crippled, the deformed, and the disabled, who are condemned as unproductive and useless burdens. T h i s truculent attitude on the part of society is the greatest hurdle that the disabled person is called upon to surmount. It is a carryover from medieval times when deformity was associated in the

Problems of the Disabled

»9

minds of men with the devil, malignity, sin, and evil spirits. Despite centuries of enlightenment this vestige of the primitive fear of the unknown and the unexplained has not been dispelled. T h e physically handicapped person thus bears a double burden, his actual disability and the social restrictions it incurs. Imperfection in nature is always more or less abhorrent to the human mind. Man has tended to make a fetish of beauty, and the human figure is regarded as acceptable only when it is normal. When it is abnormal, or deviates in any way from the ideal, the repulsion is equally strong. It is assumed that the crippled in body are crippled in mind as well. Because of this widely diffused public attitude, the cripple often 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. T h e attitude of primitive man toward the disabled has been dominant through thousands of years of human history. T h e unwritten laws of primitive society that the crippled and disabled were to be sacrificed for the good of the group were carried over into the written laws of the ancients and for many centuries determined the treatment of disabled persons. T h o u g h public and private efforts have improved the status of the physically handicapped, the repugnance and distaste with which they have been regarded throughout history still prevail. Employment of the physically handicapped becomes seriously obstructed by the prejudice of employers. They frequently rationalize their feelings on economic grounds: We naturally do not employ the afflicted when we have sound material at hand. Taken as a whole, even when fitted to the job, they are apt to prove less satisfactory, because of an accompanying mental state of depression or nervousness often to be observed. With the present stringent liability provisions under which a manufacturer must work, we can see no possibility of any extended program in our line of manufacture for the physically handicapped. There should be no closed doors against the physically handicapped persons of working age. However, we feel that the employer should not be held responsible for accidents that can be charged directly to a physical ailment.

20

P r o b l e m s of the Disabled

When carefully selected, certain defectives can safely be assigned sheltered jobs. It is a mistake to install handicapped individuals otherwise, it is unfair to them, to their fellow employees, and their employer. These attitudes (1928) show that even among the more liberalminded employers, the feeling of revulsion toward the disabled persists. T h e y may be considered representative of employers throughout the country. Of what use then are physical restoration programs, education and vocational training, if the physically handicapped are to meet discrimination and exclusion on every side? Even today (1953) this same attitude exists despite the fact that it has been submerged at times because of labor shortages. One employer, desperate for help, employed a blind dictaphone operator at the suggestion of a rehabilitation agent. Her production was so efficient that she accomplished the work, of several stenographers. More help was required, however, to meet new work demands. It was suggested that another blind operator be hired, particularly in view of the fine record of the first blind worker. Such was the deep-rooted prejudice of the employer that he refused the offer with a parting "I've done my bit." Psychosocial prejudice is frequently rationalized on the following economic grounds: first, the employer maintains that the physical disability means reduced productivity, and hence is an economic liability; second, that the disabled person because of his physical limitations is more prone to accident; third, that if he is injured, the employer will have to bear the cost of the aggravation of the preexisting disability. A critical examination of these objections reveals their flimsy basis. First, undervaluation of the individual's capacity to work is an error committed not only by laymen but by physicians as well. It should be remembered that a man lives not only with his defect, but also with his remaining sound physical and mental organs, which he utilizes automatically and in an integrated manner for the solution of day-to-day problems. T h e individual responds to his requirements as a total personality and not as a series of fragments. Second, accident proneness is a bogie frequently raised by employers to justify their reluctance to employ physically handi-

Problems of the Disabled

Si

capped workers. It is not based on fact. T h e r e have been many studies showing some measures of correlation between accidents and working conditions. T h e factors held responsible for the causation of accidents have been the technical ones of lighting, temperature, ventilation, means of protection, machinery, tools, climate, seasons, days of the week, hours of the day, scientific management, labor turnover, and so on. But aside from these technical and mechanical factors, accidents are also the result of human factors. Chambers found that 70 percent of all accidents occurred among 25 percent of the working personnel. This led him to the belief that there are "accident prone" individuals. English studies seem to confirm these findings. But is physical defect a cause of accident proneness? Here prejudice replaces scientific fact. What are these facts? T h e individual who is accident prone is one with a personality defect, not a physical defect. He is careless not only about his work habits but also about his life habits. Investigation of these accident repeaters reveals their maladjustments to the major demands of living, and the work phase of that adjustment shares in the general failure of the individual. T h e actual record on the other hand would indicate that the majority of employed physically handicapped persons are individuals with well-adjusted personalities. One study of 4,404 persons showed a lower accident rate than that of the control group. Only eight men of the first group were reported to have incurred second injuries. In Connecticut more than 8,000 workers with physical defects are at work. Other studies confirm these findings. Of 3,376 cases in the writer's experience only 12 have had second injuries. In twenty years of operation in Wisconsin, only 56 individuals were awarded benefits from a second injury fund. Though the causation of accidents may be traced to technical and human factors, physical defect is not a major contributing cause. Third, increased compensation costs from second injuries appears to be a more plausible argument for rejecting the physically handicapped from employment even though they are not more "accident-prone." However, employers have been protected from excessive liability by the establishment of secondinjury funds in the respective states. Through these funds, the employer's liability is limited to the statutory amount prescribed

22

Problems of the Disabled

for the specific injury sustained while in his employ. Any additional disability derived from the combination of first and second injuries is paid out of the second-injury fund. These funds are maintained in many ways. A favorite method is to use the unpaid death benefits of victims of fatal accidents who have left no heirs. In other states the fund is established by an assessment of one percent against the total premiums collected by the insurance companies operating in those states. T h e experience to date would indicate that this device is meeting the needs of employer and disabled employee without abuse, and without any undue financial burden on the employer. While we belabor society at large, and employers in particular, for their recalcitrance in cooperating toward a more human and efficient use of man-power, one of the chief offenders in this regard is the government. About 3,000,000 workers are employed by federal, state, and municipal agencies. These positions are limited to those "free from disabling effects." For years, the routine physical examination that accompanies the employee's application has been considered a farce, since in the average case the examination is usually superficial, performed as a matter of accommodation by most family physicians; and in many cases, serious, though hidden, physical defects are overlooked. Yet the Civil Service Commissions have maintained this fiction of physical perfection as a necessary requirement for employment. T h e attitude of the government as employer, reflects the same prejudices and false concepts of capacity to work as are found among private employers. Emphasis is placed on the defect, and the value of the remaining functional assets is ignored. T h e same shortsighted attitude manifested by industry in general, and by government, is repeated in the attitude of some labor unions toward the physically handicapped. It is true that a union member who is injured on the job will receive every assistance in pressing his claim to compensation and other benefits under workmen's compensation laws. He may also receive the support of the union in regaining his former position. On the other hand if he is incapacitated by a nonindustrial disability he will meet from the union the same resistance and disfavor that is expressed by management. For the time being, lip service is rendered the returning vet-

P r o b l e m s of the Disabled

23

eran because his is a popular cause, but it is questionable whether the same attitude will be long maintained. Previous experience would indicate the contrary. T h e rigid character of the contract between labor and management allows no room for the expression of a broad policy of consideration for the employment of the physically handicapped worker. Many labor unions now extend assistance to members who become ill or physically handicapped. T h e International Ladies Garment Workers Union, for example, maintains a wellequipped health center where free medical and surgical care is provided to members. T h e United Mine Workers has a Welfare and Retirement Fund which provides complete physical and vocational rehabilitation to injured members. T h e Fund makes the services of rehabilitation centers available to the union members without charge and in this way assures them of maximum restoration for return to employment. T h e traditional attitude toward the crippled and disabled in the United States has been one of charity. These unfortunates have been regarded with sympathy and have too long considered their plight as one of inevitable helplessness and dependency. T h e social prejudice of the man in the street is echoed in legislative halls. Philanthropic, public relief, and other similar legislative measures are designed as palliatives only, to relieve the effects of maladjustment. T h e physically handicapped are considered as a dependent minority group, not as a potential productive force; government pensions are an admission of a lack of faith that they can be utilized in the national economy. Thinking people must recognize the need for giving them a more definite economic and social position than they have had. Each physically handicapped person is an individual problem of vocational maladjustment. Yet he has never been regarded as an individual but rather as a class, a permanently dependent class. Workmen's compensation legislation, together with pressure from veterans' groups and social welfare organizations, has helped to alter this concept from a permanent to a temporary dependence. T h e ultimate aim is to change the idea of dependence altogether to one of vocational adjustment. T o that end remedies are being sought by means of new social attitudes and of legislation. T h e problems of all the disabled are similar: dis-

24

Problems of the Disabled

criminated against in the general labor market, their employment opportunities are necessarily restricted; and all of them require some degree of medical care, vocational training, placement, and in some cases pensions. T h e physically handicapped can be classified according to the origin of their disability through congenital causes, accident or disease. They can also be grouped according to age groups, as child or adult. A popular method of grouping is that based on clinical lines. Thus it would include those with neuropsychiatric disabilities, the blind, the deaf, the hard of hearing, those with speech defects, and medical invalids, particularly the sufferers from heart and lung affections. T h e largest group in these classifications are those with orthopedic defects. In the past, efforts have been centered chiefly on this group, whose disabilities were so obvious as to demand attention. Those suffering from hidden defects and other types of disability were in general overlooked and neglected; in legislative terminology they were frequently referred to as "the otherwise disabled." T h e voice of this otherwise disabled group has been heard demanding consideration of its claims for benefits and services. T h e whole area of disease and disability has been thrown open to rehabilitation services. From the standpoint of functional adjustment, the disabled may be divided into several groups. There is first of all the fully productive group. They are the ones who, if adequately treated and trained (and frequently without these aids) will be fit for employment under normal industrial conditions. T h e principal needs for this group are maintenance while undergoing the treatment and training necessary for rehabilitation, and, later, an opportunity for employment. There is a second group of disabled persons, the partially productive, who will never be fit for employment under normal conditions, but who would be fit for work under conditions in which allowance for their disability is made. Their needs are therefore somewhat more difficult to meet than those of the first group. A third group are either bedridden, confined to their homes, or so disabled as to require attendance or assistance in transportation or work. These require the greatest aid. They may need constant care and treatment, and the hope of their ever being re-

Problems of the Disabled

25

habilitated as self-sufficient members of society is very slight. However, even the home-bound can be given an interest in life and the possibility of at least a share in their own support, following instruction in practical handicrafts and some assistance in the disposal of their goods. T h e vocabulary of rehabilitation includes still other groupings. Social attitudes and legislation have crystallized around certain groups of physically handicapped persons, of which the following have been given the greatest public attention: the childcripple, the injured worker, the disabled veteran, and the chronically disabled. T h i s grouping is essentially one of social and political significance. T h e special problems and the methods of meeting these problems require further discussion. Industrialists tend to classify all handicapped persons into two large groups, the employable and the unemployable. T h e r e are no criteria for such a classification other than the judgment of the hiring agent. His decision is generally compounded of prejudice, a quick mobilization of experience and, occasionally, some objective tests of ability. J o b analysis and analysis of physical capacity have been gradually introduced into the technique of employee selection. Stimulated by the tacit support and approval of the United States Employment Service, they are receiving ready acceptance in modern employment practice. T h e advantages and limitations will be discussed in a later section. Finally, there is frequently a reluctance on the part of social workers and rehabilitation officials to admit defeat in their attempts at rehabilitating physically handicapped persons with severe physical and personality defects. Yet there must be some appreciation of the limitations of physical adjustment and industrial opportunities. A common-sense viewpoint recognizes that these cases must be considered socially inoperable and that attempts to rehabilitate them constitute a futile and wasteful gesture.

Chapter III T H E CRIPPLED CHILD

C

RIPPLED children are considered as a class not only because of their age grouping but also because of the special position they hold in American folkways. T h e y have always had a sentimental appeal, and, conversely, for centuries they have been the symbol and product of human prejudice. Half-hearted movements of charity and limited governmental aid in their behalf have in the past been overshadowed by the shame and degradation they have suffered and by the neglect of their fundamental needs. Only in the last fifty years has any real progress been made in an organized way to provide them with care, education, and rehabilitation. Today they are considered an obligation, a commitment, a part of our moral responsibility to husband and maintain, in order to develop the human resources of the nation. In the destructive attitudes of primitive tribes toward the congenitally deformed we see established the pattern that has been followed even by enlightened peoples. W e can understand how fear impelled the tribal community to destroy the crippled child, whose suffering was attributed to the work of the devil and to unseen evil forces. In the Middle Ages the role of court jester was assigned to the physically handicapped; it hardly improved their lot, yet it indicates at least a less brutal and morbid attitude toward them. T h i s background of beliefs is still reflected in the present-day status of the crippled child. People shy at the stark reality of the name. Words like pediatric and orthopedic are used to soften the harsh connotation of the term. O n the other hand the term "crippled children," was retained by one institution because of its value in obtaining bequests and donations. But we need no special terminology to tell us what a sick and crippled child is. W e do need an enlightened attitude toward the measures to assure redemption for these children through early and adequate treatment, training, and education. Conservative estimates of the n u m b e r of crippled children in

The Crippled Child

27

the United States, as revealed by surveys and census reports, vary from 500,000 to 1,000,000. This is exclusive of the number of mentally handicapped and those suffering from defects of the special senses, from organic disorders like tuberculosis, or cardiac disease. However, the trend of practice today is to include the latter with the orthopedically crippled child. From a vocational and economic point of view, crippled children may be classified in three groups; (1) those who may become fully productive and able to compete with the physically normal; (2) those who because of personality disorders or physical disability become only partially productive and; (3) those who remain or become totally unproductive. These categories are not necessarily fixed or permanent. T h e individual may possibly lift himself from a lower to a higher level because of social conditions, technological changes, fads or fashions; or he may regress to a lower level because of personality maladjustments. T h e needs of crippled children are both general and specific. T h e i r general needs are those of all disabled persons—to be recognized and given opportunities for physical and mental development. Specifically, they represent an individual problem because of their age, sentimental appeal, and their possibilities for adjustment. Moreover, crippled children are potential adultdisability problems. Until the last quarter of the nineteenth century, virtually all of the activities on behalf of crippled children were devoted to the field of asylum and custodial care. Private interest preceded and frequently stimulated public action. Many of these organizations carried on extensive and well-organized programs. T h e Elks, for example, through its special committees, spent in the state of New Jersey more than two million dollars from 1929 to 1944, on braces, transportation, medical and hospital care, the operation of clinics, outings, Christmas parties, massage, nurses, and welfare workers, shoes, artificial limbs, wheel chairs, food and clothing, as well as the maintenance of a special convalescent home for the care of crippled children. T h e Shriners have for years operated a chain of well-manned and well-equipped special orthopedic hospitals. Other clubs and community agencies have performed similarly useful services. T h e evaluation of all this private effort is difficult. Certainly it

28

T h e Crippled

Child

has made available to thousands of children systematic medical care, transportation, and prosthesis. More important, it has fostered moral and political support for more efficient governmental aid. But certain defects are evident. For example, there is considerable overlapping and duplication of services by various agencies. Frequently professional supervision is lacking. Follow-up treatment and control is also not altogether adequate. Specialized agencies have now supplemented the aims of private organizations through legislative programs designed to provide more complete services which would equip the crippled child with the capacities to make him self-sufficient as he reaches adulthood. T h e gradual assumption of responsibility for the care of crippled children by the government is not because of inadequacies on the part of private agencies. It represents rather an aspect of the increasing public interest in the general welfare of all its citizens. Social security has become part of our national way of life and programs for the crippled child are one aspect of the broader program of general welfare. But the government can be a valuable agent in promoting effective rehabilitation. In the first place, it has large resources derived from general taxation which can be used for this purpose. By grants-in-aid to the states it has stimulated the expansion of existing services and provided more efficient services where the work has suffered from a lack of funds. Furthermore, governmental assistance can also be valuable by supporting and stimulating regulations and legislation for reporting the physically handicapped who are congenitally defective. But government cannot work alone. T h e r e will always be a place for private agencies. As critical guardians they help to maintain high professional standards and to prevent the decline of public interest. One of the specific and fundamental needs of the crippled child is to be discovered. Unless he is found and his problem is brought to public attention, he cannot be helped. For years, private and public health agencies have carried out repeated surveys to unearth the crippled child, whose parents, influenced by superstitious fears, have chosen to secrete him, lest their position in the community suffer. Many parents, uninformed of the possibilities of rehabilitation, have resigned themselves to ac-

The Crippled Child

29

ceptance of the deformity as expiation for some unknown crime, and have postponed treatment until too late. Early recognition, on the other hand, has frequently provided an opportunity for correction of the defect. Many adult cripples are the result of childhood neglect. Compulsory registration of children born with congenital defects is a valuable step in discovery, diagnosis, and early treatment. Treatment must not only be rendered early, but it must also be adequate. This means that the professional services must be specialized. Specialization is required not only of the physician, but of the nurses, physiotherapists, hospitals, and manufacturers of prosthesis as well. Orthopedic surgeons play an important role in the physical restoration of crippled children. This speciality has evolved from the brace-and-plaster stage of the last century to a modern art, whose fundamental purpose is the prevention and early treatment of deformity. T o this has been added a vast array of technical advances in surgical treatment. These advances have necessitated professional skills that can only come from intensive training and experience. T o make public acknowledgment of this expert ability, there has gradually developed a system of certification by medical and surgical bodies to assure the public of the qualifications of the specialist in a particular field. By such certification the crippled child is assured better-than-average treatment. Public agencies are adopting this device in the selection of professional service for the crippled children under their care, and it has become standard procedure to refer cases to a certified orthopedic specialist wherever one is available. But expert skill is not enough. T h e r e must be adequate facilities for the proper management of orthopedic disabilities. No better appreciation of this factor can be gained than by a comparison of the facilities and attitudes in a general hospital with those in an orthopedic institution. For example, in the former, the plaster room, so important a factor in the treatment of orthopedic conditions, is given only casual consideration, whereas in an orthopedic hospital it is generally the key room in the organization. In general hospitals, nursing personnel are insufficiently trained to handle patients in plaster casts, with the result that the nursing service is less satisfactory than in institu-

30

T h e Crippled

Child

tions where special training and experience are available. Moreover, in the general hospital, orthopedic equipment, such as fracture beds and extension apparatus, is too often incomplete, in need of repair, or otherwise inadequate, These are not mere academic matters, because much of this work with its highly specialized character is being done in general hospitals. Yet orthopedic cases are not always welcomed where bed capacity is limited, because of the chronic character of the cases and the slow turnover. T h e brace problem is a matter which also requires review and reconsideration. It is an important aspect of the physical restoration services provided for crippled children. Peculiarly enough, the professional character of this service is in many cases overshadowed by commercial interests. For this reason it would seem desirable to institute better supervision of the procurement and fitting of appliances. T h e creation of the American Board for Certification of the Prosthetic and Orthopedic Appliance Industry to evaluate and certify limb and brace manufacturers has raised the standards of the entire industry by assuring that certain minimum professional requirements are met. Early discovery and medical care of the crippled child is the beginning of the program of rehabilitation which has as its aim the ultimate restoration of physical capacities. Preparation for economic reponsibilities implies the training that comes from specialized vocational or professional instruction. Plducation for the crippled child is twofold: education for life, and education for earning a livelihood. His personality development will depend in large measure on how he is treated in childhood. He cannot escape the realities of daily life in the way of prejudice and recurrent personal problems. Much of his ability to meet them will depend on whether he is enclosed in a sheltered environment or exposed to a normal school life with other children. In any case, the necessary training can be given at school or at home. At one time lack of transportation facilities kept these children from school, but this has been largely solved through public and private means. Special schools have been established and expanded so that in the more progressive states no child need suffer from lack of educational opportunities. These are generally supplemented by tutorial instruction at home,

T h e Crippled Child

31

whenever the nature of the disability is such as to preclude school instruction. As the child grows up he needs special guidance and counseling. A program must be planned around his interests and drives and must be channeled in directions that will lead toward their satisfaction. These plans must not be dominated by the emphasis given to the defect. T o be sure, it cannot be ignored, but it must not be overemphasized in deciding on a job or training objective. A full analysis of the child's capacities as well as his incapacities should be made and evaluated in relation to the physical and mental demands of the job objective. In the adolescent years the growth of the personality requires n u r t u r e and sympathetic handling. These are tender years for the crippled child, when lives can be reborn through stimulation or crushed by frustration and indifference. T h e classical causes of crippling deformities have been rickets, tuberculosis of bones and joints, and infantile paralysis. T h e use of cod liver oil and other substances containing Vitamin D and the increased custom of exposing infants to sunshine has now made rickets a rarity. Childhood bone tuberculosis also has declined with improved public health measures of cattle inspection and pasteurization of milk. Puerto Rico still has a large n u m b e r due to lack of these public health measures. Modern medicine has thus tremendously reduced the n u m b e r of completely crippled children, but global power politics has replaced them with crippled adults. Among the crippling diseases, poliomyelitis or infantile paralysis retains the crown. In epidemic years the totals reach huge proportions. It leaves in its wake a blighted youth. Nor do adults entirely escape its lethal action. Down through the years, the victims of infantile paralysis have taken their places in the clinics and hospitals and physicians' offices along with the other physically handicapped children. T h e lot of these polio victims has been dramatized by the late President Franklin D. Roosevelt, whose life and work embodied the hopes and aspirations of all the crippled and disabled. Stricken with extensive paralysis, he was nevertheless able to assume the most important role and responsibility in the most powerful nation. H e epitomized for all the

32

T h e Crippled

Child

handicapped the tremendous capacities that reside in the human mind and body to overcome the defects of disease or injury. He also left them a legacy in an organization that is entirely devoted to their special interests, the National Foundation for Infantile Paralysis. Through its March of Dimes, the Foundation supports a broad program of research in prevention and in improved methods of care, and through its educational program has trained hundreds of professional persons in these fields. By supporting rehabilitation centers and, when necessary, meeting the cost of care, the Foundation fosters the physical and vocational restoration of poliomyelitis victims. It has pledged that no patient, because of lack of funds, shall be denied the best medical care available. It pays costs of treatment according to the individual's needs. A word should be said about the treatment of poliomyelitis. Much of the information made available to the public is confusing and misleading. It is almost impossible for the man in the street to evaluate the claims of rival schools of treatment. Moreover he wants to know how well his contributions are being utilized for the help of polio victims. For this reason a brief survey of the nature and purpose of treatment is desirable. T h e early treatment of the patient has to do with overcoming the initial toxemia and saving life. These are the cases with the so-called bulbar involvement, affecting the part of the brain that controls the centers of respiration. Extensive involvement causes death. Some of the borderline cases can be helped by artificial means through use of apparatus like the respirator. This device takes the place of the paralyzed chest muscles whose failure prevents oxygenation of the blood and tissues and hence is serious enough to endanger life. Apparatus of this character is rarely found in general hospitals and sometimes not even in orthopedic hospitals. Occasionally it may not even be available in the county isolation hospitals to which these cases are generally referred in the acute stage. But these bulbar cases are the exception. Usually the paralysis involves one or more of the extremities, and early treatment is essentially symptomatic, that is, to overcome the pain associated with the sensitivity of the tissues and to prevent deformities. Deformities occur as a result of the unopposed action

T h e Crippled Child

33

of the sound muscle against the paralyzed muscle. Concerning treatment at this stage, considerable controversy exists. T h e orthodox treatment comprised rest in bed, rest of the limb, and protection of the limbs against deformity by suitable splints. Sister Elizabeth Kenny of Australia introduced hot moist applications, early motion, and the avoidance of splints and braces. These ideas have become incorporated into a system followed by those who are opposed to the orthodox treatment of rest and splints. One of the difficulties in evaluating either system is the inability to foretell the outcome in a given case on the basis of early findings. T h e nature of the damage caused by the virus is localized in the anterior horn cells of the spinal cord which have direct control over the power of the muscles supplied by them. Any interference with the life processes of these cells calls forth immediately an interruption of their function, with consequent loss of power or paralysis of the muscles supplied by them. But here is the important fact: the interruption of life processes results not only from actual destruction of the cells in the spinal cord but also from the pressure of the edema or watery discharge generally associated with and accompanying the toxic injury of the virus. In cases which show complete paralysis followed by complete recovery, the cells supplying nerve function were not destroyed by the virus but were merely in a state of shock or suspended animation. However, once the cell is destroyed there is no chance for any recovery at all, regardless of treatment. It can be seen then how careful we must be not to ascribe improvement to treatment alone; a natural disposition to restoration is a phenomenon of all human tissue. T h e r e are, nevertheless, secondary effects following the initial injury to the spinal cord which require intelligent management if the patient is to achieve the maximum amount of improvement and the prevention of deformities. W i t h respect to the relative value of the orthodox and the Kenny treatments perhaps the truth is somewhere between the two. Sister Kenny has probably claimed success for her method in some cases where recovery could be expected through the natural resolution of the disease. On the other hand, the use of warm moist packs and early motion has expedited convalescence in other instances. It must be

34

The Crippled Child

remembered that rest is nature's way of securing repair; the use of splints to prevent deformity still has a distinct value when properly applied. T h e r e comes a time two to three years after the onset of the disease when the natural restoration of function has reached its maximum. An evaluation at this time will reveal the possibility of obtaining additional function by the transplantation of muscles. For example, one of the common residuals of poliomyelitis is a condition of the lower leg in which the muscles which turn the foot outward remain active b u t the muscle which pulls the foot up is paralyzed, thus causing the foot to drop. Transplanting the peroneal muscles (those which pull the foot outward) to the tibialis anticus (which pulls it up) restores normal foot balance. Since there are three muscles which pull the foot outward, sacrifice of one of them causes n o harm. As adolescence is reached, f u r t h e r surgical assistance can be obtained through the use of operations to fix and stabilize weak and flail joints by a fusion or welding process. In a flail foot, for example, the bones of the foot and ankle can be so fused as to provide a firm support of the leg despite complete paralysis of all the muscles controlling that foot and ankle. In the same way a knee can be stiffened and strengthened to support the weight of the body even though the muscles controlling the knee are paralyzed. T h e choice of procedure and time, as well as the follow-up and supervision, is a matter for expert care. T o o frequently the operation is considered an end in itself, whereas it is only a step in the entire reconstruction procedure. It simply creates conditions favorable to the development of a functioning member by reestablishing proper leverage and mechanics. T h e education and vocational training follows the pattern for all crippled children. Special schools are available in most urban communities for the more severely disabled cases. Under special instructors classroom education goes hand in hand with physical training and some prevocational training. Interruptions are frequent, as time is taken out for surgery or the application of casts or braces. Nevertheless the average age of primary school graduates in one of these special schools was 14. Retardation is not

T h e Crippled Child

35

necessarily a reflection of mental capacity, it must be frequently ascribed to the complications associated with treatment. An example of rehabilitation through assiduous treatment and education can be seen in the case of a lad, age 18, who came to the attention of the New Jersey Rehabilitation Commission in 1933. He was severely handicapped by extensive paralysis of the niuscles of both shoulders and upper arms. One of the shoulders was fused or stiffened by operation, thus providing increased leverage for the weak muscles of the arm, which then took on added volume and power. No longer inhibited by the mechanical load, he was able to carry on his schoolwork without difficulty. Still under the tutelage of the commission, he completed an academic program and ultimately gained the degree of Doctor of Philosophy. Infantile paralysis is an example of a pure type of crippling disease, one in which the physical defect produces an impaired capacity for normal living and working. Other types of crippling deformities are more complicated. Cerebral palsy is one of these diseases. More commonly, though incorrectly, known as spastic paralysis, this disease afflicts over 350,000 children and young adults. Many of these unfortunates are shunned, locked away, and regarded as feeble-minded. Although it is possible by special medical care and physical training to restore many of them to useful lives, unfortunately facilities for diagnosis and training arc pitifully inadequate to meet the pressing need. Several new centers for the treatment of cerebral palsy have been opened in recent years, but severe shortages of trained personnel make it impossible to treat more than a fraction of the victims of this disease. A cerebral palsied child or adult is one whose central nervous system has been injured before, during, or after birth, or one who has suffered some variation in the developmental structure of the brain. These injuries may affect the motor functions only, but in some instances they also impair the mental functions, in complications ranging from simple retardation to imbecility. Generally, cases of cerebral palsy are classified primarily on the basis of motor reactions. In spastic paralysis, there is excessive muscle tension, so that the extremity

36

T h e Crippled

Child

moves stiffly like a mannequin's. T h e leg drags instead of moving smoothly, while the action of the hand is slow, delayed, and incoordinate. Another type is that of ataxia, in which the balance and coordination is impaired. Still another type, known as athetosis, is marked by an extreme degree of purposeless movement, as in St. Vitus dance. Peculiarly enough it is also marked by intelligence of high order. One man with this type of disability completed a brilliant college career and eventually became an outstanding editor and the author of several books. Others have made good, if less spectacular, adjustments. However, because of the muscular twitching and grimacing and the bizarre movement of the extremities the victim is generally regarded as feeble minded and mentally abnormal. They have therefore been deprived of the education which their intellectual abilities justified. One can understand then that the approach to this problem must follow a different line of attack from that in infantile paralysis. In the latter case the line of attack is direct and simple. In the case of cerebral palsy there are many ramifications and preliminaries which must be considered before an integrated plan of action can even be initiated. Treatment cannot go back to the causes. These are frequently beyond the control of the physician. Heredity yields no clue to the development of the disease; many of these cases are the children of apparently healthy parents with no background of hereditary taint. It has been found, however, that a certain number of cerebral palsies are caused by the R h factor. Treatment revolves around one specialized area, that is, physical therapy. While surgery offers some help in special cases, carefully administered exercise and training, punctuated by periods of rest and relaxation, help to bring about a lessening of tension and an improved control of the limbs. A number of patients recover sufficient control to carry on the routine pursuits of life. There remains the more difficult problem of those who do not possess the control necessary for learning to walk, to stand, and feed themselves. T h e problem of the retraining of these children is insistent. Yet the number of institutions available for the purpose is still inadequate. Along with the muscle training must be considered the social

The Crippled Child

37

training necessary to overcome the mental defect. T h u s it can be seen that the program requires considerable time, as well as especially trained personnel and special facilities. Whereas huge organizations like the National Foundation for Infantile Paralysis evolved, little public interest has been directed to the needs of the cerebral palsied until recently. Shortly after the first conference on cerebral palsy, held in 1949, United Cerebral Palsy Associations was organized to carry out a broad program of treatment, education, and research. T h e g r o u p now has about sixteen state affiliates, and more are in the process of organization. T h e stimulus for the formation of this excellent group came chiefly from the parents of afflicted children. Since education for living and for working are intimately associated with specific muscle training for the improvement of functional control, development of this type of service can only be adequately carried out in special schools, specially equipped and specially manned. Communities are reluctant to establish these institutions, and the lot of the cerebral palsied is therefore made more difficult by the lack of an integrated service for rehabilitation. Many states recognize the need but pay only a lip service to it. State publications r e f e r to services rendered, namely, identification, registration, hospitalization, and convalescent care, but the two last-named activities are rarely adequate. T h e following example of the grades of improvement occurring in children under treatment will indicate the slow progress usually made. A t first the patient is unable to support himself on his legs. From steps firmly supported by both hands, he proceeds to steps supported by one hand, balances, takes a step alone, walks, takes three to eight steps supported by two persons, walks, takes 8 to 20 steps toward an object, walks alone very unsteadily across the room, starts, stops, turns; walks independently in the house; walks with supervision in the street; walks independently on the street (limited); climbs stairs, meets traffic hazards. In a group of nineteen cases only five could reach the next to the last stage; one required ten years of training and development to reach that goal from a beginning with steps firmly supported by both hands. Perhaps the problems involved can best be appreciated by

g8

T h e Crippled Child

the story of one who achieved a remarkable degree of rehabilitation largely through his own indomitable will. He could not walk or talk until he was four years of age. He spent those years sitting in a buggy in his front yard protected by a big bulldog. He was regarded as mentally deficient, and surgeons were reluctant to treat him. However, after the surgical lengthening of his heel cords and the application of plaster casts for six months he was able to crawl. At six years he began to walk and play with his younger brother. He did not learn to dress himself until he was seven, and it took years to solve the problem of tying shoelaces. At seven he started school, despite the involvement of his right arm and leg and his severe speech difficulty. It was not until he was in the eleventh grade that he could read out loud, while his handwriting did not become easily legible until he was 21. Boy Scout and church activities gave him increased confidence and he graduated from high school at 19. He worked in a gasoline station and at odd jobs, but at the height of the war when man power was in great demand he was unable to secure anything better than a job in a flower nursery at $75 a month and later a janitor's job at $ 1 0 0 a month. Through a chance acquaintance he was given an opportunity for speech therapy and for advanced treatment by drugs. As a result, his tongue was loosened and he could speak without facial grimaces. Physical therapy improved his gait and posture. His weight increased and his whole general appearance changed, permitting him to find new friends and to achieve social acceptance. He entered a C P A course, courageous and confident of finding a definite place for himself in society. We have mentioned rickets, tuberculosis, and infantile paralysis as the classical examples of crippling defects. But these do not exhaust the number and character of the causes of crippling. A simple way to understand them is to classify the causes in four groups; congenital deformity, disease, injury, and acquired deformity. There is some overlapping but this classification helps to identify the cases in a simple fashion. Congenital deformities are of many kinds. Harelip and cleft palate, webbed fingers, club foot, congenital dislocation of the hip, missing bones, and amputations are some examples. T h e defect is in many instances the result of heredity. In many other

The Crippled Child

39

instances obscure influences that interrupt the normal course of early fetal development may result in deformity and even monstrosity. It is important to recognize this fact, since the hopes of optimistic eugenists concerning the control of the incidence of deformity by controlled mating is not to be given too much weight. Many congenital conditions, such as club feet and dislocation of the hip, can be cured or markedly improved if treatment is introduced sufficiently early. It is imperative, therefore, that some public health device be invoked whereby early reporting can be effected. Such a device is now in operation. State Boards of Health are empowered to enforce the reporting of congenital defects by physicians, and this report is made part of the birth certificate which the physician must sign. T h e State Department of Health refers the report to the State Crippled Children's Commission, who then proceed to provide service to the child. While tuberculosis and infantile paralysis are classic examples of diseases that produce deformity, other diseases are equally ravaging in their effects. Osteomyelitis, for example, has always been a tragedy not only for the patient but also for the family. T h e inflammation sets in suddenly, probably from a skin boil or superficial infection, travels through the blood stream and lodges in the bone, where a localized abscess forms. In the initial stages the child is very sick and the virulence of the infection may be so great as to overwhelm the protective forces of the body and cause death. In other cases the protective defenses of the body, aided and abetted by blood transfusions and chemotherapy, are sufficient to control the virulence. However, many of these unfortunate children are left with chronic inflammatory changes in the bone and with alternating periods of health and disability. T h e infected bone breaks down and is surgically removed, and all is well for a few months or even a few years, then the dormant infection again comes to the surface and again surgical attention is required. Many of these individuals have had multiple operations, with a generally enervating aftermath. Extensive surgical removal of bone also leaves weakened extremities and impaired function. T h e introduction of the sulfanilamides and penicillin have modified the tragic outlook of most of these cases and assures them at least a brighter future.

40

The Crippled Child

Accidental injuries in children are common and have varying effects. Fractures generally heal benignly, because of the compensatory factors in growth. Other conditions such as burns leave extensive scarring, which, if left untreated, produces deformity and keloid formation. T h e term "acquired deformity" includes many conditions of different origins. Flat feet, for example, may be due to congenital causes; it can also be caused by overweight, poor posture, and so on, and along with other postural defects it is a common, concealed cause of fatigue and disability. Corrective shoes and appliances play only a small part in the amelioration of these conditions. T h e most important elements in treatment are exercise and proper habit formation. Class treatment is therefore better than individual treatment. T h e r e is one type of acquired deformity which may arise from several causes but which requires special consideration because of its serious possibilities; that is, scoliosis, or curvature of the spine. In mild cases no serious disability occurs. Severe cases may result from infantile paralysis of the trunk muscles and also from a condition which for want of a better name is called idiopathic. Here a twofold disability occurs. In the first place the deformity is quite noticeable and produces a severe cosmetic defect. In the second place the distortion of the trunk and spine produces impairment of the normal breathing apparatus, with an impaired vital capacity that affects the general health and makes the individual susceptible to intercurrent disease. It is unusual to see many adults with severe scoliosis; its victims have a definite reduction in longevity because of the impaired vital capacity. Recently another group has been added to the general concept of the crippled child, namely the cardiac case. Some idea of the extent of this disease can be seen in the estimate made by a national survey that 500,000 schoolchildren in this country suffer from rheumatic fever. In 1943-1944 the Army reported 18,000 cases and the Navy 15,000. Rheumatic fever is an acute infection of unknown cause. It is often of epidemic character, usually appearing in late winter and early spring. It begins with a sore throat or bronchitis, high temperature, and swelling of the joints. Frequently the arthritic and heart symptoms do not ap-

T h e Crippled Child

41

pear until the sore throat has lasted fourteen days. T h e heart is affected in almost every case. T h e most dangerous characteristic of the disease is its tendency to become chronic, with frequent and increasingly serious relapses. T h e accepted method of treatment is prolonged rest in bed, often for more than a year, and careful nursing protection from renewed infection. All this requires expenditures and it also demands a good deal of emotional adjustment on the part of the patient and the family. Neither facility for the necessary medical care nor understanding of the disease is adequate at present. Because of the long period of bed rest many children cannot be effectively treated in homes of substandard economic levels. They require care in hospitals and homes where custodial care is supplemented by adequate medical supervision. In this respect, facilities are not available either in the way of bed capacity or medical supervision. T h e Children's Bureau recognizes the urgency and has accepted the responsibility of including these cases in their program. T h e problems of all these orthopedically handicapped are similar—the procedures for treatment and for education and the detailed techniques of carrying them out. While the details differ, the general principles are the same. Despite the tremendous advances in treatment and in organized care on all levels there is still a large gap between the available facilities and the use made of them. T o o large a number of crippled children are denied them because of superstition, apathy, religious beliefs, and lack of economic resources. On the other hand, there are many who are victims of overtreatment, because of the excessive zeal of the parent as he seeks miracles and panaceas; when he cannot obtain satisfaction from the regular profession he will seek out the quack and charlatan until his money is exhausted. Moreover, while admittedly we do not live in Utopia, it would be a mistake to overlook the shortcomings in our national efforts for crippled children that arise from professional jealousies and rigid bureaucratic regulations in both private and public agencies. These factors only defeat the aims of good management. We see then a national trend toward the increasing public as-

42

T h e Crippled Child

sumption of responsibility for the care of crippled children. T h e pattern is gradually establishing itself. State agencies, assisted by federal support in the way of funds and policy-making, have set up standards of treatment, education, and training that have formed the basis for rehabilitation. Private agencies have not abdicated, but are continuing both independently and in cooperation with public agencies on local and national levels to make their financial and humanitarian contribution. T h e National Society for Crippled Children and Adults, for example, has carried out an extensive program of research, education, and treatment for crippled children. State societies for crippled children, as members of the national society, administer this program on a state level that includes direct patient care. T h e National Society for Crippled Children and Adults is itself a member of the International Society for the Welfare of Cripples, a world-wide organization that encourages and coordinates work for the crippled and disabled in the various member countries. These and similar private organizations have complemented and, in many cases, preceded, the work for crippled children carried on by the government. T h e program requires only further expansion and continued support.

Chapter IV T H E INJURED WORKER

T

HE injured worker is a product of our machine age, of the industrial revolution with its great innovations in machinery and technology, its mass production and broken bodies. T h e large n u m b e r of industrial accidents is a shocking price to pay for industrial civilization. Each year the fatalities reach a total larger than that of our war dead, while the number of those suffering permanent disabilities runs into huge figures. T h e s e figures, however, require some interpretation. T h e term permanent disability has primarily an actuarial or legal connotation. It designates certain categories of injuries which entitle the injured to financial benefits or compensation. T h e presumption is that, when certain economic and functional impairments follow the wake of a fracture, nerve injury, or head injury, these effects can be determined only when the injury has become stabilized after the completion of medical treatment, or after the natural period for repair and adjustment. For example, the worker who sustains a fracture of the femur (thigh bone) with such complications that lie is left with a shortened leg is suffering from a permanent and irremediable condition. T h e individual who sustains an injury to the spinal cord with resultant paralysis and bowel and bladder deficiencies is suffering from permanent and irreparable disability. Permanent, then, refers to the quality of the disability, as contrasted with temporary disabilities which, as a result of time, treatment, and natural repair return to a relatively normal status and function. But the term permanent requires still further clarification. Since it is simply a legal designation, it does not therefore necessarily imply complete and irreparable inability to work or earn a living. Many fairly serious injuries may actually cause little or no loss of ability to perform a particular j o b satisfactorily. T h e loss of a little finger is a permanent injury, but one of no industrial significance to a longshoreman. Nor would partial stiffness of an elbow in-

44

T h e Injured Worker

terfere with the normal duties of a train announcer. These are partial disabilities, impairments which only in special instances interfere with the comfort or routine pursuits of the individual. On the other hand, total blindness, the loss of two extremities, or total paralysis would be really complete disabilities, frequently referred to in actuarial circles as absolute disabilities. T h e presumption is that any of these would constitute not only an irreparable injury but complete incapacity for self-support. We know of course that this is a pessimistic point of view, though equitable enough from the standpoint of a pension or compensation system. We have, then, this large number of persons who are legally classified as disabled. However, among the majority of this group the disability is but partial, ranging upward from 5 percent. T h e figures are still of no value to us in estimating the number disabled by industrial accidents who require rehabilitation service. From the author's experience it is estimated that of this large group about 25 percent require assistance beyond that which they receive from workmen's compensation. On this basis there would be, then, 250,000 industrial disabled who annually require the services of a rehabilitation agency. Until the emergence of the idea that industrial accidents, with their human and financial waste, are a proper charge upon industry, the burden of industrial accidents was largely borne by the worker himself. Before workmen's compensation laws were established, however, the lot of an injured worker was a sad one. T h e situation was something like this. A worker fell from a scaffold and sustained a fracture of the spine. Frequently the spinal cord was injured, with resultant paralysis of both legs and involvement of the functions of the bowel and bladder. He was removed as an emergency case to the local municipal or county hospital, and there, for a long period, treatment was carried out by physicians and surgeons. Neither the hospital nor the physician was paid, since in the majority of cases the employer denied responsibility on legal grounds and invoked the timehonored alibis that were considered standard defenses under existing common-law practice. These defenses were essentially three: assumption of risk, the fellow-servant rule, and contributory negligence.

The Injured Worker

45

U n d e r the r u l e of assumption of risk, the e m p l o y e r m i g h t deny l i a b i l i t y on the g r o u n d s that the e m p l o y e e was aware of the hazards i n h e r e n t in the j o b yet was w i l l i n g to take it, nonetheless. H e m i g h t also allege that he was not responsible, because the n e g l i g e n c e w h i c h precipitated the accident was caused by a fellow w o r k e r of the i n j u r e d man. P r o b a b l y the greatest d a m a g e to the w o r k e r ' s suit was caused by the c l a i m of c o n t r i b u t o r y n e g l i g e n c e . It was often difficult to prove that the e m p l o y e r had been n e g l i g e n t w i t h o u t disclosing some c o n t r i b u t o r y n e g l i g e n c e on the w o r k e r ' s o w n part, and as a result the case was f r e q u e n t l y t h r o w n o u t of court. A f t e r discharge from the hospital the w o r k e r was f r e q u e n t l y left p e r m a n e n t l y c r i p p l e d and disabled, u n a b l e to earn a living, a b u r d e n to his family, friends, and the c o m m u n i t y . U n d e r e x i s t i n g legislation the courts w e r e u n a b l e to find a r e m e d y for h i m . O n the o t h e r hand, an e m p l o y e e sustaining an i n f e c t i o n of his finger at h o m e m i g h t falsely a t t r i b u t e it to the n a t u r e of his w o r k . I n a d e q u a t e or neglected treatment can result in extensive infection

with

complications

necessitating

amputations

of

several fingers or even the h a n d . T h u s , by e m p l o y i n g a c l e v e r l a w y e r and pressing a claim for damages it was possible to o b t a i n a verdict large e n o u g h to force the e m p l o y e r i n t o b a n k r u p t c y . W o r k m e n ' s c o m p e n s a t i o n laws c h a n g e d all that. N o w

the

e m p l o y e e is e n t i t l e d to medical a n d hospital treatment as a r i g h t a n d not as a b o u n t y . T h e doctor and hospital are paid, the emp l o y e e receives money b e n e f i t s — t h e r e b y p r e v e n t i n g pauperizat i o n — a n d the e m p l o y e r is protected against r u i n o u s suits. C o m pensation legislation has thus e m e r g e d f r o m its role as a legal d e v i c e — a substitute for the i n a d e q u a t e system of c o m m o n law that g o v e r n e d the relationship of master a n d s e r v a n t — t o its m o d e r n status as social insurance. It is today an established princ i p l e and i n s t i t u t i o n t h r o u g h o u t the world. In the l o n g e v o l u t i o n that b r o u g h t it to this position there h a v e been three m a j o r steps. T h e first was c o n c e r n e d w i t h accid e n t p r e v e n t i o n . A l o n g with the dev e l o p m e n t of the safety movem e n t , which still plays a p r o m i n e n t role in p r e v e n t i n g

the

e c o n o m i c a n d h u m a n waste of accidental injuries, w o r k m e n ' s c o m p e n s a t i o n a i m e d at r e d u c i n g accidents by p e n a l i z i n g the emp l o y e r t h r o u g h p r e m i u m s paid o n the basis of the accident rate

46

T h e Injured

Worker

in his plant. With the recognition that premiums alone were not a deterrent, the law moved into its second phase, with emphasis on financial benefits received by the injured worker. T h e present phase is concerned with its most socially desirable objective—the restoration of the worker to full working capacity. Workmen's compensation laws fall short of this goal by failing to include restoration of the worker to his former social and economic position. T h e monetary benefits provided by them are soon squandered, and the injured man is left without money and in many cases without the physical means to earn a living. T h e r e is no one to observe, advise, or guide the handicapped during his convalescence or during the course of treatment, and as a result in many cases he is thrown on the economic scrapheap. Handicapped by his physical disability and the reluctance of employers to reengage him, he faces work at a lower level, chronic unemployment, or even complete dependency unless helped to regain his former status. T h e goal can be reached in several ways. Many handicapped workers if adequately treated can be prepared for reinstatement in their former jobs. T h i s was seen in a group of 2,000 men with severe disabilities which deprived them of up to 75 percent of their normal capacity for work, yet none required the special services of vocational guidance or training for a new trade or calling. Despite the nature of the disability, the safety factor operating in these instances permitted adaptation to the former job. Others, however, can never recover full working capacity. For them the opportunities in the labor market are less favorable. Nevertheless, special training will qualify them to compete with the normal worker. It is evident that an adequate program of rehabilitation would increase the number of those who could be reinstated in their original jobs without the time, expense, and effort required to change old habits and without wasting valuable years of work experience by training for new vocations. For the middle-aged and older groups this is particularly significant. Is such a program available under existing workmen's compensation laws? Does the law guarantee reasonable fulfillment of this promise of rehabilitation? What other obstacles are there outside of the law which may interfere with the successful completion of an ideal program of medical aid for the injured worker?

T h e Injured Worker

47

A cursory review of workmen's compensation legislation reveals the inadequacies of provisions basic to physical restoration. By physical restoration we mean the complete treatment of the injured worker from the time he is injured until the day he is ready to return to work. Let us follow the case of a workman who is knocked down by a truck while at work and sustains a compound fracture of both bones of the leg below the knee. A severe wound in the skin over the broken bones has exposed the leg to infection and the possibility of osteomyelitis. T h e first step in treatment will be first aid, rendered, before the doctor arrives, either by an unskilled layman, a trained firstaid man, or a nurse. Properly rendered it will consist of removing the clothing from the area, applying a clean or sterile dressing to the wound, splinting the leg with specially prepared splints or with makeshift splints such as a cane, a piece of board, or an umbrella. T h e second step will be provisional treatment by the physician. He may simply make an inspection of the wound and reapply the dressing and splint or may adjust the splint so as to provide more adequate traction. T h e third step is the definitive treatment by the physician: setting the fracture in the hospital under X-ray control, appropriate treatment of the wound, and the application of a plaster cast to immobilize the fracture until complete healing and consolidation can take place. There would then follow a period of after-care consisting of an inspection of the cast with periodic X-ray control to observe the progress of healing. It may be necessary to change the plaster casts to allow for change in the shape of the leg associated with muscle wasting. Finally, after twelve weeks the last cast is removed, the wound is healed, the bones have reached a fair degree of consolidation and may permit a moderate amount of weight-bearing with the aid of crutches. Physical therapy measures are then employed by means of heat, massage, and exercises and bandaging of the leg to protect it from the swelling that follows prolonged disuse and the dependent position. Walking and weight-bearing is supervised while frequent X-ray control is carried out until walking can be done without the aid of crutches, without fatigue or pain, and with the gradual restoration of the full motion of the knee and

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T h e Injured Worker

ankle joints and the full power of the foot, leg, and thigh muscles. These are the common steps and evolution of treatment of an industrial accident. How long does it take? T h e medical textbooks usually specify eight to ten weeks as the period required for the bones of the leg to unite. However, they fail to indicate the length of time required to restore the stiffened joints, the swollen or atrophic musculature, the weakened foot, the ability to walk and work. T h e y overlook, too, the many concomitants of injury that are not revealed in an X-ray plate. I speak not only of the economic bewilderment and problems of the patient but the many psychological and social reactions in the wake of the accident. There are the repeated examinations by company physicians, by claim adjusters, by commission doctors, and frequent visits to the industrial commission and to the insurance company. T h e patient is exposed to a new milieu in which he finds himself the victim of a maelstrom of activities, many of which directly influence his healing period. Instead of the eight to ten weeks cited the healing period is closer to eight or ten months. Now how do the provisions of the law affect this healing period as well as the ultimate results of the treatment? In the first place many laws carry a time limitation, that is, the law specifies that the employer or his agent is responsible for medical care for a specified period of time. Twenty-five states have such a limitation, varying from two weeks in Massachusetts to one hundred months in Arizona. Is this always adequate for the spinal injury, the nerve injury, the fractured hip, the osteomyelitis? For these cases nothing less than unlimited treatment can assure proper physical restoration. Yet only twenty-one states and the District of Columbia provide for unlimited treatment. Washington has no specific provision; Idaho law specifies "reasonable time." It is true that the time provision is frequently construed liberally by many states, despite the limitations imposed by the law. A n additional hindrance to complete and proper physical restoration is the legal restriction on the maximum amount of financial payment. T h i s amount generally includes not only the surgeon's fee but the total medical care, including hospitalization, nursing, and other medical expenses. A limit of $ 1 0 0 as in Maine would be inadequate for the surgical and hospital and

T h e Injured Worker

49

after care expenses of a case of fractured spine with spinal cord injury. Signs of progress are apparent, however, in the comparatively recent provisions of some states f o r maintenance during rehabilitation. N i n e states have established special funds for maintenance d u r i n g rehabilitation, or otherwise provided for cash benefits f r o m other or unspecified sources. T w e l v e states have statutory provisions for the rehabilitation of the industrially disabled, although in most cases the m a x i m u m allowances are entirely inadequate for total rehabilitation. Other phases of the law materially affect rehabilitation. Artificial limbs f o r e x a m p l e — a necessary aid to the rehabilitation of amputation cases—are not always mentioned as part of the medical services allowed. At present only some states specify prosthetic appliances. A few enlightened employers and insurance companies go beyond the requirements of the law and purchase the best type of appliance, but unfortunately this is not true of the majority of agencies. If the real intent of the workmen's compensation laws is to be achieved, the laws should include in their medical benefits special provision for artificial limbs. T h e y should indicate that the responsibility of the employer is not ended until the worker is provided not with the cheapest but the most satisfactory and adequate prosthesis. Perhaps the greatest bar to complete rehabilitation is the complex pattern of relationships that have mushroomed into the present system of compensation administration. Originally intended as a departure from the old court system and aimed at an expeditious determination of the facts through the means of informal hearings and conferences it has regressed to all the evils of the old court system. A n ideal administration is that at Ontario. H e r e there are no controversial hearings before a referee. A field investigation is made by a claims officer who interviews the claimant, the employer, and the doctor, and submits a report to the chief claims officer for decision. In the United States, the hearings are standard practice; they have degenerated into a pseudo-system of medical jurisprudence that has been frequently referred to as courthouse medicine. T h e r e are many participants in the daily dramas that take place at these hearings in every state: the injured worker, the

50

The Injured Worker

adjuster for the insurance company or employer, the employer himself, the treating physician, the physician representing the employer or the insurance company, the physician representing the state industrial accident commission, perhaps the lawyer for the insurance company, the lawyer for the injured worker, the union representative with his lawyer, to say nothing of the dozen or more satellites that have crept into the picture. O u t of the welter of selfish interests arrayed in this economic tower of Babel arises a series of dilemmas from which there is no escape. T h e injured worker starts out with the simple expectation of having his injury treated and his return to work expedited. Perhaps he is thinking in terms of accident damage suits and feels he is entitled to some compensation for his injury. A chance statement by a physician, apparently magnifying his disability, the deliberate machinations of an ambulance chascr, the efforts of a union representative to get a square deal for his client and thus justify his own position, the intransigence of the insurance adjuster—all these factors soon transform a simple case of injury into a cause requiring months of litigation and a persistence of the incapacity beyond all normal expectation. Furthermore, the referee or commissioner soon lends his efforts to perpetuate a system of jurisprudence that was never meant to be. Expert medical opinion is dragged on the scene to add a macabre touch to a fantasy that has been built on the false hopes for gain and for the personal aggrandizement of pseudo-judges. N o T a l m u d i c scholars, medieval philosophers, or dialecticians of Greece ever carried on such abstruse discussions as take place in compensation hearings. T h e relationship between injury and disease and the fine mathematical evaluations of disabilities are pure speculation that has no relation to every day working conditions. Yet this is the stuff with which compensation hearings deal. T h e y have become an arena where emotions and passions are arrayed with the same intensity as at the race track, boxing bout, and gambling table. T h e money incentive behind the whole program and the failure to visualize the objective of workmen's compensation as a cooperative enterprise to reduce the days of incapacity and quickly and fully restore the worker to his job are emphasized by the role of the physician. For years his selection has been the cause of a tug of war between the medical profession and the

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51

insurance companies. T h e medical profession wishes to retain the time-honored prerogative of the patient's free choice of a physician but the companies insist that the selection should be made by them since they pay the bill. T h e r e are numerous abuses on both sides. T h e patient does not always choose wisely; a general practitioner who spends most of the time doing obstetrics may be called upon to treat a compound fracture of the femur, with disastrous results. Many companies have on file X-rays of these bad end results which form a museum of medical malpractice. On the other hand, the companies frequently hire physicians not on the basis of professional merit but because of financial considerations. T h u s a badly crushed finger which could be saved by meticulous and careful surgery may be amputated in the office of one of the company physicians. Since the latter does a large volume of work he can afford to do this for a small fee and thus "save" the insurance company money. T h e worker is minus a finger. Physical restoration of the injured worker cannot achieve its aims under such a system. Nothing short of a revolutionary change in the philosophy of industrial accident commission administration can bring about an improvement. Some attempts have been made to establish supervision of medical practice through the certification and approval of physicians by local medical societies. T h e medical societies, through grievance committees, attempt to control the excesses which the system has created. T h e amateur and the inexperienced is restrained but the bold and selfish are not. Another helpful movement is the establishment of rehabilitation centers by insurance companies. Originally these were poorly equipped and there was a tendency to rush treatment (whereas some practitioners had the contrary tendency to prolong it indefinitely and unnecessarily). For this reason the clinics were closed in one state. B u t these centers are now properly equipped and are prepared to give complete treatment, including all those phases of convalescent training and physical conditioning seen in the military services. Among the most efficient centers of this type, one is operated by the Industrial Accident Commission of the Province of Ontario and another by a New England insurance company. T h e importance of the rehabilitation center where an inte-

5«

The Injured Worker

grated program of physical restoration, vocational guidance, and training can be carried out is as apparent for the injured worker as for all the disabled. T h e English have adopted the plan and have established many such centers throughout the country. One was founded in 1 9 1 9 in New Jersey under the joint operation of the Rehabilitation Commission and the Workmen's Compensation Bureau. At the time the injured worker was examined for the determination of his disability rating and compensation award he was also analyzed for the purpose of determining if any further treatment was required; if he was not in condition to return to his former work, vocational guidance and training was provided. If further treatment was indicated this was provided in an orthopedic clinic and curative workshop. Although rehabilitation commissions have been established in every state (in some states for twenty-five years), there has been little effort on the part of industrial accident commissions to avail themselves of this service. Representatives of the rehabilitation services have taken the initiative in offering aid but have frequently met with rebuff or indifference. All this is not to be construed as an indictment of the employer. Many enlightened employers and insurance companies carry out rehabilitation programs far beyond the responsibilities imposed upon them by the law. Indeed many of them have pioneered in advances in the field; this, however, applies only to a small section of industry, particularly large-scale employers who have always maintained a comprehensive policy of employee welfare. T h e small plant is not equipped either in philosophy or interest to take advantage of the program, and in that case the injured worker must depend on his chance knowledge of private or public facilities. T h e warstimulated employee welfare programs have doubtless increased his awareness of what constitutes proper and adequate treatment. Many features of compensation legislation affect the worker with a permanent disability. One of these is the character of the benefit schedules. Many of the laws were drafted years ago and are now obsolete in so far as they fail to take into account changing social and economic trends. T h e ultimate rehabilitation of the worker may depend on the amount of compensation he receives and this amount will depend on the liberality of the

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53

law. In the matter of total permanent disability for those with absolute incapacities (blindness, loss of two limbs or complete paralysis following spinal injury), fourteen states provide compensation for life while ten provide payment during disability. W h e n it is realized the permanently disabled will always require assistance, it is desirable that compensation should be continued throughout life. W i t h the close of the war has come the reexamination of some of our institutions that for long we have taken for granted. A m o n g these institutions is workmen's compensation. W h e n the United Mine Workers of America found that in several states the laws fail to provide adequate benefits for a man permanently injured with a broken back they sought new social measures for achieving the same purpose. Accordingly a health and welfare f u n d has been established as part of the agreement between the miners and the government from which the rehabilitation needs of severely disabled miners may be satisfied. Other unions are giving consideration to the same device. These are evidences of the failure of compensation to discharge its obligations and legal functions. Already serious thought is being given to the whole philosophy of workmen's compensation to determine whether its function and purpose cannot be more effectively performed under a pension system similar to social security. A workman who has lost an eye, a leg, or an arm is at a special disadvantage because of the employer's fear of increased compensation payments if another accident occurs. T h e loss of a second member would totally disable the worker. H e is at a disadvantage if he receives compensation for the second injury only, since his working capacity has been completely destroyed by it. T h i s controversial issue has been one of the chief stumbling blocks in the way of employing handicapped persons. A horrendous legend has grown up around it. Yet many employers made no effort to discover the facts; for years they have complained that if they hire handicapped men the insurance company will raise the rates. T h e problem has been solved by the establishment of second-injury funds. Thirty-five states have set u p funds of this kind to make u p the difference between the legal compensation and the actual loss caused by the injury. Although compensation in all states is paid on a weekly basis,

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The Injured Worker

in the case of long-term payments it is sometimes commuted, that is, paid in larger amounts over a shorter period, or paid in a lump sum. For the man undergoing lengthy vocational training this doubling up of the payments is a great help. Commutation of the entire amount is frequently recommended by compensation commissions, and is sometimes effective as a rehabilitating agent. For example, a painter aged forty-four was severely burned; his hands were so badly scarred that he could no longer work as a painter. With the compensation award, received in a lump sum, he was established in a small stationery and confectionery business, which he carried on successfully. T h e laws of most states permit commutation at the discretion of the industrial commission, but provide no other legal check. Some states have overcome this weakness by setting up machinery for the selection of deserving and qualified recipients of lumpsum payments and for providing continuous supervision. Those responsible for administering the funds are alive to the hazard in distributing large sums of money. They realize that workers who have had no experience in handling large sums are ready prey for swindlers. A n ironworker, aged forty-two, fell off a scaffold and injured his back and hip, fracturing one of the bones in his spine. He was badly incapacitated and an award of 50 percent of total permanent disability was allowed. This entitled him to compensation for two hundred and fifty weeks at $20 a week or a total of $5,000. T h e money was given to him in a lump sum. After paying off some debts and buying some clothes and furniture he bought for $4,000 a restaurant which was doing a flourishing business. He prospered for several months until the former owner opened another restaurant nearby and took most of the trade away. T h e r e was nothing in the contract of sale to prevent his doing so. T h e present system of commutation offers no incentive to the employer or the injured worker for rehabilitation. T h e injured man fears a reduction of compensation payments if he returns to work, while the carrier stands by furtively investigating any evidence of earning capacity. For example, let us take the hypothetical case of the young salesman who has had a high-school education and is run over by a truck in the course of employment and loses both legs. He is awarded total compensation for the loss

The Injured Worker

55

of both legs. In some states if he shows any earning capacity the award is reduced, thus restraining the worker from any constructive attempts at rehabilitation. Suppose, on the other hand, that after he has been completely restored with artificial legs the carrier makes a careful analysis of the man and finds that he is interested in becoming a doctor or chemist. T h e carrier underwrites his education at a cost of $4,000. When he is definitely placed, a commutation is made of his total compensation, the usual 5 percent deduction is made, and the $4,000 is also deducted. In other words, there is here a dual incentive, on the part of the company to reduce its cost and on the part of the man to gain for himself an education. While we have been chiefly concerned here with the deficiencies of the law and the practice in regard to physical restoration we have also alluded in passing to the need of the injured worker for vocational counseling and training. We have said that for the most part these needs have been ignored or overlooked by the legislators and hence were rarely given consideration in compensation administration. In several states, however, definite provisions for vocational rehabilitation have been included. It is obvious that rehabilitation depends in large measure on the aims and purposes of workmen's compensation and the efficiency with which it is administered. Present practices are limited by selfish shortsighted attitudes, by excessive litigation, by failure to direct the interests and activities toward truly valid goals. Canada has pointed the way. Can we follow the same course? Only by a revolutionary change in attitude.

Chapter V T H E DISABLED V E T E R A N

I

N 1945 the war was over. T h e dead were buried, the wounded were slowly recovering, eulogies were rendered and tribute paid to those who hastened the end of the greatest war in history. In the space of a few years a miracle was performed by a nation of clerks, bookkeepers, workers, farmers, and insurance salesmen. T w o gigantic military machines were demolished, not by supermen or the heirs of a military dynasty, but by the boys from our farms and high schools, from our factories and our offices. In 1945 a nation wearied by the tragedies and stresses of war looked forward to a time of recuperation and lasting peace. On J u n e 25, 1950, five years of an uneasy peace culminated in the invasion of South Korea by the North Koreans. We were shaken out of our complacency by the threat of a new aggressor; the war which we thought was over was now found to be only an episode in a long and indefinite conflict. One inevitable result of this series of discontinuous military conflicts was the increase in the total of disabled military personnel for whom rehabilitation services must be provided. As long ago as 1636, the Pilgrim Fathers at Plymouth decreed: "If any man shall be sent forth as a soldier and shall return maimed, he shall be maintained competently by the Colony during his life." From this basic philosophy of responsibility to our military injured, the grateful nation has evolved the present concept of restoring the injured servicemen to full and productive living. In large measure, rehabilitation of the civilian handicapped grew out of the activities carried on by the military services and the Veterans Administration for the rehabilitation of disabled servicemen. Technologically at least, these services offer the military casualty the kind of total rehabilitation that is still only an unrealized ideal among the civilian handicapped. Unfortunately, public revulsion for all handicapped persons and administrative shortsightedness has eaten away much of the benefits made possible by scientific progress.

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57

A f t e r the W a r between the States country boys out of uniform trooped to Chicago and New York, seeking jobs only to be rebuffed on every side. T h e 4,000,000 veterans discharged after World War I also found plenty of promises but a country unprepared to reabsorb them either economically or socially. T h e apple sellers of that period are still fresh in memory. And what of the man with a missing leg or an empty sleeve? Recently a famous actress endeared herself to the veteran population by announcing that the reason Hollywood was losing money was because it persisted in making pictures about blind veterans, paraplegic veterans, and similar unpleasant subjects. Shortly after the war, residents of resort towns on the East and West coasts where amputees were stationed asked to have them sent elsewhere, because of the morbid effect on vacationists and the harmful influence on business. These, of course, are isolated incidents, but to some extent at least, they reflect the opinions of an incredibly large part of the public. T o o many Americans eulogize and lionize disabled servicemen for a few brief months of often uncomfortable publicity and then forget them. T h e y become part of the vast army of the handicapped whom we would rather not look at, rather not think about. T h e familiar stereotype of the returning war hero who is acclaimed by his home town and then forgotten until election day has a basis in reality. T h e deep-seated prejudice felt for the physically handicapped is too strong to be washed away by a few words spoken from a bunting-draped platform. " O u r war hero" soon becomes "that cripple." T h e prejudice toward the physically handicapped individual, be he war hero or congenital cripple, and the short memory of the public are revealed in the story of a man who lost both legs at Bougainville. He had been sent to the amputation center at Mare Island for final treatment and rehabilitation. Along with a group of other Pacific casualties, he was asked to participate in an industrial incentive campaign. Reciting their experiences before large numbers of employees in shipyards, airplane factories, and other defense plants, they exhorted, cajoled, and urged the workers to stay on the job, to increase production, and to buy war bonds. T h e campaign proved very successful, and our man's part in it was so outstanding that he was strongly

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T h e Disabled V e t e r a n

recommended to be sent to the East coast on a similar project. However, when it was learned that he had lost his legs at Bougainville, the authorities turned him down. T h e y wanted a fresher casualty, one from Saipan or Guam. In the face of these attitudes and of administrative action that blows hot and cold, one can understand the cynicism of disabled veterans. One can also understand their qualms and fears as they ponder the future. Many a tropic night in the Solomons or the Marshalls, in Europe, in Africa, in the Aleutians, their eyes were fixed on some symbol of home. For many, this was the Golden Gate Bridge or the Statue of Liberty. Months later they were to remember the exact moment they passed it, remembered too that they had then considered themselves lucky to have left an arm or a leg with the Japs, because it entitled them to get home that much faster. Once ashore at the hospital, however, the painful self-searching began again. Will I be a helpless cripple? Will I be able to earn a living? Will my friends avoid me? My family, my girl— what will they think? These doubts and fears were reinforced when, during the first liberty ashore, they found people staring curiously, furtively, or brazenly, conversation dying as they entered a room, and misguided citizens raising an embarrassing fuss about "our heroes" or merely asking foolish questions: "Did you lose your arm in the service?" " N o , ma'am, they drafted me this way." T h e resolution of their doubts and fears cannot wait until these men are discharged from the service. Nor can rehabilitation wait for nicely formed organizations to spring full bloom into existence. It must be instituted soon after the return from combat areas, when convalescent training and rehabilitation can proceed without danger. A program of this character was carried out at Mare Island for the rehabilitation of casualties from the Pacific. It was geared to the special needs of the amputee but it also included the orthopedically disabled, the neuropsychiatric case, and others suffering from general medical and surgical conditions. T h e program consisted of three phases; physical restoration, vocational guid-

The

Disabled

Veteran

59

ance, and work training. It also took into consideration the special needs of the various age groups, of officers, and enlisted personnel. T h e amputee who was evacuated from the South Pacific by air or ship was brought to the hospital for the completion of the surgical management of his amputation stump. By skin traction, special bandaging, plastic repair, and revision, the stump was made to fit an artificial leg with the maximum of comfort and utility. Even before the final stages of wound healing, exercises were begun as soon as possible, both in bed and out of bed. T h e s e included simple setting-up exercises for general body conditioning and special exercises for the stump. Later the amputee was urged to participate in sports. Special swimming classes were organized for all amputees, and tennis and badminton were prescribed for the arm cases. As soon as the stump was sufficiently conditioned, sometimes within four to six weeks after operation, a temporary prosthesis was applied. T h e patient was given instruction in standing, balancing, and walking, on the level, upgrade, up and down steps. W h e n the stump had shrunk, a permanent prosthesis was applied, and training was given in more complex f u n c t i o n s — driving a car, dancing, roller-skating, and especially in work demands over long periods. Before discharge the patient had to pass an achievement test that certified him as capable of using the prosthesis for the routine pursuits of life. In the early days of hospitalization, while the patient was in bed recuperating from surgical procedures, a limited program of occupational therapy was introduced. Leather work, fly-tying, knotting, the care of miniature gardens, finger painting, and carving airplane models were a few of the activities in which he was encouraged to participate. For the arm amputee training in writing and typewriting with the remaining arm or with the prosthesis applied to the dominant arm was important. Interest in leather work, whittling, or making jewelry served as a stepping stone to interest in a correspondence course or a self-help course on Diesel engines. T h u s the ground was prepared for the Educational Officer, with whom considerable time was spent in discussing plans

6o

The Disabled Veteran

for the future. These discussions took into consideration the age of the patient, his educational background, his work experience in and out of the service, as well as his hopes and ambitions. When the patient was out of bed more intensive counseling was provided. Standard aptitude and interest tests were administered and, if needed, psychiatric consultation was provided. Botli service and nonservice agencies were available for this purpose. These included not only the Educational Officer but also representatives of the state rehabilitation agency, United States Employment Service, Red Cross, and industrial teachers and workers. T h e choice of the training program had to meet with the full approval of the patient. T r a i n i n g took into consideration the length of hospital stay and the necessity for frequent interruptions for surgery and limb fitting. It included not only correspondence and tutorial courses but also special classes on the grade-school level, high-school level, and university level given in the hospital and in near-by institutions. An example of rehabilitation in a hospital situation is that of an officer who was wounded in the battle of Peleliu, losing his right arm at the shoulder. Before the war he had taught social studies and had coached football and basketball. Arriving at the U.S. Naval Hospital, Mare Island, he expressed an interest in further education, particularly counseling and vocational guidance. Rehabilitation counselors pointed out that his disability would be a social handicap in his chosen field, but the lieutenant's interest and drive in the field of education was so strong that he brushed aside these objections. In an attempt to acquaint him in fields other than teaching, he was referred to a large manufacturing company in the San Francisco Bay area. His personality made a deep impression on the management and he was offered a position as veteran's personnel manager. A call from his former superintendent of schools urging him to return drove any thought of business from his mind. He decided definitely to continue in the educational field. He therefore enrolled at Stanford University under a professor who was at that time organizing a counseling program for first offenders at San Quentin prison. Arrangements were made for him to start his course of training at San Quentin prison under the supervision of the guidance professor. He thus had the

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61

added advantage of valuable experience in a practical situation. In the meantime he returned to the hospital for further surgery and limb fitting. His schooling did not interfere with his convalescence. Under an ordinary hospital situation he would have been forced to "sweat out" his convalescence without organized help in furthering his educational and vocational plans. H e completed his educational work and credit for his master's degree and upon his discharge from Mare Island accepted a lucrative offer at a university as a student guidance officer. T h e hospital situation provided an ideal setting for case studies. A man could be observed over a long period of time, interviewed frequently, caught in different moods and phases of adjustment on the ward, his reactions to discipline watched for, and observed as he responded to training, learned to handle his problems and to face new situations. When his wounds were healed, many a patient's first thoughts were of his first leave. Before he went home, however, he was counseled regarding his future vocational status and was advised to gather all the information he could about his family's wishes and his former employer's attitude, and to investigate any employment leads in his home area that might interest him. One lad, for example, lost both legs at Saipan below the knee. He had been a farmer, and had completed a high-school education before he entered service. After careful analysis of his aptitudes and interests the counselor felt that farming would be out of the question, and a tentative plan was devised to train him as a farm agent. He would attend a nearby agricultural college while still a patient at the hospital and as soon as temporary limbs could be fitted. However, he asked for a leave of thirty days to visit his family, whom he had not seen in three years. T h i s was granted and he was allowed to go home with his temporary limbs. At the end of his leave a request was received from his father asking for an extension of another thirty days. Still another request for an extension was received and, after considerable discussion, granted. T h e boy returned at the end of three months, tanned, with considerable increase in weight, and with his stumps in excellent condition. "What did you do with your time?'' he was asked. "Well," he said, "me and my pappy brought in the whole feed crop. I operated a tractor and a binder. My

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T h e Disabled Veteran

pappy said I was better than any farm help he ever had." He returned to the farm after he was fitted with permanent artificial legs. In the service program, the patients were again interviewed on returning from leave, and the vocational and educational plans previously made were reexamined, affirmed, or altered to fit newly acquired information or newly awakened desires. At this time the patient was urged to make more or less definite, although not necessarily final, plans for his rehabilitation during the remainder of his stay in the hospital. There were a few who elected to remain in the service. Sam lost his right leg over Guadalcanal. He was shot down by a J a p Zero and as he bailed out the enemy dived after him, cutting off his leg with the propeller. He dropped into the sea and by a miracle was picked up and flown to a base hospital four hundred miles from the scene of action. After a stormy time he was evacuated to the amputation center at Mare Island and followed the routine processing of physical restoration and fitting of prosthesis. Sam was interested in nothing but flying. His heart was set on returning to the sky from which he had been so rudely ejected. His persistency and indomitable will prevailed. He returned to the Pacific as air operations officer advancing to Group II flying, and was thus unrestricted except for actual combat. T o be of any value vocational guidance must be carefully adapted to individual needs. T h e following are illustrative examples. A seaman who had lost four fingers of his right hand was interested in a career in medicine. Having demonstrated that he was qualified by his past educational performance and by his high rating on an intelligence test, he was sent to a nearby junior college to commence his premedical courses and to make up high school deficiencies. Another seaman, with a below-the-knee amputation of the right leg, wished to become a watch repairman. Through the California State Vocational Rehabilitation Bureau, arrangements were made for him to try his skill at this trade. He found that he had neither the basic dexterity nor the inclination to go on with it, but finally found with the Tennessee Eastman Corporation the type of work he really desired. This man made his mistakes while still in the hospital, and thus escaped the frustra-

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63

tion that ordinarily follows costly mistakes made after discharge. A private whose right leg was amputated above the knee as a result of wounds received at Cape Gloucester had formerly been an apprentice lens grinder. During his convalescence he continued his apprenticeship. A paratrooper who lost his right leg above the knee at Bougainville had completed one year of college preparation but had failed in chemistry. He was sent to a nearby junior college and not only made up his year of chemistry but made further progress with his college course. T h e proprietors of a local chain store became interested in two other leg amputees and volunteered to teach them the grocery business from the ground up. T h r o u g h this arrangement, the amputees gave their time to the firm and received in return a type of training not obtainable on the hospital compound. Work training also gave the amputee an opportunity to discover how well he was prepared to meet the physical demands of the job. A machinist who lost his right leg below the knee was trained in the Navy dental clinic and later found a place with an uncle who operated a large office for making dentures. Another serviceman, similarly disabled, wanted to become a ballistics expert; he was trained for it in one of the county police offices. Still another was placed in employment training as a refrigerator mechanic for a large bottling company, while a third, whose left hand was injured by gunshot, was employed at a state game farm for breeding pheasants and partridges. A man who had lost his left arm and left eye secured employment training as a glass blower at the Radiation Laboratory of the University of California. Others were employed in aircraft assembly work, as electricians and machinists, as bookkeepers, draftsmen, printers, telephone service men, auto repairmen, wholesale meat handlers, radiomen. T o some patients large pay, steady employment, or professional careers were no great incentive. One man wanted to be a skating rink manager and, in order to meet some of the business problems of that job, undertook typing instruction at evening school. Another was formerly in the show business. T o him vocational training held no appeal, for even with his leg amputation he still felt that he could go back to the kind of life which

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T h e Disabled Veteran

had always meant color, excitement, and deep emotional interest for him. Work training had an additional value as social training. Conditioned and trained as a fighting man in the service and exposed to a different scheme of life, filled with hazards, many a disabled serviceman sloughed off many of the controls of family, church, home, and work place. He lost his normal respect for money or property. His personality adjustments were developed for the purpose of maintaining himself in the special service environment. In a work training environment he soon learned the value of money, of respect for property, of proper labor-management relationships, all those homely but important virtues of punctuality, efficiency, and the like. Most important, the work training project was for him a laboratory in which he was helped to make a vocational choice. It was also the training school for his transformation from soldier to citizen. T h u s it can be seen that mass production methods cannot be applied to the solution of the individual problems of the physically handicapped. Certain principles, however, must be observed. In the first place, physical restoration must be complete, that is, surgical and medical care must have been completed, and in the case of an amputation the loss of a member must be replaced by the best type of prosthesis. It means also convalescent training and physical and mental conditioning of a kind that will restore the patient's general physical constitution to the best possible state and provide him with a new outlook on life. T o discover how these amputees fared in returning to civilian life, let us look at the record. A veteran who lost his right arm at the shoulder at Bougainville has had continuous employment with an automatic music company. In addition to this satisfactory work adjustment "his adjustment to community activities is 100 percent." Liaison officer between workmen and engineers is the position enjoyed by another, who lost his right arm at Cape Gloucester. A third, who suffered an amputation below the right knee at Guadalcanal, has been continuously employed as a machinist in a welding shop, ever since he was discharged from the hospital. In all, 90 percent of 750 amputees discharged from Mare Island were either at work or attending school two years after discharge. In the words of one patient, " W e never thought much about

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rehabilitation until our present predicament. It can mean everything or nothing—everything to the man who is farsighted enough to realize that soon he will be out in civilian life competing with men like himself who have recently been discharged." Other wars with their quota of disabled veterans have left many with the disillusionment of broken promises. Rehabilitation in service fulfills these promises not after demobilization but before discharge. A similar program was carried out in the Army and in the Army Air Force. T h e full measure of surgical and medical care was supplemented by an intensive and carefully planned program of convalescent training, including physical conditioning, occupational therapy, and an educational program. T h e primary purpose of the program was to restore men to duty and to reduce the number of hospital days for illness and injury. Although the program was not specifically designed for the permanently disabled, nevertheless counseling facilities were introduced and even emphasized toward the close of war, and the soldier about to be discharged was aided in reestablishing himself in civilian life. Thus, it can be seen that for the first time in all our wars planning for the veteran preceded demobilization. T h e primary responsibility for translating these plans into action after demobilization belongs to the Veterans Administration. When the United States entered the first World War, it was planned to enact a law for the care of the disabled and the dependents of the dead and to offer insurance at peacetime rates against death or disablement to the armed forces. T h e various parts of this undertaking were at first handled by three agencies, the Bureau of War Risk Insurance, the Rehabilitation Division of the Federal Board for Vocational Education, and the U.S. Public Health Service. By the Act of August 9, 1 9 2 1 , an independent bureau called the Veterans Bureau consolidated the Bureau of War Risk Insurance, the Rehabilitation Division, and as much of the United States Public Health Service as then related to the examination of servicemen and their assignment to hospitals. By the World War Veterans Act of J u n e 1923, 1924, the bureau was enlarged and decentralized. Many regional offices were established to hear

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complaints, to rate and award compensation claims, and to grant medical, surgical, dental, hospital convalescent care and vocational training. T h e director of the Bureau was further authorized to utilize for the care of the sick and disabled the existing and future facilities of the U.S. Public Health Service, of the Departments of War, Navy, Interior, and the National Home for Disabled Soldiers and other governmental facilities. On J u l y 21, 1930, an executive order consolidated all governmental agencies affecting ex-servicemen of all wars into a unit called the Veterans Administration. This meant bringing under one head the U.S. Veterans Bureau, the National Home for Disabled Volunteer Soldiers, and the Bureau of Pensions. General reorganization followed, under a load of work which continually shifted and increased as each new upheaval occasioned by new legislation created new classes of beneficiaries. T h e Veterans Administration is a large and comprehensive organization dealing with many problems of the veterans adjustment, including schooling and educational training as well as medical care. Its medical program is one of the largest in the world, and the program administers 151 hospitals with more than 119,400 hospital beds. A n average of more than 100,000 patients were cared for under this program each day during 1950. Its annual budget is over $650,000,000. T h e program of medical care is stupendous. T h e possibility of making such care available to fourteen million veterans, and possibly their dependents, poses a radical departure from our ordinary concept of medical science. For our puipose, however, we are primarily interested in that phase of the program concerned with physical restoration activities, which will remove an employment handicap and make a person productive and employable. These activities are carried out under the Department of Medicine and Surgery by the Division of Physical Medicine and Rehabilitation, under the direction of Dr. A. B. C. Knudson. This department provides treatment activities in physical therapy, occupational therapy, corrective therapy, educational therapy and manual arts therapy, audiology and speech correction and blind rehabilitation. There are three general categories of patients who are served

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by the Division of Physical Medicine and Rehabilitation: tuberculous, neuropsychiatric and general medical and surgical patients. T h o s e patients in V . A . hospitals who require vocational counseling prior to selection of a suitable vocational objective are provided with this service. Consideration is being given to the transfer of the hospital function of Medical Rehabilitation Advisement from Vocational Rehabilitation and Education to the Department of Medicine and Surgery. T h i s would seem to be a wise procedure, as all hospital rehabilitation activities should be coordinated under one department, thus insuring an integrated hospital service. T h e educational therapy provided in the hospital offers courses from grade school to college level. Although several thousand patients have been assisted to secure their high school diplomas through these courses, the primary purpose is therapeutic. T h e courses do not interfere with the regular V.A. educational program, served by a different department. Educational therapy is used in the Veterans Administration as part of the total physical medicine and rehabilitation program, to provide the mental activity and stimulus that should be present d u r i n g the physical reconditioning program. Manual arts therapy for long-term patients is carried on separately from the occupational therapy program in V . A . hospitals of more than 1,000 beds. It is utilized as part of the treatment program, to determine physical fitness for work, measure work aptitudes, increase tolerance, and provide some prevocational job exploration. T h e regular occupational therapy activities are also carried on under the Division of Physical Medicine and Rehabilitation, as part of the total treatment scheme. Corrective therapy and physical therapy are also carried on under the program. T h e Prosthetic and Sensory Aids service, under the direction of Dr. Augustus T h o r n d i k e , operates a very extensive program which provides artificial limbs and other prosthetic devices to veterans. One of the best features of this program is the prosthetic and orthopedic appliance teams that operate out of Veterans Administration offices. T h i r t y such teams, consisting of physicians, limb makers and orthopedic appliance specialists, are now in operation in various p a n s of the country. T h e s e recently

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organized teams have proved to be very effective in providing an integrated approach to the many problems which beset the veteran amputee. 17,500 veteran lower extremity amputees have been provided with prostheses thus far. T h e service also carries on a program of research on artificial appliances, in cooperation with the National Research Council, designed to develop improved types of artificial limbs for the benefit of the civilian population as well as the veterans. At the Veterans Administration regional office in New York City, there is an excellent exhibit of prosthetic appliances which was set up by this service, and which is open to anyone interested in this subject. A comprehensive program of rehabilitation has been set up at Oteen, North Carolina, for the 15,000 tuberculous servicemen. T h e program provides not only medical care, but the important ancillary services of physical and occupational therapy, job counseling, and psychological and social services. T h e program in aural rehabilitation is still insufficient for the 65,000 veterans who have hearing disabilities from serviceconnected causes. At present, rehabilitation for these hard of hearing servicemen is achieved through cooperation with existing private agencies and institutions. T h e Veterans Administration has an audiology unit of its own in New York, and hopes to set up a similar unit on the west coast, and perhaps in other cities as well. T h e Veterans Administration has a very good program for blinded veterans, which provides all of the services essential to the rehabilitation of the blind: physical orientation, travel instruction, Braille, vocational counseling, and psychological assistance. During the Second World War, Valley Forge Hospital was the seat of much of this activity, and the work done there was a model for civilian centers. T h e Veterans Administration program for paraplegics, developed after the close of the Second World War, is ideal in many respects. Together with a few nongovernmental institutions, it carried out a pilot program which has developed the knowledge, personnel and facilities for the rehabilitation of paraplegics. Few civilian paraplegics receive this type of integrated care; while the 2,400 veteran paraplegics receive excellent

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rehabilitative care at special V.A. hospitals and centers, nothing comparable is available for the far larger numbers of civilian paraplegics. Of course, not every paraplegic can be rehabilitated to the self-care and independence which makes noninstitutional living possible. A few, because of severe physical complications or inherent personality weakness, must remain in a hospital environment for all of their lives. T h e majority, however, can be rehabilitated to self-care and vocational independence, and the success of the V.A.'s program has proved this. One of the best known of these special centers was located in Van Nuys, California. When the Birmingham Veterans Administration hospital was closed down, the move was attended by a great flurry of public protest. It was felt that the monetary saving to the government did not justify closing down one facility when the total number was already inadequate to meet the needs of paraplegics served by the Veterans Administration. An influx of paraplegics with non-service-connected disabilities into Veterans Administration hospitals was responsible for over-taxing the facilities, it was believed. T h e present (1952) paraplegic population of Veterans Administration hospitals is only about 40 percent service-connected; the remaining 60 percent is made up of veterans who have suffered paraplegias as a result of civilian accidents. Undoubtedly, paraplegic veterans returning from the Korean campaign will further over-tax available facilities and more will have to be constructed. Of the many types of orthopedic disabilities that require hospitalization and after care the amputee and paraplegic are characteristic in that each requires specialized care. We have described the broad program for the rehabilitation of the amputee in service amputation centers. Here we saw an ideal plan of management which included psychological preparation of the patient, adequate surgery, after care of the stump, procurement of prosthesis and training in its use. T h e amputation centers are being abandoned, leaving only a few for the testing of new appliances. T h e Veterans Administration has established one large amputation center for the procurement of prosthesis and training in its use. Aside from this center, the procurement program has been developed around a carefully supervised arrange-

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T h e Disabled Veteran

ment with private manufacturers. One important feature of this plan is the issuing of a prosthetic service card to every veteran amputee; this entitles him to service and repair up to the amount of $35 without the need for special administrative approval. Canada, on the other hand, operates a central limb-making factory, which employs a network of field agents (all of them disabled veterans), who are given comprehensive training in handling the manifold problems of limbless veterans and are paid decent salaries on the job. When it is learned that a limbless soldier is returning from overseas, a field agent is assigned to the case. He visits the family to prepare it for the homecoming even before the soldier returns to Canadian soil. He meets the veteran as soon as the boat lands, and then follows him right through the hospitalization period, sees that he gets the right kind of appliance, helps him to learn how to use it, aids him in job placement and keeps in touch with him until he is rehabilitated in his home community. He gets to know the man thoroughly, and the veteran feels he is being treated as an individual and not as a case number. T h e English procedure is also national in scope under a centralized plan. After several years of experimentation among private industry, a single manufacturer was placed under contract to manufacture, furnish, and service limbs. T h e desirability and practicality of a similar scheme, that is, a centralized program under government responsibility, is a matter for further study and consideration. In the absence of a centralized governmental agency, the veteran amputee will have to rely on the private manufacturer. But even here improved control over existing practices will ensure the amputee a satisfactory limb. These controls can be exercised by licensing, setting up of standard specifications, and finally by approval of the limb by trained and quali fied personnel. Paraplegic patients require special braces and facilities for the training in the normal pursuits of walking. At the same time they also require a broad program of occupational, educational, and vocational training to keep from becoming shut in. It can be seen then that the problem of providing medical care whether on a hospital or outpatient basis is so vast that departure from past practices may be necessary. Such departures are being

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considered and are now in actual use, utilizing community facilities and community physicians on a contract basis with state medical societies. This means that the veteran can go to the doctor of his own choice for the same treatment and care he would receive if he were a private patient paying his own bill. Professional standards are maintained and no charity is involved. T h e doctor receives his payment from the medical agency of the state veterans administration. T h e fees are liberal enough to ensure the services of the best physicians and surgeons. T h i s new practice will be watched with great interest for it probably points to the only way a complete and efficient program can operate, that is, within the framework of medical care for the whole population. If it is taken out of the framework it cannot succeed. T h e numbers involved as well as the philosophy of treatment make it indispensable for satisfactory treatment. As complicated as is the program for medical care even more complicated is that of vocational guidance and training. In the interwar years the Veterans Administration carried out a program which by 1928, when vocational training had closed, showed that 179,519 veterans had participated in the program, 8,773 had dropped out for various reasons, 1,999 died in the course of training and 128,747 had satisfactorily completed their work at a cost of $645,000,000. Of this group 40 percent had trained for jobs in industry, i6i/£ percent for the professions, 13 percent each for agriculture, clerical work, and trade. T h e majority were Army privates between 26-30 years of age. Married men outnumbered the bachelors. T h e typical trainee had about six years of elementary schooling before enlistment. T h e largest group underwent about three years of rehabilitation. After discharge, the average man was earning $ 1,000-$ 1,500 in his new job, an improvement of $300 over his previous job. T h e greatest economic gain was in the low-income groups. Public Law 16 reopens this system and amplifies it. It offers subsistence of $90 a month and free education to injured veterans for a period up to 4 years. But before veterans avail themselves of these remarkable opportunities they must have some idea about their vocational objective. For the vocationally literate veteran who knows exactly what he wants to do and is well integrated and organized toward his goal, this is no problem. T h e majority of

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the boys, however, are confused and vague about their plans. T h e y require competent guidance. Unfortunately the number of well-trained personnel is extremely limited, and those that are available are not being fully utilized for the reasons already discussed. T h e rehabilitation of the war disabled cannot be viewed piecemeal. It cannot be taken out of the context of the total needs of the veteran. Nor can it be taken out of the total needs and welfare of the nation. N o better example of this close interrelationship is the matter of pensions and jobs. Fundamentally, veterans prefer jobs to pensions, but the number of jobs that are open will depend on the total economy of the nation. T h e desired objective is 60 million jobs. If that goal can be attained the veterans pension problem will recede to insignificant proportions in relation to the total economy. On the other hand, if full employment cannot be achieved by private or public planning, then the pension system may become one of the great economic problems facing the nation. In monetary terms, Congress has provided liberally for the disabled veteran. T h e Veterans Administration has likewise exercised a liberal attitude toward the interpretation of ratings set by Congress. But the system as operated is too mechanical for the human and social elements involved. For a time there was no extra allowance for family dependents. At this writing, additional disability compensation because of dependents ranges from an extra $21 a month for a childless married veteran to an extra $56 per month for a married veteran with three or more children. Totally disabled veterans receiving maximum disability compensation receive $360 a month; if he has a family of five, his total monthly income is only $416 a month. This is maximum compensation and only awarded in unusual cases; even then, it is hardly adequate for food and housing in a metropolitan area. Furthermore, many a disabled veteran who is rated medically as a partial disability is totally disabled from an employment standpoint, although his pension allowance does not take this into consideration. Many men leaving the service feel insecure about the future. Some are ready to seize any financial crutch that is offered. A pension is a financial crutch. Resort to it may discourage re-

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habilitation, and may even rouse an unconscious desire to win a larger pension by getting sicker. T h e present system encourages veterans to seek security in pensions instead of in gainful jobs. Pension ratings are made on an estimation of the extent to which a disability reduces a man's earning capacity, a determination that is a test for philosophers and mathematicians (actuaries) rather than for physicians or engineers. Nevertheless, if a man is considered unemployable, he is given a total disability rating. If his handicap is estimated to reduce his earning ability by 10 percent, he is given a 10 percent rating which entitles him to $ 1 5 a month. A 30 percent rating entitles him to $45, and so on until the maximum of $ 1 5 0 is reached. Men with partial disability ratings (those less than 100 percent) are frequently the victims of emotional conflicts in that they fear the loss of pension rights if they attempt to improve their vocational or financial position. Important changes are, however, taking place. T h e scale of disability pensions remains the same but morale and treatment have been altered. Medicine and prostheses do a more efficient job, and wounded are encouraged to rise from their beds and walk. T h e Veterans Administration is responsible for providing medical care and vocational training but reemployment is a problem beyond its jurisdiction: this is the collective responsibility of the entire nation. Employment of the war disabled is a national problem and a local problem. On the national level the effectiveness with which the disabled are absorbed into the industrial economy depends on general employment in the post-war period. Whether we can reconvert our economy from one geared to total war to one capable of achieving a high level of peacetime production had troubled economists after the close of World War II. That problem has been solved in the development of the larger problems of the present political situation. T h e anticipated post-war recession did not occur; the advent of the Korean conflict has restored the economy to what is almost a war-time basis. Even physically disabled veterans are not finding it very difficult to get work in the expanding defense industries. However, we cannot depend upon the artificial economics of defense production to provide jobs indefinitely. T h e veteran

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handicapped, like his civilian counterpart, must be accepted as a productive member of society, not as a "marginal worker" who is the last to be hired and the first to be fired. These disabled servicemen have demonstrated their right and ability to become a part of our permanent working force. Full employment at a high level of production is a matter in which the disabled veteran has a particularly important stake. In World War I several foreign countries adopted a policy of compulsory employment under which each employer was forced to hire a percentage of workers from the large army of physically handicapped veterans. In this country the policy did not reach the floors of our legislative halls, but there may be ruminations that will take form in an open movement if the employment level of the nation falls sharply down. As a local measure, key groups and agencies can perform a special function in promoting reemployment. These are the United States Employment Service, management, labor unions, Selective Service, veterans' organizations, state veterans' committees, state rehabilitation bureaus, and community agencies such as veterans' centers under public and municipal control. At present, the problem is not one of unemployment. There are sufficient jobs available and the difficulty is that of finding enough workers who are properly trained. This means that once again the handicapped will be called upon to play an increasingly important role in the economy of the nation. T h e Department of Defense has established a special manpower commission for this purpose, and one of its functions is to recruit and utilize the marginal workers: the handicapped, the superannuated, and the married women who are not normally part of the working force. T h e Office of Vocational Rehabilitation has established a special service to train handicapped persons for work in the defense industries; as part of this program, long-term rehabilitation of some handicapped persons is being deferred to permit them to receive short-term training for immediate employment. Not only the veterans of World War II, but those returning from the Korean conflict as well, must be fitted for employment. T h e fact that a man is physically unfit for military service does not mean that he has an insurmountable vocational handicap. Men and women with missing limbs, blindness, deafness,

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neurological disorders and other forms of chronic disability can and do become productive parts of the economy if they are given the proper training. During the Second World War, the War Manpower Commission performed a herculean task. It not only stabilized and encouraged employment, but it also sponsored training courses, fostered the employment of handicapped women and the superannuated, and give the lie to the myth that physical restrictions mean impaired industrial productivity. It participated in the referral of discharges from hospitals, so that on return to their home community discharged servicemen could contact or would be contacted by a representative from the local U.S.E.S. office. One phase of this liaison that has an important bearing on the adjustment of the veteran was observed in one of the Army hospitals for the rehabilitation of amputees. An excellent educational program had been prepared within the hospital walls. At first only a small percentage of men took advantage of it. When an amputee was asked why he did not use facilities that were only about three doors from his entrance, he replied, "If they want me, let them come to me." This was not necessarily pure apathy; it was compounded of old habits along with a conditioned resistance to anything new or strange. This pattern of reluctance was revealed by many sources. Self-reliance had become a habit; the soldier had learned to dig himself out of his own difficulties, and he did not readily turn to the numerous agencies set up for his use, until he was in desperate circumstances. A typical case in point is that of " J o e Souczak," the soldier described by John Hersey in "Joe Is Home N o w " (Life, J u l y 3, 1944). Only by the patient's understanding and through the help of a few persons close to him can he find a niche for himself and settle down into a normal pattern of living. It is necessary to take him by the hand for the first few steps, for he must be literally reintroduced to society. After this he can find his way alone. Very few of the dischargees responded to letters sent by the U.S.E.S. to their homes. However, when visited by the U.S.E.S. representative they showed no resistance to service but welcomed it and cooperated. During the last war one of the most gratifying movements has been the establishing of community agencies to assist the return-

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ing veteran in securing employment and in many other ways. Yet the typical reluctance has prevailed. Of the many amputees who left Mare Island very few made use of the local agencies, although the nondisabled did so. A frequent criticism was that the veteran was constantly referred to other agencies and to innumerable other places, until the cry " T h e y gave me the runaround" was difficult to overcome. It was partially met by the establishment of so-called one-stop veteran services, whereby referrals elsewhere were kept to a minimum. Of all the services for the returning veteran, the one most freely utilized was the local Selective Service Board. T o their buddies in the hospital the boys would write, "Mack, don't be afraid of them; they will help you." T h e members of the reemployment committee on these boards were local businessmen or other public-minded citizens who volunteered their services. T h e y knew the community. Often they knew the veteran personally and were therefore able to make him feel a welcome and integral part of community life. One phase of the reemployment problem was that of assisting the veteran to get his old job back. In order to ensure this, a definite section was included in the Selective Service Act (Section 8), guaranteeing reinstatement to a former position or to one of like seniority and pay. Contrary to anticipation, the matter never became a major issue. Many veterans were in the age group just out of school and had held no job previously. T h e outdoor life of the service had changed the views of many; still others sought and found outlets for new talents and skills developed while in the service. Moreover, because of the high state of employment, veterans were easily absorbed into their old organizations or found employment elsewhere. In July, 1945, one firm reemployed 9,000 applicants for reinstatement of the 103,000 who had left to go to war, and took on an additional 26,700, besides. Industry made preparation by maintaining contact with former employees through correspondence or company publications. It held institutes to enlighten foremen, supervisors, and executives as to the needs of the returning veteran, particularly the handicapped. Many employers granted a training or reconditioning period, while others set up a broad plan of training for advancement. T o a large extent this was true even in smaller

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plants, although individual personality and special local conditions were frequently the determining factors. There were initial doubts over the reemployment of the neuropsychiatric, particularly when his restlessness, retarded adjustment, and occasional horseplay upset the routine of the plant. Actually a large number of neuropsychiatries have been assimilated without great difficulty, despite the apprehension and false prophecies not only of management but of psychiatrists as well. T h e transition from soldier to worker was encouraged by plant placement committees and also by a veteran coordinator, a man who was a veteran himself, understood the veteran's problems, talked his language, and inspired his confidence. T h e coordinator introduced him to the foreman and followed up his progress in the plant, facilitating his transfer to another job, if this was desired. T h u s former machine workers might be moved to clerical work and, in one case, a veteran who had been advised not to do any heavy lifting had the opportunity to become an apprentice tool- and die-maker. T h e advice and counsel of a placement committee was available to promote the smooth and rapid reintegration of the worker to the plant environment. In an oil refinery, 80 disabled veterans with disabilities ranging from amputations to head injuries were employed as inspectors, mechanics, processors, laboratory assistants, shipping clerks, and accountants. On an inspection of the plant I found three amputees; two of them with above-the-knee amputations were working under a tank can repairing a feed line. A l l three worked a regular shift, received no special privileges and no coddling. They had been welcomed to the plant, introduced to the foreman and to various jobs and given an application. T h e variety and responsibility of such duties as readying gauges, making charts, testing samples, and making recordings made the job interesting to the competent worker. A department head who was reluctantly persuaded to try a handicapped worker was so impressed by the results that he asked for all he could get. Absenteeism was nil. Foremen cooperated in making it possible for patients to get to Mare Island for weekly check-ups without losing pay or the chance for overtime. It was found that in every instance the employer observed the

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G.I. Bill of Rights in both letter and spirit. T h e number of reported violations was negligible. Of course, the veteran was a little disappointed at the absence of the $ 1 5 0 jobs he heard so much about. He learned, too, that the increased cost of living and the withholding taxes made a big difference between what he was earning and what he had to spend. In various ways the serviceman acquired an unjustified impression of labor's role in the war effort. Reports of the occasional strike on the home front were magnified; there was no spokesman for labor on the fighting front and the bad impression was frequently reinforced by personal experience. Since the serviceman was in no position to understand the real issues, he came home with a very unfavorable reaction to labor. Only on his return could this be modified. T h e change was gradually accomplished as he learned that 85 percent of the nation's war materials were union-made and that the unions had pledged no strikes for the duration—wildcat strikes amounted to three hundredths of one percent of total working time. During his resocialization, the disabled veteran learned, too, of trade union plans for his reemployment. In one area (San Francisco) the mechanical trade unions were jealously guarding their own work opportunities for their own veteran members. T h e official C.I.O. policy called for cumulative seniority rights for the time spent in service since September 16, 1940. Thus, if a member of the C.I.O. worked in a shop from 1938 until drafted in 1941 he would have seven years seniority upon returning to work in 1945. Other features of the plan exempted veterans from initiation fees (ranging from $2 to $50) on joining the C.I.O. and waived dues payments for all members while in service. T h e attitude of the unions toward the reemployment of disabled veterans varied. Some insisted on resisting the full interpretation of the Selective Service Act, not for personal reasons but for fear that it would deprive them of their rights under contract with employers and collective bargaining. T h e majority of the unions were very liberal; their contracts with employers not only assured the reinstatement of the veteran employee but even gave him preference. Others, in addition, facilitated his status in the union by the suspension of dues in service and reduction of dues soon after reemployment.

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T h e role of veterans' organizations in reemployment has not been dominant for the simple reason that so many other agencies exist for the purpose. One new organization of the kind takes the broad view that veterans should consider themselves citizens first and veterans second, and that if the employment situation is healthy throughout the nation then it will be healthy for the veteran. One organization is devoted entirely to the needs of the disabled veteran, namely, the Disabled American Veterans. It serves as a link with the Veterans Administration and has handled more than 900,000 claims, obtained 160,000 medical examinations, and established disability compensation benefits in excess of $100,000,000. T h e special advantage in securing employment is one of the foremost benefits that the United States offers to veterans. T h i s principle of the Federal Government is eighty years old. First introduced after the Civil War it has been modified and enlarged, and was culminated in the Act of 1944, which unites in one detailed law all of the executive orders, various statutes, and commission regulations under which veterans are given preference in Federal employment. By directing the granting of five- and ten-point preference to veterans and placing ten-point veterans at the top of certain registers, Congress has determined that the policy of the government shall be to give veterans preference over nonpreference eligibles with a lower rating in the register. Many a disabled veteran looks forward to an easy job with the government. T o sincere men who are qualified, the service-connected disability gives a ten-point preference. Certain classifications, such as elevator operator, guard, or messenger, have been made exclusively available to veterans. T h e disabled veteran heads these lists as a result of his preparation by service hospitals through vocational guidance and training. Since this work training has frequently led to full-time and permanent employment, the hospital has been of special value in acting as liaison between service authorities and industry, in addition to the help provided by United States Employment Service through its special knowledge of selective placement and the job opportunities available for these special cases. One phase of state rehabilitation activities has frequently been overlooked. This has to do with rejected draftees and with non-

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T h e Disabled Veteran

service-connected disabilities. Men in the latter group are not entitled to the vocational training and placement services of the Veterans Administration, but they can utilize the services of the state rehabilitation agencies. T h e general picture for the readjustment of the war disabled and their rehabilitation is a hopeful one. Changing attitudes brought about by the war concerning the working capacity of the physically handicapped, the completion of a maximum degree of rehabilitation before discharge from service, the sincere desire on the part of industry and labor, the community interest and planning which were not present in the last war, all point to a constructive outlook. What is still needed is the flame that will keep interest alive.

Chapter VI THE CHRONIC DISABLED

T

HE chronic disabled are a poorly defined group having no political significance yet representing an important public health program. Included among them are congenitally deformed adults, victims of crippling highway accidents, chronic invalids, and the aged. They present wide variations in age, types of disability, working capacity, and general outlook; their social and economic problems are closely related to the nature and origin of their defects. For each, the future is largely determined by whether the disability is static or dynamic. T h e chronic invalid is handicapped not only by the day-to-day fluctuation of his illness but also by the uncertainty of his cure; no valid estimate can be made of his ability to perform continuous as well as productive employment. A static disability (for example, a club foot or a deformity resulting from a fracture) carries no such uncertainty; its immutable and permanent character permits at least some opportunity for planning a rehabilitation program.

T h e n u m b e r of the chronic disabled has been variously estimated at from two to five million. They form the major portion of the so-called severely disabled group, the paraplegics and hemiplegics, the severe heart and lung cases, and the arthritics. Because of their limitations their absorption into society as productive members has been regarded as impossible. Countries where social insurance is well establishd have not denied their right to public assistance. Invalidity pensions are granted if, in the judgment of an inspection board, working capacity has been reduced two thirds. T h e method for arriving at this decision is not well defined. T h e opinion is usually an arbitrary one based not on any systematic method for determining disability but on the joint decision of the examining board. Nevertheless, the principle of pensions for invalids is clearly established. It implies, of course, that the majority cannot be restored to useful and productive working capacity. While it is true that rehabilitation is not as favorable as in other groups, nevertheless, a hopeless at-

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titude is not justified. Pensions should only be considered if rehabilitation services are not available or have been tried without success. T h e State of New Jersey has recently passed legislation for the totally and permanently disabled which takes into consideration the possibilities of rehabilitating a considerable percentage of this group. Basically, the law provides financial assistance to needy persons with total or permanent disabilities; all or part maintenance may be provided under the same legal restrictions as those which govern old age assistance. T h e disability must be of an extent which prohibits useful employment within the community or within his competence. T h e lower age limit is eighteen years, since New Jersey provides services to handicapped persons under eighteen through its Crippled Children's Commission. It is hoped and expected that this new legislation will be administered in cooperation with the New Jersey Rehabilitation Commission, so that disabled persons can, if possible, be trained for useful employment by the rehabilitation commission while their living expenses will be provided under the new law. This is the spirit, if not the letter, of the law; restoring, rather than merely supporting, the chronically disabled is the progressive pattern of legislation for this group. Of the individuals who go to make up this group of chronic disabled, the congenitally defective are a small but important part. T h e adult handicapped by a congenital deformity probably has not had the benefit of treatment in childhood or his disability has been so great that medical and surgical treatment could provide only limited improvement. For example, individuals with congenital amputation have a simple problem of prosthesis. Adjustment can be made by restoring the missing member. But the individual born with missing bones, or with joints that are defective in development, or with permanent stiffness and muscular deficiencies, can achieve only partial improvement through orthopedic surgery. Failure to undergo accessible treatment has condemned many to a life of uselessness. Here, the superstition of parents has been the responsible factor. On the other hand, adequate surgical and orthopedic treatment has been unavailable to many crippled

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children, who have therefore grown to adulthood with a physical defect and impaired working capacity. Congenital defects have one mitigating aspect: with few exceptions they are static, fixed, or unchanging. T h e congenital amputation, club foot, harelip or cleft palate has reached some degree of stability, so that predictions can be made as to their f u t u r e effect on working capacity and plans can be made accordingly to utilize the residual unimpaired capacities. T h e advance of orthopedic and plastic surgery and the services of rehabilitation agencies for crippled children have greatly reduced the n u m b e r of unproductive persons in this group. Even the severely malformed child need not be regarded as a necessarily hopeless case. One of the author's patients is a child, now three years old, born without arms or legs. T h e boy does not have shoulder or hip joints; he is only a head and torso. When the distraught mother brought the boy to a clinic for congenital amputees, she summed up her frustrations and anxieties in three questions: Was it my fault? What can be done for my child? Shall I have other children? I was able to give her a reassuring answer to her first question by explaining that such births are genetic "sports" and that the parents could have had no possible influence or control over their child's condition. In answer to her second question, I pointed out that we had partial answers, not complete answers. One of our patients, totally paralyzed from the waist down and a double leg amputee at the hips, had learned to ambulate on crutches and artificial limbs. Since her child had strong abdominal muscles, it was not unreasonable to suppose that he could do at least as well as this patient when legs were fitted and he received the necessary training. Arms would be provided through the technique of pectoral cineplasty, in which the live muscles remaining in the chest wall would be utilized to activate prostheses. T h r o u g h careful and complete training and rehabilitative teamwork, the child could be saved from a life of total dependence and invalidity. Her third question was hardest of all. As a physician, I had to explain that she would take a statistical risk in bearing another child; the probabilities were that if she bore four children, one other one would be malformed in some way. I had scarcely

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completed my answer when another woman in the clinic raised her hand and said, "I was faced with the same problem when my daughter was born without an arm. I've since had several children, and they are all normal in every way. My answer is 'mother, go ahead and have more children.' " T h e boy's mother has since had another son, who is perfect. T h i s child's case is, of course, extreme. Nevertheless, it demonstrates that rehabilitation is not left helpless when facing a problem of this magnitude. T h e great destructive force of this age in the United States is neither the engines of war nor the hazard of industry. It is the automobile. T h e toll of crippling highway accidents looms large among the number of those permanently disabled from all causes. Each year the death total is greater than that of the war, while those permanently maimed run into the hundreds of thousands. These accidents are no respecter of age or persons. They cut across all economic classes, and the variety of residual disabilities is legion, from the simple cut from flying glass, which may nevertheless disfigure the injured person, to the fractured spine with an accompanying spinal-cord injury and paralysis of both legs, and permanent loss of control of the bowel and bladder. T h e extent of this threat to the national existence can well be understood by the campaign being waged to reduce the n u m b e r of accidents. T h e National Safety Council, insurance companies, and other agencies are devoting their engineering and educational energies to promote widespread public appreciation of the significance of highway accidents. Accident prevention is being practiced at all levels, nation, state, and local; yet sudden death and its sister, crippling deformity and disability, still ride the highways. T h e nature of the disability depends in large measure on the extent of the initial injury. Small skin lacerations or cuts and soft-tissue bruises will heal with very little after-effect. On the other hand, the result of fractures of the skull, spine, and extremities depends not only on the character of the injury b u t also on the character of the treatment. T h i s treatment is of two kinds, the emergency treatment and the definitive treatment. Definitive treatment refers to the specific treatment necessary

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to provide complete healing and restoration of function. For example, in the case of fracture of the knee or thigh bone it would refer to the setting of the fracture u n d e r anesthesia in the hospital under optimum conditions and proper X-ray control to produce accurate replacement of the broken bones. It refers also to the repair of severed tendons, severed nerves, amputations, exploration of the abdominal cavity, in the case of crash injuries to the abdomen with involvement of the spleen, liver, kidney, or bowel. Obviously these injuries cannot be adequately or completely treated at the scene of accident or in the emergency room. T h e definitive treatment of accidental injuries in this country can be said to be well organized and competent. But emergency treatment is still far from what it should be. T h e treatment of these accidental injuries has come to assume so important a place in our national life that the surgical profession has given cognizance to it by creating a special branch called traumatic surgery. T h e steady improvement in technical methods and standards of treatment has gone on under the exacting stimulation of the American Medical Association on a national level, by means of scientific exhibits and demonstrations, and by the American College of Surgeons on a regional level, through repeated conferences and special fracture meetings and exhibits. Many of the functional disabilities resulting from these injuries could be considerably reduced if followed through by appropriate treatment to maximum physical restoration. T h e reconditioning programs in the Army and Navy have demonstrated the value of systematic physical therapy and convalescent training to reduce disability and restore working capacity. However, only a limited amount of this service is available to the civilian. Recognized physical therapy departments are available in only a small percentage of hospitals. In too many, physical therapy is not available at all, while in others it is relegated to a dungeonlike compartment in the basement of the hospital, without supervision or an appreciation of its role in the patient's rehabilitation. T o o many patients are discharged from hospitals with the information that time and nature will resolve their disabilities. A limited amount of this work is carried on in doctors' offices. It is generally of the type known as machine physical

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therapy. Machines do the work, whereas intelligently directed massage and exercises and splinting are required. As far back as 1919, the need for this kind of service was felt in New Jersey. Accordingly, five rehabilitation clinics or centers were established. T h e i r work not only benefited a large number of physically handicapped persons but also demonstrated the value of the service so ably that physical therapy departments were established in several hospitals. In England similar rehabilitation centers were established in 1936 to modify the severe physical and economic effects of accidents. T h e lessons learned in these centers contributed in large measure toward the development of the rehabilitation program in the military services. Expansion of facilities on the basis of all this experience is not only desirable but necessary. From the standpoint of ultimate economic and vocational rehabilitation accidental injuries are favorable in that with few exceptions they fall into the category of static disabilities. After appropriate time and treatment the disability remains stable and not subject to the fluctuating and dynamic character so common to chronic disease. T h e problem of the chronic disabled is by and large the problem of chronic disease. Vital statistics show that tremendous strides have been made in conquering the diseases of early childhood but cancer, diabetes, cerebral hemorrhage and diseases of the heart arteries and kidneys are taking an increasing toll of human lives. Sufferers from chronic illness require a long period of treatment before they can be rehabilitated; a lingering, progressive illness like cancer necessitates constant care and attention, while a fairly constant level of disease demands careful supervision if it is not to become worse (diabetes). All such persons require extensive medical care, possibly with hospital services. Much of the care is provided at home, where conditions are rarely favorable. Very few homes are equipped with proper sanitation, ventilation, light and heat, or accessibility to the outdoors. How many families can regulate their home activities to the needs of an invalid? Generally, it is the latter who must make the physical and emotional adjustment. Of more importance is the lack of professional services, such as nurses services, and a planned routine of recreational or occupational activities. While

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the community could provide the nurses it is doubtful if the total need could be met by home visits. T h e nursing home is a better solution. It meets the need for an intermediate type of care between the home and the hospital. Because the number of patients is small, the atmosphere is homelike, and the patient is given a normal interest in every day life. T h e emphasis is on custodial rather than restorative or rehabilitation services. T h e problem of providing proper and adequate facilities for the long-term ill has been closely studied by the Commission on Chronic Illness, a group formed in 1949 by the American Medical Association, the American Hospital Association, the American Public Welfare Association and the American Public Health Association. Now an independent agency the commission has developed a broad program of research and education into chronic illness and its effects. T h e group sponsored a national conference on chronic disease in 1 9 5 1 , provides an excellent publication, and has undertaken several research projects, including a survey of the extent of chronic illness and the development of a model community plan for surveying facilities for the care of the chronically ill. It is generally agreed that chronic patients need specialized care in separate institutions; after the acute stage of illness is passed they should not be retained in general hospitals, where the facilities are unsuited to chronic patients and the necessary care too costly for most of them. Maintenance of a large professional staff and the upkeep of equipment and plant bring the daily cost of hospitalization to a prohibitive figure if the patient must remain for several months. Compromises are necessary and result frequently in neglect of the chronic patient and an undue financial burden to the general hospital. Special hospitals for chronic disease combine the services of a general hospital with the advantages of a nursing home on a large scale. T h e y are designed to give the chronically ill every service for their comfort and restoration to health in so far as possible. T h e y are organized in such a way as to provide every scientific facility for diagnosis and treatment and also custodial and domiciliary care, which, in kind, will depend largely on the nature of the disease. For the incurable cancer case there will be availa-

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ble skilled nursing care. For the hopeless paralytic and longstanding chronic heart case, custodial care. T h e r e will also be a constructive program of diversional and curative work formulated for each patient according to his physical condition and the probable duration of hospitalization and, wherever possible, leading gradually to vocational readjustment and employment. T h e social and economic burdens connected with long periods of disability are so great as to demand careful consideration. Relief rolls contain a considerable number of these cases. T h e National Health Survey disclosed that chronic illness has a definite relationship to economic status. Included in this large group are many who are the victims of crippling diseases. Any disease or disorder which leads to incapacity could be called a crippling disease. For example, a patient's capacity to work can be limited by a disorder of the heart, lungs or kidneys, but here the term is conveniently restricted to disablement of the locomotor system. Among the more important causes are the chronic rheumatic diseases. Probably no single medical disorder leads to greater individual suffering and loss of efficiency or to greater national cost. Today chronic degenerative diseases stand as the last barrier to longevity. In 1901, the life expectancy of white males was 49 years in the United States. In 1951 it was 67.2 years. But long life is not always an unmitigated blessing, since a person rarely reaches the age of 65 without some symptom of chronic disease, illness, or physical or mental deterioration. There are two types of senility. In one, degenerative changes occur in the blood vessels of the brain without pronounced changes in the brain itself. These patients live to be very old without strokes, conserve their mental faculties (witness the late George Bernard Shaw), although some reduction of mental energy may take place. T h i s first type may be called normal senility in contrast to the type in which severe mental deterioration is associated with greater changes in blood vessel and brain. T h u s we have physiologic or normal old age and pathologic old age (in which senile features appear prematurely or to an extreme degree), and all the gradations between these two. T h e marked increase in longevity is one of the significant aspects of public health progress in the twentieth century. T h e

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phenomenon is more than a simple actuarial calculation; it carries social repercussions that are bound to affect our way of life. Dr. Howard A. Rusk of the N.Y.U.-Bellevue Institute for Rehabilitation and Physical Medicine estimates that by 1980, one out of four workers will be disabled, one will be chronically ill, one will be over 65 and only one will be what we call "normal." Advances in medical science have increased longevity, but our society has not yet found a way to provide economic as well as physical survival. T h e years to come will see increasing numbers of those whose lives are prolonged, while the war toll of young adults will probably continue to add to the disproportion. T h e problems incident to the phenomenon are many; not the least of these will have to do with the tremendous economic and political aspects of pensions and social insurance. It is significant that, although the percentage of older people in our population is increasing, the percentage of older people in our working force is decreasing. Increasing urbanization is responsible for this; fewer and fewer persons are self-employed on farms where they can work as long as they choose. Instead, they are employed in industries where the arbitrary age of 65 has been established as the formal end of a man's usefulness. Industry shows a tendency to take an arbitrary attitude toward the worker over forty, considering him superannuated, a man of decreased productivity and increased accidental risk. None of these allegations has been proved. On the other hand, the record of the older war workers was as free of accident and as good in proficiency as that of younger workers. But the employers are not entirely mistaken about age as a burden and increasing liability. Many of their prejudices have been confirmed by the newer knowledge concerning the process of aging. A person who has regarded the man of sixty as full of intelligence and wisdom, having, through training and experience learned to solve the problems of daily living quickly and successfully, would be amazed to hear that, at sixty, mental energy and many mental traits (such as memory) may be far below those of the man of twenty. Furthermore, it might be disturbing for him to hear that full learning capacity is reached at fifteen years of age. But these facts are essentially admitted by scientists who have made a serious study of the problem of aging. While there is

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considerable disagreement as to what constitutes intelligence, mental capacities, mental energy, aptitudes and traits, and as to whether these aspects of mental function are a reflection of a single mental power or a select group of mental powers governing our actions, there is no disagreement about the effects of aging on this power. As contrary evidence, reference is frequently made to the great accomplishments of men of great age—Goethe, Copernicus, Michelangelo; but a careful review of their activities discloses that the work they did at an earlier age was revealed only at a later date. Furthermore, investigations of achievements in science, literature, military science, business, and industry reveal a high proportion of young men as leaders. Actually, the process of aging is an inexorable one. Decreased functional activity for most bodily functions sets in at least at the age of thirty and in the case of the eye as early as twenty. What then shall we say of the man of sixty? T h e answer is obvious; the slow and steady decrease in body efficiency becomes considerable at sixty. It is true that there are those who despite the passage of the years retain their bodily vigor and mental faculties to a surprising degree, while others at a much younger age are old both in body and mind. Pensions and other social measures for the aged recognize this reduction in efficiency and industrial usefulness. T h e aged, therefore, become a definite part of the group of the chronic disabled. T h e needs of the group have been outlined: more adequate medical treatment, special hospitals, sheltered conditions of work, and pensions for the severely disabled. T h e modern attitude differs from previous attitudes in considering this group a source of considerable labor supply and productive work capacity. This was amply demonstrated in war work and even before the war, in special industries that endorsed the view employing none b u t physically handicapped, the majority of whom are severely disabled. T h e attitude of official agencies has also changed in that consideration is given to rehabilitation, to providing assistance and services in vocational adjustment. In other words physical disability has no meaning except as it refers to what an individual does to solve his own problem and what private and public agencies will do for him in easing that burden.

PART

II

Principles of Rehabilitation

Chapter VII PHYSICAL RESTORATION

T

HE physician has always been interested in the total welfare of his patient, in his physical, mental, social, and vocational recovery. This is what he means by the word cure, a term which has conditioned his whole concept of treatment. By it he understands that he is to obtain for the patient relief from symptoms, the restoration of working capacity and the capacity to engage in all the routine pursuits of life. This, too, is the aim of rehabilitation. T h e two terms are therefore synonymous. T h e treatment of a fracture, or pneumonia, or gastric ulcer has as its goal the restoration of the individual to his pre-illness status. But these accidents and illnesses are only temporarily disabling, although many months (as in the case of fracture) may elapse before full function is restored. Normal working capacity is anticipated after the relief of symptoms and the return to normal function. In the military services, return to duty was expected after the natural resolution of disease and injury had taken place and all the devices of modern medical and surgical management had been applied. Frequently recovery was delayed, however, not so much by the disease or its complications as by certain concomitants of a long illness. These by-products have been recognized, but they have not been adequately evaluated. During the course of illness something happens to the patient that is only in part dependent on the morbid process which laid him low. Rest in bed and immobilization bring about a subnormal level of functioning. Few laymen fully appreciate the ravages of inactivity, although everyone is familiar with the slow progress of a patient who is not anxious to return to duty or go back to an unpleasant home or a difficult work situation. T h e labels "goldbricking" and "hospitalitis" have been applied to cases of this kind. T h e military services were quite aware of the physical and mental deterioration resulting from prolonged convalescence. T h e loss of man power vital to the needs of war service directed

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attention to the causes of this serious condition and toward ways and means of preventing and correcting it. Correction required no special miracle. T h e armamentarium was already there: physical therapy, physical training and conditioning, and occupational therapy had been in use for a long time. What was needed and what was inaugurated was a system whereby these methods could be used effectively to reduce the term in the hospital and send the patient back to duty not only relieved of his symptoms but ready in mind and body to resume his task. This was the philosophy behind the rehabilitation program in the Royal Air Force, the Army Air Force, and the Army and Navy. Specifically, all patients were divided into groups according to the stage of convalescence. T h e bed patient (Group 4) was given suitable exercises by a trained instructor under medical supervision, and the hours of the day were carefully apportioned between occupational therapy and educational activities. T h u s there was no time for the development of mental fantasies or wasted muscles. Physical and mental activity provided not only improvement of specific muscles but indirectly improved the entire circulatory system. Indirectly, too, the digestive and metabolic system benefited, so that recovery time was cut in half. For the ambulatory patient (Group 3) a more vigorous program of exercise and occupational therapy was instituted, still within the tolerance of the patient's physical capacities. For the advanced ambulatory patient (Groups 1 and 2), soon to be discharged or returned to duty, an intensive program of physical conditioning was carried out. This included strenuous sports like basketball and all the tough assignments—even a fifteenmile hike with full pack—necessary for graduation back to service. T h e three elements in the program, then, were the physical conditioning, occupational therapy, and educational services. Physical conditioning included physical therapy with the timehonored means of heat, massage, electrotherapy and hydrotherapy where specifically required, as in the sequelae of fractures, infections, and nerve injuries. It also included the employment of all physical training measures, including individual and group calisthenics. For individuals partially immobilized by a plaster cast the exercises were modified. In other words the

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gymnasium and athletic field were brought to the bedside. T h i s was literally so, in that portable apparatus was frequently used on the ward. Even modified badminton and ball games were played by patients in bed. For the ambulatory patient a wider range of activity was possible, both in the gymnasium and out of doors. In no gymnasium would you see a stranger crew of athletes. T h e man skipping rope had a broken ankle; the one with a metal plate in his head was wrestling with an opponent who hopped around on a bandaged foot; the lad with six bullet wounds in his left side was chinning the horizontal bar; while another with a shattered thigh bone punched a bag. Circling around these lads were three men on roller skates; each of the skaters had left a leg in the South Pacific. A n important part of the convalescent training program was the use of occupational therapy. T h i s had come of age. It had graduated from the basket-weaving, embroidering, and beadmaking era of the last war to a comprehensive and integrated service with valid objectives. Many of these former modalities are still used, as are a host of additional activities—leather work, fly-tying, knotting, miniature gardens, finger painting, airplane models. All these bed activities help to immunize the patient against the virus of hospitalitis with its indolence, procrastination, and lack of ambition. T h i s is also true of the beneficial effects on patients with heart disease, arthritis, and tuberculosis. These arts and crafts are also employed for their functional value, in that they supplement the work of the physiotherapy departments by reeducating a partially paralyzed hand, or a stiff wrist or shoulder following fracture, or the impaired use of the hand following infection. But weaving on a loom or making a leather wallet or purse or a beautiful vase is no physical preparation for return to employment as a riveter, a construction worker, or a coremaker in a foundry. T h e activity must present in capsule form a preview of the essential physical demands of the job. For example, if a bricklayer has a disabled hand we do not ask him to carve a few boat models in balsa wood, but give him a thousand bricks and have him build a wall, a house, or perhaps, at the start, simply arrange the bricks in a design on the floor. He commences his

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task with a certain misgiving; he cannot manipulate more than a few bricks in an hour. But day by day the number increases until he finds himself able to handle as many bricks as he would under normal work conditions. Similarly, a sign painter who was uncertain whether his stiff shoulder would permit him to pull the ropes that raised and lowered his swinging scaffold was conditioned to the work demands by the construction of an overhead pulley attached to weighted bags of sand. When he could lift a sufficient weight he knew he was ready for work. Of course it is not always possible to duplicate a patient's work place or work condition (only Hollywood could do that). But for a steam-shovel operator, the other patients, under the direction of the clinic engineer, could build equipment that in all essential respects would be similar to the levers and pedals of the actual shovel. T h e best occupational therapy, therefore, is to have a man exercise with the tools to which he is accustomed. By so doing, he does not have to learn a new technique, the proper muscles are utilized, and he himself is able to note his progress and help decide on his fitness for work. An occupational therapy department that is properly equipped and manned works in close harmony with the physical therapy department. It should include three sections: (1) a program of arts and crafts which can be taken to the patient's bedside; (2) a special shop or department on the hospital compound that will provide as wide a variety of activities as personnel and finances will permit. T h e basis of such a department is a carpentry or woodworking shop, and to this can be added a weaving room with various kinds and sizes of looms, sewing machines, and equipment for printing, besides the customary handicrafts. (3) T h e third would be the prevocational shop to act as a laboratory for evaluating aptitudes in order to help him find interesting and suitable work. Training of this kind would apply to those who had no fixed type of employment, or were marginal or casual workers, and also to those prevented by permanent disabilities from returning to their former work. Activities that could be used for this purpose are printing and bookbinding, sign painting and commercial art, jewelry and clock repair, electric work, machine and metal work, drafting, radio repair, shoe repair and clerical work, including typing, penmanship, book-

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keeping and the operation of business machines, mimeograph, multigraph, ditto machine, adding machine and comptometer. O n e feature of the rehabilitation program in service hospitals was developed to a greater degree in the Navy than the Army. T h i s was the establishment of educational services, which varied in content and scope from providing simple reading material of trade, business, or occupational interest to intensive courses of study leading to the completion of high school credits and to a promotion in rate. T h e service supplemented the physical conditioning and occupational therapy of the convalescent. It was of limited value, only, for the short-term hospital case, but was of greatest value in the lengthy hospitalization of the orthopedic and plastic surgical cases, as well as those who were planning for the future after their discharge with permanent disabilities. A t present, the Veterans Administration is carrying out in its hospitals this same type of educational service, with very good results. (See Chapter 5.) W e have been discussing the role of physical conditioning and convalescent training in expediting the process of recovery in those cases where restoration of former working capacity can be expected from the natural resolution of the disease or injury. T h e r e is another category of patients in which restoration to the previous social and occupational status cannot be obtained by ordinary medical and surgical measures. Because of residual impairments, all the resources of treatment fail to bring about return of working capacity. T h e man who has lost his arm can no longer play the violin. W i t h a permanently stiffened knee the longshoreman is useless at his old job. Prolonged illness with its enervating psychic trauma may so alter a salesman's personality as to make it impossible for him to fill his former position. Nevertheless, every effort should be made to discover whether the maximum physical restoration has been achieved, even though the disability is of long standing. In surgical cases this may be accomplished in three ways; by surgery, by functional reeducation, and by prosthesis. T h r o u g h the use of standard orthopedic operations, physical disability may be reduced and function increased. Permanently stiff joints following fracture or infection may be made movable through arthroplasty. T h i s is an operation in which the anky-

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Physical R e s t o r a t i o n

losed or stiffened joint is pried open with appropriate tools, diseased tissue or overgrowth of bone removed, the joint reshaped into its normal relationship, and a metal cup inserted to provide a smooth gliding surface for joint action. Other joints that have been left with marked restriction of movement following injury or infection can be considerably improved by operations designated as capsuloplasty and synovectomy. In these operations the joint is opened and all the diseased tissue causing a blocking of movement like a jamb in the door is removed from the interior of the joint. Secondly, tight bands of scar tissue which envelop the joint are cut in such a way that freedom of movement is restored. These methods are possible without endangering the patient's function and are specifically designed to improve the range or motion by removing both the internal and external sources of obstruction. Individuals who are permanently disabled because of fractures that have failed to unite require stabilizing operations to restore their working capacity. In the leg below the knee, a common site for ununited fractures, the patient is unable to bear weight or to walk without braces or crutches until the bones of the leg are stabilized. This is accomplished by bone grafting. In this procedure, bone is removed from the sound leg, or even shifted from the affected leg, in such a way as to form a bridge across the ununited area; after a period of eight to ten weeks it becomes welded to the underlying bone and provides a firm framework able to withstand all the demands of weight bearing. Paralytic deformities may be helped by changing the mechanical conditions by surgery. For example, after severe involvement of the foot muscles by infantile paralysis the patient is left with a flail foot that is unable to support the body weight because of the lack of power to hold the ankle in a stable position. By fusing the ankle joint and the small joints adjacent to it, the foot and ankle become stabilized and able to sustain the weight of the body. T h e patient is then able to walk unaided without a brace. T h e fusion process is accomplished in many ways. One way is to r u n a skewer of bone through the joint to act as a bridge across it. Still another method is to expose new bone by removing all the cartilage from the joints to be fused, and by holding them

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together until the raw bone on one side grows to the raw bone on the other. Paralytic cases can also be materially helped by tendon transplantation. Because of the human safety factor, live tendons can be shifted to take the place of paralyzed tendons, without destroying function. For example, at the side of the foot there are three tendons all of which have the function of turning the foot outward. One of these may be removed and transplanted to the tendon which normally pulls the foot upward, without destroying the outward-turning function of the two remaining tendons. Similarly, the knee is surrounded by many tendons that can be utilized to establish function in a paralysis of the extensor muscle (the one which kicks the leg out and holds the knee in a straight position). T h e application of these procedures may be illustrated by the case of a nineteen-year-old aviator who crashed, sustaining injuries which threatened his life. A fracture of the skull, a facial paralysis, a compound fracture of the right elbow, a fracture of the spine, internal injuries, compound fracture of the right ankle, and paralysis of the left foot with resultant foot drop were the immediate sequelae of the accident. T h a t he lived was a tribute not only to the excellent medical attention he received but also to his own physical resistance, his safety factor. It is difficult to kill a man. Four months later an evaluation of his condition showed that he had recovered from some of the injuries but was left with so many disabilities, together with a few new complications, that hope of physical or vocational rehabilitation seemed altogether remote. He had developed a severe deformity of the spine, a complete fixation of the right elbow, a draining osteomyelitis of the right ankle, and a persistent paralysis of the left foot. A series of operations was undertaken. A bone graft stabilized his weak spine, an arthroplasty gave him motion in his right elbow, the entire ankle bone was removed from his right foot in order to stop the infection, and a fusion operation was performed on the left ankle to give it stability. Three years after the accident the patient was able to walk without the aid of apparatus or special support and was attend-

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Physical Restoration

ing a course in aviation engineering with excellent grades and with a definite opportunity for employment. H e was turned down for the A i r Corps, but ran a private training school for civilian flyers. A twenty-nine-year-old chauffeur presented himself for treatment for an ununited fracture of the right tibia and fibula sustained in an industrial accident three years earlier. He had had six operations, including several grafts, all of which failed to produce union. H e was again operated on with a massive bone graft, resulting in complete union and a good weight-bearing leg. Employment was secured for him as a painter. A fifty-six-year-old man was referred for a reconstruction operation on his fingers which were ankylosed in an extended position as a result of an old injury. T h e fingers were stiffened in a bent position permitting increased function of the hand. He secured a position, himself, as a bill collector for a furniture store. Rehabilitation surgery not only increases function but may also remove a cosmetic defect. Improvement in the physical appearance is an important factor in helping the disabled person reach his objective. A twenty-year-old boy was severely burned by exploding gasoline. T h e extensive scars on his neck and arms were not only unsightly but seriously interfered with the function of his elbow. T h e removal of the scar in the elbow required a large sacrifice of tissue which could only be replaced by skin transferred directly from the abdomen according to modern methods of skin grafting. T h e operation resulted in almost complete restoration of function to the elbow. T h e greatest triumphs of plastic surgery have been in the removal of facial deformities and scars resulting from severe burns and other injuries sustained in warfare. T h e transplantation of skin and cartilage from one area to another again emphasizes the great power and resources of the body in maintaining its physical unity. Here, however, these resources must be supplemented by the technique, judgment, and training of the skilled plastic surgeon, together with the utmost courage and persistence of both patient and surgeon, since many of the procedures are longdrawn out, often requiring several stages at long intervals apart for the consolidation of the gains made at each step. N o t all the problems are complicated or long drawn out. A

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boy who was born with six fingers on one hand f o u n d it impossible to secure employment because of the extra finger. H e was repeatedly told that it would be dangerous to employ him, because "you have too many fingers," implying that he would be sure to catch one of them in a machine. T h e removal of the extra finger made him a " n o r m a l " boy. If physical conditioning and convalescent training is desirable for the short-term hospital patient with pneumonia, hernia operation, or appendectomy, it is mandatory for the long-term case. Most illnesses and injuries requiring prolonged rest in bed are complicated by a chain of disabilities flowing directly from the long period of inactivity. T h e r e is first of all a loss of what is called muscle tone, a flabbiness develops that is not present in normal muscle. Added to this is a loss of heart muscle tone; this also is a condition of flabbiness that diminishes the power to send blood throughout the tissues to maintain their normal function. T o the many anxieties arising from personal and financial problems that affect the patient's will to get well must be added loss of cerebral tone, a flabbiness of function of the intellectual and emotional apparatus. Recent years have emphasized the unification of all living processes and the interrelation and interdependence of the physical and mental capacities of the body. Inactivity does more than invite day dreams. It destroys the powerful integrating reflexes and habits that have been built u p by the discipline of day-to-day living under the restraint and stimulation of personal needs, family demands, school, and occupational requirements. W o r k is not merely an activity; it is an emotional release, a stabilizing force in daily living. Inactivity destroys this energizing factor. T h i s is the great social tragedy behind the degradation associated with unemployment. It is a double burden for the unemployed w h o is also physically handicapped. T h e natural healing properties of living tissues can be stimulated and hastened by the judicious use of physical measures. By the development of the m a x i m u m physiological functions, a disabled person may find it possible to return to his former vocation and employment. T h i s should always be the primary goal of the rehabilitation service. Change of vocation is a severe strain on morale, especially if associated with a reduced earning capacity.

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Physical restoration cannot be achieved by piecemeal methods. Correction of a local disability is of no value if an atrophied body and mind still remain. T h e correction of all these defects is the aim of physical conditioning. T h e methods involved have already been described in relation to the short-term hospital case. T h e y are of even more important application to the long-term case, in which, however, more specialized care is required. Greater emphasis is directed toward the specific defect in an effort to reduce the physical incapacity and to hasten biological adaptation. T h i s can be illustrated by the case of a tailor who had an infection in his hand that left him with a disabling stiffness in the hand and fingers. T h e disability was so severe as to make it necessary for him to reconstruct his social and industrial life. T w o courses were open to him: to seek employment at a very much reduced earning capacity or to obtain further medical aid with a view to improving the physical condition of his hand. By a course of intensive after-treatment, utilizing all the means available in the field of physical therapy—massage, splinting, manipulation, hydrotherapy—the tissues were improved to a point where increased motion was obtained. Among the large group of the disabled who seek the services of rehabilitation agencies, the amputation case is one that requires careful consideration. Many rehabilitate themselves, because their educational or vocational resources are unimpaired by the handicap, or because they have well-adjusted personalities, or because of fortuitous circumstances. On the other hand a larger number are unable to help themselves. For them employment is facilitated by providing artificial appliances. By replacing the lost member, the prosthesis serves to remove the psychological aversion toward the crippled and offsets the prejudice of the employer through the increase in the patient's productivity and working capacity. On discharge to civil life the amputee is faced by a triple threat to his scheme of life. First of all there is the physical defect, imposing upon him a distinct disadvantage in the competition of everyday life. T h e n , too, there are the thousand and one emotional reactions he must undergo, from severe depression to the elation that comes with the sense of safety upon returning "stateside." Lastly, he must meet the truculent attitude of society and its wall of rejection.

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Physical restoration can minimize these threats in many ways. In the first place, through surgery, physical therapy, and occupational therapy, convalescence is accelerated and the stump prepared for an artificial appliance. T h r o u g h the latter the means of function is restored. W h i l e function may be restricted, in some instances full duplication of that lost by amputation is frequently obtained. T h i s is the case in below-the-knee amputation, particularly if great pains are taken to secure accurate limb fitting. In those who suffer amputation above the knee, full restoration of weight bearing and walking is not always possible, but the majority give remarkable performances. T h e upper extremity is more difficult to replace by artificial appliances; it cannot be duplicated like the lower leg, it can only be imitated. Fitting the arm amputee with a prosthesis requires not only mechanical ingenuity but discriminating psychological analysis. Many prefer to get along without a prosthesis. For the majority, however, apparatus is necessary. In the latter case the prosthesis must be fitted to the patient's whole personality—not to his stump. A n arm with a hook attachment will satisfy the work requirements of most individuals. However, for the man who has to meet the public in professional or public relations, utility has to be sacrificed for appearance. In any case, the fitting of these appliances is the fundamental step in the patient's whole rehabilitation plan. It is not enough that amputees be fitted with an appliance. T h e y must be trained in its use in order that their work or training program does not have to be interrupted by surgical attention to the stump or major repairs to the prosthesis. T h e y are taught to drive a car, walk up and down steps, and condition their stumps to a full day of weight bearing. W i t h his hook, the amputee works in the special workshops until he has completed a specific project, such as a table or bench, or until he has satisfied the supervisor that he has learned the rudiments of the use of the hook. But physical restoration is more than the furnishing of artificial substitutes for the lost parts. It is complete only when a reintegration of the patient's whole personality has been achieved. T h i s was the idea behind the program of the Royal Air Forces in England. Rehabilitation centers were established to eliminate the physical and mental factors that favored a continuation of

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the disability. In many cases, months after surgical treatment had been completed the incapacity was still total, because minor disease changes remained, confidence was lacking, and morale had been destroyed. T h e body had been treated but not the mind. T h e treatment of fractures had been concentrated on securing union of the fracture. No treatment had been directed to the tone and volume of the muscles, stability of the joints, the circulation of the limbs, the control of edema, the relief of adhesions. It had been assumed that when a man was discharged from a hospital he soon returned to work. However, investigation of industrial accidents disclosed, for example, that a simple operation on the cartilage of the knee had been followed by ten months of incapacity. It was not realized that stiffness, swelling, weakness, and wasting might appear insuperable difficulties to many patients—who after all are inexperienced, who fear that the weakness may be permanent, who are overwhelmed by the prospect of normal work with its strains and hazards, and who express their fears in symptoms of neurasthenia and malingering. Through organized physical and recreational activities, rehabilitation centers strive to overcome residual disease changes, restore confidence in the completeness of recovery, and bridge the gap between the exercises given in the fracture ward and the stresses of normal work. We have been discussing the physical restoration of surgical cases, fractures and amputations, and the crippling defect of paralysis, nerve injury and arthritic deformity. However, physical restoration has also demonstrated its value when used for medical cases, such as heart diseases and tuberculosis. T h e modalities of physical restoration can be applied to provide remedial services in almost all types of disability. Present rehabilitation legislation has enlarged the scope of services to include other than the strictly orthopedic cases. Thus, large numbers of persons with employment handicaps due to chronic medical disease or mental illness have benefited from the techniques and principles of rehabilitation that were first applied to the orthopedic cases. More and more, physical restoration is coming to mean integrated medical care.

Chapter VIII REHABILITATION CENTERS

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ANY advantages are to be gained by concentrating services for the physically handicapped in one place. In a rehabilitation center, complete services can be made available for the training of the amputee in the use of his artificial limb; the hard of hearing can have their hearing devices selected, tested, and adjusted; the severely disabled can learn how to meet the physical demands of daily living; the orthopedic case can receive further physical conditioning; the medical and surgical case can test and rebuild his work tolerance; the partially productive individual who cannot find a place in the full production line can be given sheltered employment. All these and more are the beneficiaries of the services of a rehabilitation center. Aside from the obvious advantages of time saving there are greater advantages to be gained from an integrated rather than a piecemeal type of service. Physical therapy for example, is practiced universally by physicians and physical therapists. Yet a limited value is obtained from this important type of treatment because it is not coordinated with other forms of treatment. A stiff elbow following fracture will show some improvement after twenty minutes of heat and massage. But if this is followed by specific exercises under competent supervision, and not left to chance or the casual direction to use it as much as possible, still greater improvement can be expected. If in addition, the patient is given a project which will call into play the active motion of the arm in carpentry, operating a printing press, or in cutting and embossing leather still greater improvement can be expected. Rewards derived from the completion of a beautiful piece of creative work or from remuneration for this activity provide additional mental and emotional benefits. T h u s a full day's activity built around treatment provides physical and mental improvement that cannot be duplicated by any other procedure. Furthermore, the concentration of facilities in one place fosters a contagious spirit of teamwork and cooperative effort on the part of

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all personnel that is bound to be reflected in the heightened morale and general improvement of the patient. T h e aim of planned and integrated treatment is the restoration of handicapped persons to productive employment. T h e aims of piecemeal and unorganized treatment may be the same, but they cannot be realized without the kind of planning and continuity found in the procedure of a rehabilitation center. T h e program of physical conditioning and convalescent training in military establishments has endorsed this idea and practice. Coordination of services in a single facility such as the rehabilitation center has economic advantages as well; it avoids the loss of time, labor, and money through duplication of services. T h e general hospital, with its necessary emphasis upon acute cases, cannot provide the long-term, integrated care that is possible in a rehabilitation center, nor can the private physician afford the equipment, space, and personnel to provide these services in his office. T h o u g h the idea of rehabilitation centers has been dramatized by military experience, it has had a long history, one that has had only limited acknowledgment in public practice. Orthopedic hospitals have utilized the services of physical therapy departments and gymnastic training for a long time. Social service departments in special and general hospitals have given some assistance in the rehabilitation of physically handicapped persons, but they have been hampered by the lack of government aid— the backbone of the modern program for the disabled. One of the first centers to be established in the United States was the Red Cross Institute for the Disabled, created to meet the needs of the training of casualties of World War I in 1 9 1 7 . Except for the establishment of an artificial limb manufacturing department, physical restoration played a minor role in the program; emphasis was placed on vocational training and adjustment of the severely disabled. Now called the Institute for the Crippled and Disabled, the center is housed in large modern quarters in New York City, and has been a leader in the field of rehabilitation for nearly thirty-five years. Its comprehensive program includes the following: shop for the manufacture and fitting of artificial limbs and training in their use; classes for the physical adjustment of the severely disabled, including hemiplegics and para-

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plegics, teaching them to perform the necessary routine of everyday living—getting in and out of bed, dressing, eating, walking, and learning to master the difficulties involved in traveling. T h e institute provides facilities for services of vocational guidance and selective placement, together with adequate follow-up. It has facilities for a limited number of resident patients. In addition it has served as a teaching center for students in the fields of physical medicine and rehabilitation. T h e Institute played a major role in the establishment of the New Jersey Rehabilitation Clinics in 1919, which continued to operate until 1945. When a legislative program was first being considered in the United States, the experience of the Institute was influential in shaping its organization and development in New Jersey. During this period more than 7,683 individuals received the services of physical restoration in these clinics. This physical restoration phase of rehabilitation was emphasized since it was found that the majority of the disabled could be restored to employment if their disabilities were fully and completely treated. T h e clinics were equipped as orthopedic and physical therapy clinics with special types of functional reeducation devices and apparatus that would permit active use of injured or disabled limbs. But in conjunction with the physical treatment there was available a curative workshop equipped with carpentry, painting, printing, photography, and similar work operations to supplement physical treatment. T h e use of the curative workshop is today an established principle. Designated by various names—industrial, curative, sheltered, occupational—these shops have three objectives: to restore function, provide sheltered employment, and to determine work capacity. Of these three objectives, the curative workshop attached to the Newark Clinic of the New Jersey Rehabilitation Commission was concerned primarily with the restoration of function and the determination of work capacity. T h e workshop was unique in that it was the first to be associated with a Workmen's Compensation Bureau. It was equipped as a complete woodworking and paint shop, containing all the tools used in carpentry and cabinetmaking with the exception of automatic machinery. It also provided a complete print shop with type cases, presses, and associated material.

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Show-card writing, photography, and artificial-flower making were added occupations that provided a wide variety of operations consistent with physical capacity. T h e activities were divided into three classifications of practice: light, standard, and heavy. T h e patient could pass from one to another as he demonstrated his ability. T h e activities lasted a full day, if the condition of the patient permitted, in order to stimulate the demands of ordinary work on a full-day basis. As a result of this combined treatment in the clinic and curative workshop, 7,683 cases were rehabilitated. Of these patients, 2,434 had disabilities which required treatment from three months to two years, frequently preceded by long periods of treatment and disability prior to coming to the clinic. Yet 6,433 were restored to their jobs without the intervention of vocational training or guidance. T h i s job restoration was accomplished after varying periods of treatment; 5,250 after three months, 727 after 6 months, and 656 after 9 months; 1,251 cases were turned over to the vocational director for training and placement, as they were unable to return to their former employment. A n early rehabilitation center was established in New York City in 1922 by the American Rehabilitation Committee, Inc. It was known as the Curative Work Shop for the Disabled. It has been operated continuously, providing vocational reconditioning services for all types of disabilities, since that time. It is now known as the Rehabilitation Center for the Disabled. It is located at 28 East 21st Street, New York City. It was established primarily for the post-traumatic cases complicated by neurosis. This reconditioning service is known as work therapy. It is not a production work shop. It offers many kinds of work and uses them for the rebuilding of physical and work capacities. Since 1943 it has had in weekly attendance orthopedic and psychiatric consultants. It has also opened its doors to the emotionally and mentally ill. Its work activity services have been found extremely helpful in the readjustment of these latter persons to the social and vocational life of the community. Rehabilitation centers and curative workshops have also been established in various places under community supervision. In Milwaukee, the curative workshop provides physical therapy and occupational therapy for young and old and for all types

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of handicaps, and is partially self-supporting. One of the most comprehensive is the Cleveland Rehabilitation Center, which provides a complete outpatient physical restoration service for all kinds of disabilities. It includes a large physical therapy department, a pool, and a curative workshop. For the severely disabled it offers extensive occupational therapy, vocational training, guidance, and facilities, together with transportation facilities, and provides sheltered employment in a wide variety of work activities such as reconditioning furniture, upholstery, sewing, and so on. Within the last decade, several additional rehabilitation centers have been opened in various parts of the country. In N e w York City, a two-million-dollar Institute for Rehabilitation and Physical Medicine was the first building to be erected in the developing New York University-Bellevue Medical Center. T h i s rehabilitation center, under the direction of Dr. Howard A. Rusk, has earned world-wide professional recognition in the short time since it was started. T h e Woodrow Wilson Rehabilitation Center, in Fishersville, Virginia, the Rabat-Kaiser Institutes, and the Kessler Institute for Rehabilitation (of which the author is medical director) have all been established as voluntary, non-governmental centers for the rehabilitation of handicapped persons. All these centers owe their existence to the whole-hearted support of the communities of which they are a part. One of the outstanding institutions in the country is the chain of shops known as the Goodwill Industries. T h e y are located in 93 cities in 35 states, Canada and the District of Columbia. Established originally as a philanthropic and religious movement, they have developed into a sound national system of sheltered workshops with ramifications of such value as to require special discussion. T h e shops developed out of the skillful utilization of discarded material. T h e collection, reconditioning, and sale of material, with the attendant promotion and office activities, have afforded opportunities f o r the development of many skills, the teaching of some trades, and millions of hours of productive employment as the material is converted into useful products. Most of the operations are concerned with the reconditioning of furniture, household appliances, electrical and

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mechanical articles, clothing, shoes, dolls, and similar material. In a small number of these shops, manufacture of new goods is also undertaken, thus giving an opportunity for craftwork. These activities provide repetitive operations required for certain of the more seriously disabled persons, and the craftwork itself is an outlet for their artistic skills. Many are so seriously handicapped that they must be transported to the shops in special conveyances. These are the arthritics, hemiplegics, paraplegics, and others with serious visual and cardiac disabilities. With the exception of on-the-job training for handicapped veterans, generally those with minor disabilities, industry has not carried on any extensive rehabilitation programs. Organized treatment from the day of the accident to the date of r e t u r n to employment is the exception rather tlian the rule. Industry has been content to provide treatment prescribed by law, which does not include rehabilitation in the larger sense of the term. Physicians engaged in large-scale industrial-accident practice have from time to time organized compensation clinics where emphasis has been placed on volume and therefore hurried treatment. This mass-production treatment has no relation to the modern conception of rehabilitation. T h e use of a heat lamp in the treatment of an injury to the shoulder for fifteen minutes three times a week without any further treatment or associated activities designed to rebuild the function of the part and to maintain the entire body in good mental and physical condition is a travesty by modern standards. Several insurance companies have attempted comprehensive rehabilitation methods only to meet with political and legislative limitations on their efforts. However, progressive employers and insurance companies are not dismayed by these obstacles and are proceeding with the establishment and development of rehabilitation centers. T h e clinics of the Liberty Mutual Insurance Company in Boston, and the Employer's Mutual Insurance Company in Wausau, Wisconsin, are examples of this progressive effort. Other companies have given serious consideration to the benefits of an integrated program: in this, the Workmen's Compensation Clinic at T o r o n t o has been outstanding. It has stressed the technique of full-time treatment as the only satisfactory way in

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which disability can be reduced and function restored, thereby permitting the earliest possible return to work. T h e clinic activities are allied with the entire administrative procedure of Workmen's Compensation, so that work restoration and pensions are closely related, and the primary goal of restoration to work emphasized. T h e Toronto clinic has been a strong exponent of reproducing the man's original work activity as part of rehabilitation treatment rather than types far removed from it. Rehabilitation centers have a professional and moral responsibility to educate the profession and the public through the establishment of clinics, lecture courses for therapists, nurses, and physicians, educational films, student in-service training, and publications. T h e public is educated, too, about the nature, causes, and prevention of handicaps, and about the potentialities of the rehabilitated handicapped patient. T h e community must maintain its interest in the rehabilitation center's work, so that the patient can be discharged to acceptance by, and productivity in, the community to which he must inevitably return. Research is a vital, though often neglected, aspect of rehabilitative work. Facilities for basic and applied research should be part of a community center. Rehabilitation science cannot progress until we have the answers to some fundamental questions about the nature of physical disability and its effect on the human organism. For example, successful placement depends on our knowledge of how a specific physical disability has affected the patient's general working capacity; our presently inexact methods of determining physical fitness frequently hinder placement of a disabled person. T h e science of pathology is exact; we must have an equally dependable science to determine residual capacity and adjustment. One of the major potentialities for limited rehabilitation services that has been overlooked is the hospital. Certainly the individual who must spend a month or more in the hospital can use these services to advantage, and for the long-term case they are indispensable. Many of the larger hospitals, and some of the smaller ones, have physical therapy departments; a few, too few, have occupational therapy departments. By establishing a committee that would include one or more physicians interested in rehabilitation and that would work with the phys-

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ical therapist, the occupational therapist, the social worker, and the state rehabilitation agent, the services could be organized toward early restoration of health and employment. T h e active work of the committee could be channeled through a rehabilitation officer, who selects suitable cases and arranges for the various services required. T h e physicians may be general surgeons interested in amputations; orthopedic surgeons whose cases ordinarily run a long and chronic course; internists interested in the rehabilitation of cardiacs or pulmonary or neurologic cases; or the pediatrician interested in cerebral palsy or rheumatic fever cases. T h e function of such a committee would be to establish policies, approve and supervise techniques, and maintain professional standards at all times. T h e cooperative effort of this team would be employed in behalf of all the longstanding cases. Through this type of service, the handicapped can be assured of continuity of treatment, early and complete restoration of function, and return to gainful employment. One of the major difficulties in the establishment of community rehabilitation centers is the estimated prohibitive cost: actually, the cost of these centers is not as great as might be imagined and there are many ways of solving some of the specific financial problems. T h e Kessler Institute for Rehabilitation in West Orange, New Jersey, is an example of what the community can do with little money. T h e institute was established at a cost of $21,000 and is now entirely self-supporting through direct patient fees when the patient is able to pay part or all of the cost; fees from agencies and organizations referring patients who cannot pay; and donations which enable the institute to provide free service to patients ineligible for assistance from social welfare agencies. During 1950, the institute gave 17 percent of its services without charge, and 53 percent of its services for partial payment. T h i s was possible despite the fact that the institute, not being exclusively local, receives no help from the Community Chest, nor does it receive any assistance from the government. However, the entire attending and consulting medical staff of the institute serves entirely without compensation. In addition to providing services in the plant, the institute

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has a well-organized program of follow-up and home care for discharged patients. This center is a pilot plant and illustrates what the community can do for its physically handicapped population with much cooperation and comparatively little cost. T h e time will come when every community will have a rehabilitation center, just as it now boasts of modern hospitals, police stations, and fire companies. T h e center will receive severely and chronically disabled persons from hospitals, on referral from physicians and social agencies, and through the offices of charitable foundations and governmental agencies. Ideally, such centers will provide the complete range of services to patients, including physical therapy, occupational therapy, nursing and medical care, prostheses, vocational exploration and training, job placement, psychological assistance, home care and follow-up. It is not necesary to have so elaborate an organization for a beginning, however; after a modest start, services and personnel can be added as the need increases and financial support is obtained. In addition to patient care, the ideal rehabilitation center will provide education and research as well, thus operating a threefold program of maximum benefit to the patient and the community.

Chapter IX VOCATIONAL GUIDANCE

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HE art of vocational guidance has made rapid strides in the past thirty years. It has emerged from a nebulous status identified with phrenology, clairvoyance, and fortunetelling into a well-integrated system of techniques designed to help a man find the calling in life that promises him the greatest personal satisfaction and the maximum use of his talents. Stripped of bombast and pretension, it presents a system of ideas of immense practical and social significance. Financial gain and social status provide a form of ego satisfaction that differs in quality from the typical sense of well-being gained in the fulfillment of a real vocational interest. T h e boy who wanted to go to sea but who was persuaded by his family to study medicine may attain financial success and social position and still be a very unhappy man. Similarly, many a good baseball player has been lost to the arts and many a good artist or scholar to sports. T o match fundamental needs and physical and mental capacities to a vocation is the ideal of vocational guidance, but a goal that is rarely achieved. Such is the character of the human safety factor, however, that satisfactory adjustments nevertheless take place. T h e average individual is equipped to fulfill successfully the physical and mental requirements of at least thirty job families. If he chooses any one of these, the probabilities are great that he will be happy, efficient, and successful; and the ramifications of each job family are so vast that the chances of choosing a successful vocation are not 30 to 1 but more nearly 30 times 30, or goo to 1. Intuition and chance generally determine this choice. T h e fact that the physical and mental capacities of 998 out of every 1,000 individuals are so much alike accounts in large measure for the efficiency with which the world's work is done. T h e primary difficulty is to satisfy ego needs. T h e aim of vocational guidance, therefore, is to introduce rationality in the place of intuition, and fact for chance, in mak-

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ing the choice of a job objective. If this holds true for the socalled normal man, it is of especial application to the physically handicapped, since it is assumed that the choice of vocation is narrowed by the physical defect. Nevertheless, the principles of vocational guidance are the same for them as for those who are not handicapped. A man's vocational scheme of life cannot be separated from his total personality pattern. Nor can this pattern be discovered by a medical examination. It is a condensation of his whole life. H e is not merely a man with a stiff hip, b u t a man who comes from a small Western town, who has had two years of high school, who has worked in a machine shop for three years, who is married and has a family, who has abilities and aptitudes, interests, hopes and dreams of the future. It is important to expose as many facets of his make-up as possible. T o do this the counselor employs the tools of observation, interviews, tests, measurements and records. In addition to training and experience primary requisites are time, tact, and understanding. Observation in a hospital environment is obviously of great value in an evaluation of the patient's personality—its pattern (organized or unorganized), the manner in which he adjusts to the daily problems of living in the hospital community, his adjustment to specific individuals, to the general over-all idea of discipline and control, to the prevocational opportunities furnished by the department of occupational therapy. He may make many false starts, shifting his attention from one occupation to another until he finds a definite and sustained interest. T h u s the period of hospitalization can be used as an experimental laboratory for determining not only what he would really like to do but also for estimating how much he can do in view of his physical disability. This information will help to verify or disprove the choice recommended by the counselor. T h e real test will be the actual performance of the patient under normal employment conditions or under a close simulation of them. Short of the ideal control and supervision provided by the hospital environment, the only alternative is the interview or a series of interviews. T h e value of these will depend on many factors. T h e length of time devoted to them, conditions under which they are given, the attitude of the interviewer, and the

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rapport between client and interviewer will materially affect the results obtained. T h e single interview offers an opportunity to gain supplementary information and the multiple interviews for verifying old information or disclosing misinformation due to barriers established at the first interview. Clues are brought out that cannot be obtained by any other means. A frank discussion of a man's aims and ambitions may reveal a motivation that largely counteracts a mediocre test score. On the other hand, an appealing personality may cloak a fundamental restlessness that will deceive the examiner, unless adequately explored. A case in point is that of a good-looking boy of twenty, slender, and of average height. He had suffered a minor injury to the hand with some loss of usefulness of the thumb. While he was being treated as an orthopedic case it soon developed that the minor disability of the hand was no serious handicap. He changed his projects from week to week with a restlessness that spelled marked emotional instability. His first interview showed a high score on the vocational-interest locator in the art field. He had had some experience in this field on a school paper, and was now assisting in the preparation of hospital posters on the compound. It was felt that with this background a course in commercial art was warranted. Additional interviews revealed, however, that he was not interested in further schooling, had not entirely finished his highschool course, that his grades were not satisfactory, that he left school to join the Marines, and that his art interest, while predominating over any other, was not of a quality to indicate success in a highly competitive field where the minimum requirement was at least a high degree of skill. On the other hand, it was discovered that he was interested in people and liked to make a good impression on them, and that he talked easily and well in a group. He seemed to be better equipped in a field where personal relations were important considerations, as in salesmanship or promotional work. T h u s the interview discloses not only the presence or absence of emotional stability but even psychopathic traits. T h e pattern of personality—friendly or withdrawn, cooperative or aggressive —is also observed. T h e richness or the drabness, the creativeness of the individual's mental life, the sort of things he is interested

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in as hobbies, his attitude toward society, home and family, are all tapped in an exhaustive study of his personality. Information is thus obtained that cannot be recorded on the questionnaire schedule or on the score of the aptitude test. It is registered on the sensitive receptors of the examiners. T o this end the interviewer must have the requisites of warm and sympathetic appeal to the examinee. T h e amount of information obtained will depend in a large measure on the ability of the examiner to establish rapport with his client. In evaluating the total personality pattern, in addition to the outlook and extent of mental activity, it is important to explore the varying amount of aptitudes and special abilities he possesses, whether mechanical ability, clerical ability, manual dexterity, art or musical ability, or special motor skills, and more particularly his interests, aims, ambitions, drives, and strivings. Conclusions concerning these traits and characteristics may have already been determined by the result of interviews or as a result of actual observation in the course of the hospital stay. By the use of tests and measurements usually to supplement what has already been learned, a fairly complete picture is obtained of the range of vocational possibilities. T h e chief disadvantage of these tests is the tendency to rely too heavily on the scores and the failure to supplement them with equally important subjective information. Many of the tests have been borrowed from psychiatry and clinical psychology and adapted to the needs of vocational guidance. A m o n g these devices are the personality tests. By means of an inventory of the individual's attitudes toward the problems of daily living, his bodily health, habits, occupation, religious, social and sexual attitudes, as well as his family a n d marital relationships, moods, morale, phobias, obsessions, and compulsions, are exposed to the scrutiny of the examiners. By filling out a questionnaire of several hundred questions or by the simple expedient of sorting about 500 cards into three groups answering leading questions concerning his reaction to the routine pursuits of life by " T r u e , " " F a l s e , " or " C a n n o t say," the patient reveals himself to the examiner. For the industrialist, the inventory is presumed to serve as a subtle and infallible index to the virtues of fidelity, punctuality, productivity, respect for property, loyalty to employer, thus indi-

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eating a maximum of traits leading to productive and continuous employment and an absence of the characteristics of the troublemaker, the radical, and the chronic absentee. For the psychiatrist or clinical psychologist, the inventory reveals not only personality traits but also clues to psychoneurotic and even psychotic tendencies. Not all reactions to the tests, however, yield routine results or profiles. There was the case of the marine, for example, exposed to the heat and humidity of the tropics, a victim of malaria and dysentery, who during the rigors of an amphibious operation almost came to blows with his superior officer because of confused orders amidst the excitement and difficulties of the landing operation. T h e marine was threatened with a court martial for his insubordination. When tempers had been soothed, the officer thought better of it, since his own serious tactical errors would have been exposed to inquiry. Yet, it was necessary to remove the marine to maintain the discipline of the battalion. It was decided to have the recalcitrant marine transferred to the hospital as a case of "combat fatigue." Along with other battle casualties and N.P. cases he was evacuated to a large mobile hospital where a comprehensive program of diagnosis and rehabilitation was available. In the course of the examination by the psychiatrist, the marine was asked to fill out an extensive personality inventory questionnaire consisting of several hundred items. His first reaction was one of severe resentment and then of amusement. He answered one, two, and three questions. Finally he scrawled across the entire page, "Dear Doctor, there is nothing the matter with my head. It's my big mouth that got me down here." In addition to pen and pencil personality tests, vocational guidance also utilizes so-called projective techniques for ascertaining personality patterns. T h e subject is asked to interpret pictures with ambiguous ideas or meaningless forms such as ink blots. These apparently innocuous forms vary in shape and contour. T h e subject's reactions yield clues to his imagination and association of ideas and also to the way he solves most of his problems. T h e tests are based on the assumption that every individual lives in a unique world of his own and the pattern of that world

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may be revealed from his actions and behavior under controlled conditions. Under these conditions, an estimate may be made of his endowment and of the manner in which he deals with his own problems. U n d e r the careful eye of the observer the personality is unfolded in many subtle ways as an attempt is made to solve the problems presented by the test material. It will be revealed whether he is a friendly or outgoing personality, or a withdrawn seclusive nature; whether he is antisocial or aggressive, or eager and cooperative. T h e richness and creativeness of his mental life, his avocational interests, his attitude toward society, home and family, and toward rehabilitation are thus tapped. What is the personality pattern of the physically handicapped person? Is he a devil incarnate, a malevolent creature whose behavior inspires dread and a feeling of revulsion? Is he an object of pity from the very nature of his make-up? What do the personality tests reveal? D o they confirm prejudices of this kind, the secret primitive fears aroused by his plight? Or do they once and for all destroy these diabolical myths, these false legends? It has been customary to regard the physically handicapped person as a distinct personality type, with traits and qualities and impulses, fixed and irreversible, that set him apart from others. R e f e r e n c e has already been made to the deep-seated prejudice that has arisen from atavistic fears and have persisted to this day. Besides this, there have also been unscientific statements made by scientists attempting to associate structural forms with distinct mental patterns and characteristics. But perhaps the greatest disservice has been performed by writers who have created the image of the crippled and deformed as a definite stereotype. F r o m Dickens down to the novelists of the present day modern times, writers have been guilty of creating this false picture, an image which can only be dislodged with difficulty f r o m the m i n d of the average man. T h e same depressing attitude can be seen in the plethora of recent literature on the veteran's problems. It is also shared by the stage and cinema, where the returned soldier is so often treated as infantile, unable to think for himself, a hopeless psychoneurotic, a one-dimensional monster, a dour and melancholic character harboring a potentially destructive force in an

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unshakable grudge. Certainly there will be those whose war experience has produced mental trauma and residual mental scars that may fail to heal. On the other hand, there will be those who have been sufficiently matured and developed by their manifold experiences to assume leadership in public affairs. T h e majority return substantially unchanged, with a resiliency of mental and social adjustment that is the basis of human achievement and character. So, too, there are some physically handicapped persons who are overwhelmed by their disability and slump into the status of permanent burdens upon family, community, and friends. Others compensate for their handicap so successfully as to become outstanding in social and personal achievement. However, most make a varying but satisfactory adjustment to the daily demands of living. But does not the disability affect the development ot personality? Indeed it does, and may even dominate it. But for the majority, the physical handicap is only one of many factors shaping growth and maturity. T h e nature of the disability and the point in a man's life at which it occurs will influence his whole make-up. Nevertheless, it must be remembered that the total personality pattern is not a series of loose and unorganized values, but is inclusive. T h e physical disability is only one facet of that pattern. It is a mistake, therefore, to think of the cripple or the handicap as a personality type, seclusive, withdrawn, misanthropic, diabolical. T o think this way is to revert to demonology. But even personality tests may be one-sided and misleading. Developmental characteristics in the individual may affect the value of the test; a general anxiety or inhibition may be mistaken for a psychotic pattern, because it causes an apparent blocking. Thousands of these tests have been administered and tabulated; they are said to reveal certain consistent patterns in psychotic and prepsychotic individuals. Nevertheless, their value for the purposes of vocational guidance must be carefully and critically scrutinized. In projective tests like the Rorschach and Thematic Apperception Tests, the subject's individuality is emphasized. In intelligence tests, deviations from the norm are sought. In other words, how closely does he conform to the standard of intellectual

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achievement for his age group? T h i s intellectual achievement is the result of many factors, heredity, educational and economic o p p o r t u n i t y , emotional accidents, training and the stimulation of experience. It is expressed by the symbol I.Q. W h a t is this I.Q. supposed to measure? Is it a special and isolated trait or capacity or is it some aspect or f u n c t i o n of mental ability? W e are familiar with the fact that respiration, digestion, excretion a n d movement are aspects of the f u n c t i o n i n g of the body. So, too. learning new facts, doing mathematical problems, designing machines are the result of the f u n c t i o n i n g of the m i n d . Unfortunately, the a m o u n t of material produced, such as the n u m b e r of mathematical problems solved or the a m o u n t of literature written, cannot be used as complete index of mental ability. W e must also know the quality or excellence of the performance, the time r e q u i r e d to perform it. T i m e and m a g n i t u d e can be measured by the ordinary terms or units of physics, b u t the quality of the performance does not lend itself to q u a n t i t a t i v e estimation. Otherwise, Longfellow, who wrote more t h a n Coleridge, would be given a higher place in the category of poets and any lightning calculator would surpass the genius of N e w t o n . W e are faced then with this d i l e m m a of trying to evaluate mental capacities through materials produced by these activities, but we lack the tools of measuring them adequately. Statistical m a n i p u l a t i o n , such as weighting and scaling, do not avoid the f u n d a m e n t a l pitfall, namely, the lack of any satisfactory q u a n t i tative u n i t in evaluating qualitative p h e n o m e n a . Psychometric testing has nevertheless obvious advantages and disadvantages. By means of standardized forms, it provides a rough picture of a man's intellectual attainments by c o m p a r i n g h i m with large population groups, making it possible to see what his relative position is. High and low scores are of some h e l p in evaluating this relative position b u t scores that fall between the maximal and minimal values are of n o real help. For o n e thing we must a b a n d o n the idea that a person is born with an I.Q. that remains constant t h r o u g h o u t his life and represents his "intelligence." T h e potentiality for intellectual development u n f o l d s in the course of his development. W h i l e heredity may provide some limiting factors, full f r u i t i o n will depend in large measure on the influence of e n v i r o n m e n t , from which he will assimilate

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and reject knowledge and ideas as they fit in with and support his own scheme of life. T h e intelligence test does not measure a specific talent or trait, but the aspects or functions of intellectual equipment by which he has learned to solve his problems and make adjustments. Is the intelligence of the physically handicapped impaired? No. Although it is commonly believed that impaired physical function is associated with impaired intelligence, actually there is no connection or correlation between the two. T h e child who is crippled early in life and spends his years in bed or in hospitals will have a diminished opportunity to develop mental abilities, unless special effort is made to provide guidance and supervision for him. T h e mental development of a man who acquires his disability late in life is certainly not retarded thereby. T h e educational opportunities and the stimulation of a wholesome family life will be far more decisive factors than the handicap. In the field of vocational guidance, much emphasis and popularity has been accorded the tests of special abilities commonly called aptitude tests. Does each one of us have a creative talent which, if discovered, may change us at once into geniuses? Will these batteries of psychological aptitude tests furnish a reliable index to our traits, capacities, and abilities? For a long time, a small hierarchy of tests such as finger dexterity, vocabulary, and spatial-relations tests gained a popular appeal as a short-cut to the evaluation of special abilities. In these, as in intelligence testing, high and low scores are helpful in evaluating special abilities, but all other scores give no clue to the potentialities inherent in all of us. T h e average man can do the average job. Training and motivation are the factors which help to compensate for the average ability and to stimulate outstanding performance. One of the difficulties in evaluating the validity of these aptitude tests is the fact that we are dealing primarily with experimental situations. For example, to determine the capacity for attention, the Borden Test is frequently employed. This consists in submitting written material to the examinee in which he must cancel out every "a" that he sees. T h e examinee finds this test easy to cope with. But if you ask him to scratch out every second or third "a," the result does not measure the capacity of attention exclusively. A new factor has been introduced. This

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involves a special attitude which the patient is unable to assume, namely, abstraction rather than concreteness. T h e purpose of the test, then, is only to learn experimentally how a patient can perform. T h e patient may fail; that is, he may not measure up to a standard of achievement as determined by the score of thousands of individuals. Yet in a practical situation where the trait under test is required, he may succeed. Conversely, he may be successful in the experimental condition but fail in the practical application. In addition to many intangibles (fatigue, attitude, and motivation), the patient may actually know roundabout methods of achieving a given result in the experiment. T h a t is, the experimental conditions are not set up to be altogether exclusive of other ways of achieving success, such as the use of other traits. An individual may sometimes perform well, sometimes poorly. This fluctuation does not always depend upon fatigue. Even fatigability may fluctuate. Some of the changes may be caused by a catastrophic condition. Others may fail from a perhaps temporary incapacity for abstract thought. Moreover, in this case, the use of roundabout methods may secure good but misleading results. For example, a test in which an abstract procedure is necessary may be performed by use of the memory. Considerable semantic difficulty has arisen from the ambiguity of the vocabulary employed in aptitude testing. T h e word "achievement" is applied to what the patient can do at the moment in a given field of activity. T o this concept we have applied the term "acquired ability." Since it is almost impossible to separate native ability from acquired ability the results of any of the tests must be viewed with much skepticism on the basis of language alone. Furthermore, the theory of testing is based on the assumption of individual differences. We have already indicated the fallacy of this premise. T h e data reveal that instead of the wide differences that are presumed to exist in the capacities of different individuals, the reverse is true; namely, that men are much alike in this respect. We now think we can measure a few basic aptitudes like the spatial perception needed by the architect or the finger dexterity necessary to a pianist, but no one has yet isolated specific aptitudes. We know of no such tests for journalism or teaching; a

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basic aptitude such as inductive reasoning would apply to both. T h e most important criticism of aptitude testing is its claim to prophecy. Far from being able to predict success in any vocation, it is limited to inference only, to a statistical probability. As such it must be heavily discounted. Only in conjunction with the mass of data and information gleaned from long observation and repeated interviews can it be of real value. Nevertheless, aptitude testing has advantages. It enables the interviewer to get a quick rough measure of the subject's relationship to the group. It also gives the subject an opportunity at self-appraisal. It challenges thought and opens new fields to think about; it also provides an additional opportunity to observe the patient under pressure. Its great disadvantage is the heavy reliance on the test score. There are other means of finding clues to the patient's reasons for engaging in specific types of employment. For a great many, chance is the most frequent factor. For those who express a definite inclination to follow a definite occupation, even a superficial appraisal of the reason is difficult to determine. Does the ambition arise out of a genuine interest and from abilities already demonstrated? Is it a rationalization, a whim, or a fantasy, or does it stem from some deep emotional urge or drive? A young marine had been discharged from a Naval amputation center where his physical restoration had been completed and where he had been furnished with an artificial leg and had been conditioned in its use. He had not gone beyond the fourth grade in school, yet now insisted on going to college, apparently associating college with prestige and social position. He was finally satisfied by enrolling in a "college" for barbers. At the weekly staff conference at this center the educational officer reported an unusual vocational choice. One patient said he was interested in "office appreciation." "What kind of a job is that?" he was asked. " Y o u know what music appreciation is," he replied; "there are those who cannot play or sing, yet they enjoy watching other people play or sing. I like to watch other people work in an office." T h e term vocational interest by itself does not differentiate between the influences that determine the choice. Tests have nevertheless been devised which, by means of a poll of likes and

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dislikes, help to arrive at the vocation which seems to offer the greatest emotional expression. Occupations are divided into areas classified as personal, social, business, mechanical, scientific, mathematical, musical, clerical, persuasive, artistic, literary. Some of the tests are so devised as to apply primarily to the professional level: doctors, lawyers, engineers, scientists, educators. Yet none of these tests answer the question why a particular j o b family was given the greatest preference. Perhaps the answer is to be sought in strong emotions experienced early in life. T h o s e who definitely make an early choice have an opportunity to orient their lives toward its fruition. T h e s e are the vocationally literate. For some of these, vocation becomes a holy grail to be worshiped, searched for, and pursued. T h e entire scheme of life is organized and integrated toward one goal. Distractions are not permitted, lest there be the least dissipation of energy. An example of this is seen in two surgeons who at an early age were turned by maternal influence toward a medical career. In both cases neither was interested in manual activities, presumably because such interest might detract from the fundamental goal and lead to some less satisfactory work. One surgeon was engaged in the most mechanical of surgical specialties, orthopedic surgery, yet on the mechanical aptitude tests he had an extremely low score. Furthermore, his resistance to mechanical work of any kind was so marked that not only were ordinary chores out of the question but avocations and hobbies such as bookbinding, woodworking, and printing were rejected. Yet the tools required in bone surgery, and especially automatic machinery like electrically driven saws, were operated with more than average skill; such mechanical abilities as this surgeon possessed were preserved primarily for the work that gave him the greatest emotional satisfaction. T h e importance of emotional identification as the basis of vocational interest and j o b preference was revealed in a study of a thousand physicians who were asked why they had entered medicine as a career. A small number of the replies cited altruistic motives or the desire for prestige. Another small group quite frankly admitted that they were influenced largely by the money-making possibilities; b u t the majority replied: " M y father was a doctor"; " M y grandfather was a doctor"; " M y uncle was a doctor." T h e largest group were those who said, " T h e

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family doctor was kind to me as a child when I was seriously ill. I shall never forget him." Here, then, is the basic motive behind the choice; identification with an individual in a situation of such strong emotional content as to influence the life pattern. Confirmatory evidence was revealed in a study of five hundred physically handicapped individuals. They were asked to recall their earliest memory, no matter how trivial. Almost invariably it concerned a kindness from someone who had never been forgotten: "I recall when I was two years old I fell down the steps off our porch. T h e neighbor picked me up, wiped my dirty, bleeding forehead and bought me a lolly pop"; " T h e parish priest came to visit, as in Ireland, and brought a sack of potatoes." T h e standard vocational interest tests completed by this group indicated a high degree of correlation with the job families followed by the individual thus remembered. For example, the helpful neighbor was a machinist; the young man who remembered him showed a high interest in mechanical trades. In this present period of emphasis upon full utilization of manpower, many persons not normally on the working force will seek employment, either in the defense industries or in other work where defense demands have created labor shortages. Many persons entering the labor force for the first time, students graduating from high school and colleges, and persons making vocational readjustments because of handicaps or changing demands will have special problems, for they do not know their abilities. How can they choose wisely? How can they pick a job which will yield not only a livelihood but also the happiness and fulfillment which we believe to be every man's birthright? T h e tests already described will be used to help answer these questions. They are widely used in schools and colleges and by many industries, and the Army and Navy has used them to pick out men eligible for specific jobs and to eliminate the vast waste in hiring by rule of thumb. Veterans with occupational problems have an opportunity to take these tests. T h e y will help shape millions of lives. But intelligence testing, personality testing, aptitude testing,

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and the testing of vocational interests is still not enough for vocational guidance. T h e information obtained from all these sources must be crystallized in the selection of a distinct objective for the patient. T h e objective and its allied fields, frequently referred to as the job family, must meet the mental, physical and temperamental qualifications and interests of the patient. T h e next step is to provide vocational information. T h e counselor may describe the nature of the operations involved, the tools and skills required, length of preparation, the places where preparation and training may be secured, educational and physical requirements, possibilities of advancement, wages and working conditions. T h e patient may learn about the nature of the work he has selected by a demonstration or a visit to a place where he can see all the operations. In the final analysis he may even undergo a trial period of probationary training. T h u s vocational guidance can be seen as a complicated process in which the counselor correlates the social, emotional, intellectual, and inherited factors with the economic future of the person being studied. Vocational counseling for the handicapped is essentially the same as counseling the non-handicapped; the only difference is that the additional factor of disability in the latter case must be added to the already numerous factors that determine a man's fitness for a job. Vocational guidance is desirable for the non-handicapped; for the disabled, it is essential. It is not a magic formula opening the door to an occupational heaven for the individual. T r i a l and error, fortuitous circumstances, the many intangibles of living are the determinants, and the recognition of the irrational forces at work in determining human behavior, emotions, and action is the first step in the insight and understanding that is the basis of sound counseling. It is just as presumptuous for vocational counselors to usurp the role of psychiatrists as it is for the latter to usurp the role of God.

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by years of prejudice, the physically handicapped have been forced to accept menial jobs from antiquity down to present times. T h e war years are not a satisfactory criterion as to the attitude of society. Periods of unemployment produce special problems for the crippled and disabled. They have a high priority on the list of discharges and layoffs. T h e sympathy of the employer is no protection for them. Nor is compulsory employment legislation of any real value since it is generally honored in the breach rather than in the observance and quickly vitiated by all sorts of amendments and exemptions. Moreover, governmental interference of this kind only serves to increase the resentment of employers toward the handicapped. T h e only way in which handicapped persons can be made a permanent and respected part of the working force is through education of the employer to the abilities of the disabled, and through adequate training of the handicapped so that he can compete with the nonhandicapped in an open labor market. ESTRICTED

Real rehabilitation has as its goal the development of selfreliance and independence. Such self-assurance can only come from the deep inward satisfaction of expert knowledge and ability secured through training. It is for this reason that emphasis in any rehabilitation plan must be placed on the preparation and training, in accordance with the best principles of vocational guidance and counseling, to meet the competition of the nonhandicapped on the level of skill and ability in the special field of choice. In the past, only lip service had been paid to this principle. Economic need was so great, prejudice was so marked, and the field of opportunity so restricted that expediency was the principle followed. T h e potentialities of men and women were wasted, to their economic and social degradation and the permanent loss to the national economy and welfare. For many years, a controversy has raged between two schools of educational thought in this country. On the one hand, there

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is the group that emphasizes the value of a broad cultural training as the basis of personal and national progress. T h e other group as vehemently supports the thesis that no education is of value that does not have a vocational or utilitarian objective. For the physically handicapped this controversy is of mere academic interest. For them there is no choice between a cultural education and vocational training. Unless the disabled person is equipped with a special skill, he will be unable to compete in the open labor market. H e will be unable to meet the prejudice of the employer hidden in the rationalization, "Sorry, but the insurance company will not let me hire y o u . " T h e myth that hiring disabled workers will raise a company's insurance rates is still not completely stamped out, despite the educational activities of societies for the handicapped and even the insurance companies themselves. However, once the employer has learned of the existence of second injury funds, and has learned of proved accomplishments of handicapped workers during periods of labor shortages, he can no longer use this rationalization to support his instinctual prejudice against the handicapped. O n e employer used this dodge to a one-armed Kentucky boy who applied for work in a factory. B u t the y o u n g man was not deterred by this remark. H e insisted on meeting the insurance company representative. H a v i n g received training as a welder by the Kentucky Rehabilitation Commission he felt confident of his ability to perform the work for which he had applied. H e had devised a homemade prosthesis consisting of two paddles strapped to the remaining stump of the right arm. W i t h this homemade apparatus he convinced the insurance company representative of his ability and was finally hired. His record at work was outstanding. N o t only was he an efficient and productive worker but he was creative as well. He patented several improvements which with his accumulated savings brought him into a high income class. T h i s is a success story that has been duplicated hundreds of times. It testifies to the value of vocational training and the opportunities that are made available to those who are trained. T h e r e are, of course, exceptional individuals who, in spite of a disability, require no special skill or training to make a sue-

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cessful vocational adjustment. They already possess emotional and intellectual abilities as well as commercial or industrial experience that bring them into demand particularly in times of shortage of critical types of manpower. But for the rank and file, vocational training is the basic step to successful adjustment. Realizing the fundamental importance of this need, state and Federal agencies have devoted themselves with unceasing zeal toward its fulfillment. Perhaps some idea of the aims and perspectives in the early years may be gleaned from the ideas expressed at the First National Conference on vocational rehabilitation in 1922. Said the assistant superintendent of the Missouri schools in his address of welcome, " Y o u are engaged in a new work. In our country nothing like it has been attempted before." T h e director of the Federal Board for Vocational F.ducation said, " T h e real problem is giving the physically handicapped the training which fits them for the occupation for which you wish to train them so that they may become full-fledged wage earners." An official from Pennsylvania said, "Each rehabilitation record presents its own physical, economic, training and employment problems and must be considered individually in the light of all factors affecting it for the complete success of a rehabilitation program." From Montana's representative the session heard, "Mental and physical rehabilitation must precede the training, and the desire for training must come from the disabled person. Give the man or woman the work that he or she is interested in and the work that they can follow after their training is completed. Men are mechanically inclined or they are not. They are agricultural, industrial, commercial, or musical, or they are not. If you try to make a farmer out of a mechanic you will probably waste your time and the taxpayer's money." Speaking of rehabilitating handicapped agricultural workers, a representative from Iowa said, " W e must be careful to distinguish between the problem of finding proper training opportunities for the son of a moderately well-to-do farmer who has some of the family resources to help him and the farm laborer who has earned his living by hard labor and now finds himself unable to make a living that way." A Missouri State University representative stated, " I t is most important that a great principle such as this

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be ingrained into the thought of our people and that they be made to realize that nothing short of complete vocational rehabilitation must be made the goal of modern philanthropy." It has taken thirty years to see the realization of the thesis presented at this meeting: that, given a sound mind and ordinary intelligence, there is no trade or vocation in which ablebodied persons may engage that cannot be carried on by a physically handicapped person, if some consideration is made for his disability. T h r o u g h trained and competent counselors he can be prepared for a definite job objective after suitable guidance measures have been employed. His course of training is closely supervised to see that it meets his needs and is within his physical tolerance. T h e success of such a program depends in large measure on the caliber of the personnel performing the counseling service. T h e qualifications of many are far from adequate for this great responsibility. T h e requirements are many and complex. T h e counselor, for example, must be familiar with industrial operations and job families in all their many ramifications. Medically, he must be able to interpret the physician's report as well as to make his own evaluation of the patient's defects. Most important of all, he must possess powers comparable to those of a psychiatrist in understanding human personality and all complex problems of motivation and adaptation. His is a position somewhere between a teacher and a physician. Present counseling practice is just now being raised to the level of a professional status. Yet to maintain proper standards of service this must be the ultimate aim of all vocational counseling. Better salaries should be provided consistent with the qualifications and responsibilities involved. Improvement in the character of counseling personnel in public agencies is being fostered by means of intramural training as well as by encouragement of extracurricular training. It is important, however, to recognize the need for the professionalization of the field. T h e modern concept of vocational training for the physically handicapped is to provide the type of education or training which will improve the powers of the individual so that he can secure employment on the basis of vocational skill and experience. This training may be carried on in the form of general

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education on all school levels, special training, trade, commercial, and agricultural training. Generally, training is instituted after the patient has left the hospital and after the completion of medical and surgical treatment. But some consideration should be given to the wide possibilities of vocational training at the bedside. This phase is overlooked in general hospitals, although it is well developed in military and veterans hospitals and rehabilitation centers. A twenty-year old coal miner suffered a broken back as a result of a rock fall in the mine. T h e spinal cord was completely severed, and the young man was paralyzed below the waist. In addition, the injuries to his legs were so severe that both were amputated at the hip. He could look forward to nothing but dependency, he thought, and this produced a severe psychological problem. Through the offices of the United Mine Workers Welfare and Retirement Fund, Ben was sent to a rehabilitation center. There it was discovered that, as a result of the severe pain he had suffered, he had taken large quantities of opiates and had become addicted to them. With psychotherapy, the addiction was cured and Ben was entered on a program of physical reconditioning. He gained weight, developed the muscles in his arms and torso, and finally learned to ambulate on crutches and artificial legs. After discharge from the institute, he was sent to another center for vocational training in radio repair work. He married a nurse, is presently employed as an inspector in a radio materials manufacturing corporation, and he and his wife are able to support themselves in their small suburban home. Someday, Ben hopes to be a rehabilitation counselor and practice as a team with his wife, who is a specialist in rehabilitation nursing. Another coal miner lost both legs above the knee as a result of a mining accident in 1938. Before referral to a rehabilitation center twelve years later, he had become excessively overweight as a result of inactivity and could not be fitted with prostheses for this reason. He was given physical conditioning to prepare him for the use of artificial limbs, was taught to walk on them, and was given some business training. He and his wife now operate a successful small restaurant.

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A triple amputee was fitted with two artificial arms and a leg. H e had been an electrical worker, but job retraining made it possible for him to return to the company for which he had previously worked, in the capacity of inspector. Success stories like these have not influenced most hospitals to explore the possibilities of bedside training for long-term cases; inpatient training is still restricted to military and veterans hospitals (where it has been very successful) and to a few rehabilitation centers where it has become an accepted part of a three-dimensional program of restoration. Yet the man with a fractured femur who spends from three to six months in the hospital could very well use this time profitably by prepariil^ himself through training for a new job or for improvement in his old job. T h e idea is of especial application to the chronically disabled, like the tuberculous, who spend long periods in sanitoria, frequently without any constructive program of training or rehabilitation. But it also applies to a large number of cases in ordinary hospital experience. For example, a y o u n g Negro boy had been ill for several years with a progressive weakness of his legs, resulting in complete paralysis of his legs and loss of control of bowel and bladder. Study of his case revealed that the cause of the paralysis was a spinal cord tumor. T h e tumor was removed surgically but it had already done irreparable damage to the spinal cord. T h e boy's outlook seemed hopeless. A l l he could look forward to was life in a wheel chair as a shut-in and homebound case. However, at the hospital he was provided with braces and with these was taught to walk and to help himself without assistance. A t the same time he was taught to operate business machines. A musician who had been a member of a band was so crippled by arthritis that he could neither walk, stand, nor sit up. B u t he could do all three after one hip joint was made movable by the insertion of a metal socket. H e spent his hospital time productively learning harmony and arrangement. Still another patient used the time following a reconstruction operation on her hips to study Spanish and advanced accounting, to augment her qualifications as secretary to a financial institution. Rehabilitation of the physically handicapped through vocational training has attained adult stature and maturity. It has

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been tested by a quarter century of experience and reveals a record of outstanding successes obtained throughout all the states. A review of a few of these successes will indicate the variety of activities and techniques involved. A young woman, paralyzed below the waist as a result of a spinal cord tumor, had spent years of total dependence in a city hospital. She was totally bedfast, suffered bladder and bowel incontinence, and was unable to care for her personal needs. At the time the case was called to the author's attention, the city hospital authorities had decided to send her to the poorhouse, because they could no longer afford to maintain Lucy in a hospital bed that was needed for acute short-term cases. It was suggested that she be sent to a rehabilitation center for rehabilitation and vocational training, but the city could not maintain her in the center since it was outside the city limits. After an estimate was made of the cost of Lucy's rehabilitation, an appeal was sent to a religious charitable foundation, not of her faith, and an allowance given which was matched by one from another religious group of her own faith. With this sum, Lucy was admitted to the rehabilitation center. She received physical therapy to provide general conditioning, was taught to ambulate on braces and crutches and to care for her personal needs. Lucy had a chance to explore her vocational interests and aptitudes in the occupational therapy shop, and it was shown that she was skilled in arts and craft work, possessed considerable manual dexterity, and had a strong interest in working with color. T h e career of photo coloring was suggested, and a volunteer photographer taught Lucy the trade as part of her occupational therapy program. By the time Lucy was discharged from the institute, she had become skilled in this work and easily found a position with a large photographic business. Lucy is now self-supporting, lives alone and cares for her needs, travels to and from work unassisted every day, and has made a perfect psychological adjustment to her disability. Instead of spending her life in a poorhouse, Lucy has become an independent member of her community and leads a reasonably full and satisfying life. Another young girl had become paralyzed as a result of an attack of poliomyelitis. Although she had originally planned to

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be a research chemist, she realized that with her handicap, plus the fact that she was interested in a field where women have difficulty in being placed, she must consider another choice. She decided to operate a telephone answering service for physicians and other professional persons in her home community. After she had attained maximum physical rehabilitation, the cooperation of the telephone company was enlisted to provide her with the necessary equipment. While in the rehabilitation center, she had been taught the work and had practiced as a part-time operator at the hospital switchboard. She has built up her small business to the point where it provides a satisfactory income. Desirable as it is to institute vocational training there will be many, particularly among the older people, who haven't the money to take the training. For them, some sort of subsidy should be supplied. T h e Veterans Administration, recognizing this need, provides maintenance for the disabled veteran during his period of training, with different amounts for single and for married men. In civilian rehabilitation the same measure has been long in use. Unfortunately the amounts are not as liberal as those provided for disabled veterans, and there are numerous restrictions as to the period of maintenance and eligibility for it. T h e provisions should be so liberalized that adequate economic assistance is accorded the physically handicapped person to complete his training. T h e State of New Jersey has liberalized its financial assistance to the totally and permanently disabled, but it would be desirable to extend liberal legislation such as this to all classes of the disabled during the time when they are trained for a vocation. If they are given enough to live on until their training is completed, they will be able to take jobs in the community, support themselves, and more than return the funds expended on their behalf. While vocational training will always be one of the basic needs in effecting satisfactory rehabilitation closures, yet it is recognized that at times other methods may be followed. For example, twenty-five years ago a boy of sixteen sustained the loss of his right hand in an industrial accident. He visited the rehabilitation office and told the counselor his story. His father was totally blind; the boy had ten younger brothers and sisters, and as the

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eldest he was the family breadwinner. His query: What could rehabilitation suggest that would make it possible for him to support his family of thirteen? T h e boy was bright; his education had been less than the eighth grade. T h e counselor suggested completion of elementary and secondary schooling with a profession as an objective. T h e comeback was instantaneous, " T h a t won't support my family now." T h e boy had his own idea. He desired a commutation of his compensation award sufficient to buy a taxicab. All he wanted from the counselor was aid in getting a taxi license at the local city hall. No arguments could sway him from his course. He knew what he wanted and the counselor helped him to get it. He was provided with an artificial hand, won the commutation of his compensation, purchased a taxi, and got his license. He developed a loyal clientele, prospered and purchased a restaurant and tavern. He sold the latter for $18,000 and had accumulated about $20,000 in additional assets. His most recent and successful venture was the acquisition of a 110-acre golf course, which is today worth over $200,000. All during this period the patient was in periodic contact with his former counselor. This is rehabilitation aided by moral support, confidence, and friendship between the counselor and handicap rather than by training alone. T h e wide variety of problems indicated by the foregoing cases are evidence of the fallacy of thinking that formulae or techniques can be devised to solve the specific problems of the handicap. But rehabilitation is not a service for mass treatment. It is a highly individualized service. Every person must be accepted as a separate entity and a separate plan must be designed to meet his specific need. Public and private vocational, technical, business or commercial schools that offer well-planned courses, are accepted media for certain specific training plans. Modern concepts of vocational training for the handicapped include utilization of existing facilities for vocational training of the nonhandicapped; this system provides not only economy by avoiding duplication of training facilities, but it also provides training for the handicapped in an atmosphere of normal competition with the nonhandicapped. This provides for the disabled person the stimulus of matching his ability against normal persons, which he will

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be called upon to do when he enters the competition of regular industry. It is an accepted principle in rehabilitation that the handicapped child should be schooled with the nonhandicapped in the regular school system if the physical capacities of the disabled child permit this. Vocational training of the disabled adult should have the same goal, and for the same excellent psychological reasons. It is easier, and better, to modify facilities in a regular training institute than it is to provide a separate and distinct facility for the disabled person. T h i s ideal may not be possible for the severely disabled person who must have constant mcdical attention in a supervised environment during his training period, but it should be attempted for persons with only moderate disabilities. T r a i n i n g within the trade or industry, by the employer, has not been well developed in this country, because it is based necessarily on the hitherto unaccepted system of apprenticeship. T h e custom of requiring a novice to serve a period of preliminary training in a trade or craft goes back at least to the guilds of the Middle Ages. In Queen Elizabeth's time, it was the custom for the apprentice to live with and work for his master for seven years. Upon the introduction of machinery and the division of labor, the old system began to decay although European countries have always carried on continuous and systematic apprentice training. In the United States the system has been entirely replaced by modern vocational training and, in general, by education which is primarily cultural and only incidentally vocational. When the United States is confronted by a production emergency, such as at the beginning of a war, programs for rapid training are devised. T h e y are not, however, adequate for the all-round skills required by many jobs. While some industries using lineproduction methods could train a number of specialized workers, only individuals with much broader training and experience could assume the responsibility of supervising the construction of engines and turbines and pumps. Toolmakers, repairmen, designers, engineers, planners, and estimators must be all-round craftsmen, and these can only be developed through long training and practice.

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During the Second World War, the need for skilled workers had to be met. T o that end, industry and labor mapped out programs of apprentice training. Federal and state agencies gave their help. Standards for the selection of applicants were raised, rations for various industries were set, adequate job experience and supplemental training were provided. All these improved standards were incorporated in various labor-management contracts. On-the-job training (or work training) was exceedingly well emphasized in the war when the need for workers in the battle of production was so urgent. Industry with the help of labor and the teaching profession devised a thousand new ways of training green hands in short and even longer courses in the performance of simple and complicated types of industrial operations. All sorts of methods were employed, including newer ideas of visual instruction with movies, strip films, and other graphic materials. Many physically handicapped persons in war industries received the benefit of this type of instruction and training. T h e lessons learned and the techniques developed are still available. Supplementing these on-the-job training courses, evening courses were sponsored as part of the Engineering, Science, and Management War T r a i n i n g Program. For the civilian physically handicapped, work training is an excellent means for verifying the desirability and practicability of the job objective selected and the vocational training undertaken. Here the protective shell of the classroom is removed and the man finds himself exposed to the demands of everyday industrial experience, with its many personal problems as well as physical and vocational demands. T h e success or failure of the choice of work will soon be noted by his own satisfaction and by his own productivity. Aside from using the work training program as a laboratory for determining the wisdom of his job selection it is also a conditioning laboratory where he builds up from day to day his tolerance to work demands and his manipulative and other skills in production. T r a i n i n g of the handicapped by industry is excellent not only for the obvious practical reasons, but also because it is an indication of the acceptance of industry of the handicapped worker as a respected member of the working force. Sometimes a large in-

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dustry will make provision, in its industrial training program, for handicapped persons who will then be given jobs in the industry upon completion of the course. Many industries requiring skilled workers during times of labor shortages make this a regular practice; to the extent that they accept handicapped persons among the trainees, they are showing the enlightened attitude that will operate to their own advantage when the graduates of the program are added to the regular staff. A less common form of industrial training is exemplified by the Joseph Bulova School of Watchmaking in Queens. At this school, handicapped veterans (and a few civilians) receive training in watch repairing entirely at the expense of the Joseph Bulova Foundation. They do not then receive employment at the factory, for they are too highly skilled for factory assembly work, but they are ready to take jobs in their own communities as watch repairmen. T h e school, which was started in 1946, has graduated several hundred skilled workers in the past five years. T h e men receive an average of one year and ten months of training. T h e company has had a policy of hiring handicapped workers for many years, and persons with various types of severe disabilities have been placed in nearly twenty of the company's fifty departments.

Chapter XI PLACEMENT

T

HE goal of all rehabilitation activities is the successful placement of the physically handicapped worker in remunerative employment. In the past, success has depended on the persuasiveness or selling ability of the placement officer on the one side, and on the humanitarian attitude of the employer on the other. These methods are no longer adequate. Education of the employer then becomes a primary problem. Without industrial acceptance of the rehabilitated disabled worker, rehabilitation has failed in its mission. Beginning in 1946, a week devoted to employment of the physically handicapped has been observed annually by presidential proclamation. T h e aim of National Employ the Physically Handicapped Week is to acquaint employers and the general public with the capacities of the disabled worker. T h e committee responsible for the observance functions all year round, sponsoring essay contests, awards, radio spot announcements, and similar public education devices. Although some experts feel that this technique tends to segregate the handicapped into a special group, there is no doubt that it has achieved considerable success. Each year, the committee points to the increasing numbers of handicapped persons successfully employed in an increasing variety of industries and professions. T h e effectiveness of the large number of crippled and disabled who were prepared to undertake the work of the nation was well tested during the war years. T h e war's work on the home front was performed by the substandard 4FS, the superannuated, and the women. Yet the records were beginning to be forgotten five years after the war, until the Korean crisis and its production demands once again forced employers to recruit workers among the marginal employment groups. Placement of the disabled must be straightforward on a direct and businesslike basis. T h e recommendation of a physically handicapped person for employment is his fitness for that job:

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his physical fitness and his vocational fitness. The certification of the latter is no special problem. While many employers readily admit the validity of a demonstration, they are still unsure of the applicant's physical fitness to perform work. There is no way in which general capacity to work can be determined. Attempts have been made to evaluate general physical fitness by various methods and criteria, with unsatisfactory results. For example, one of the common ways is to make this determination on the patient's general appearance. Anthropologists and anatomists have frequently used this method as an index to physical fitness. One such grouping divides people into three classes according to body form—endomorphs, mesomorphs, and ectomorphs. T h e endomorph is the heavy-set individual with large visceral organs, extroversion, and overweight. T h e mesomorph is recognized by the fairly symmetrical muscular and bony development of the athlete. The ectomorph is characterized by small viscera and a preponderance of skin surface—the person who is referred to as "skin and bones." The proponents of this method are not content with mere classification. With each of these groups they postulate definite correlations, as agility, endurance, fatiguability and personality traits. Another school similarly divides individuals into four types, namely, digestive, muscular, respiratory (because of a large chest), and cerebral (all head and brain). Each is presumed to have correlative capacities for muscular and mental effort. Other adherents of the classification mania describe twenty-four types according to adaptability to work, but only on the basis of physical appearance. By one of the classical methods, personality traits were associated with physical characteristics. The terms pyknic, sthenic, and asthenic differentiate these groups. An extension of this idea can be seen in the association by Lombroso of physical stigmata with criminal behavior. A critical review reveals the basic error of all these studies. In the first place there are no pure physical types. We are a mixture of different types. Secondly, the criteria establishing each type are purely arbitrary and man-made. Thirdly, the form of the body is not an index of work capacity, since adaptation and training and motivation are factors of greatest importance. It would seem foolish therefore to cast horoscopes on the basis of

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an imaginary relationship between physical development and capacity to work. T h e r e is no index of physical fitness exceot the ability to do one's j o b and live to a ripe old age. T h e establishment of false indices produces nothing more valuable tnan a sense of inferiority in any individual classified according to these criteria. In other studies of physical fitness, the human body has been compared to a machine. T h i s comparison would at first seem reasonable. J u s t as a machine expends energy in the performance of any work, so does the human body. T h e work done in ascending a mountain, a staircase, or a ladder is the product of the weight of the body and the vertical height ascended. T h e work of the cyclist is the product of the distance covered and the passive resistance of rolling friction. It would seem therefore that one might well evaluate the efficiency of the human machine against work done by an inanimate machine. T h e mechanical analogy, however, is not valid. In any motor, the total expenditure of energy may be divided into the static expenditure needed to overcome the force of friction and the dynamic expenditure which corresponds to the useful work done. In inanimate machines the static expenditure is small compared to the dynamic expenditure, but this is not the case in the animal organism. T h e latter is always at pressure because, if it ceased to be, life itself would stop. Estimates of physical fitness are frequently based on tests of muscular strength. Police departments often use these tests to determine the physical fitness of applicants. B u t instruments like the dynamometer for recording muscular strength are subject to serious error; the results depend not only on actual strength, but also on the size and shape of the grasping hand, as well as previous trade or athletic experience. Moreover, muscular activity is complicated and its effectiveness derives not only from intrinsic muscular strength b u t from the nervous system as well. Back of a prizefighter's blow is strength, plus splitsecond timing, plus accurate localization of the target. These are influenced largely by the state of the nervous system. They may be developed by training. During the early days of the Second World War attempts were made to screen applicants for the Air Corps. Short-cut methods

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were sought and used. O n e of them was based on the response of the heart and circulation to effort. T h e test, one of cardiovascular efficiency, was carried out by taking the pulse and blood pressure before and after exercise and comparing them to arbitrary normals. It was assumed that the result represented the efficiency of the body in its adaptation to work. But these formulae are false, since they do not evaluate the whole body but only a small part of it. Furthermore, they fail to take into account the safety factor, while the entire hypothesis underlying their use is based on the fallacious concept of man as machine. Another favorite test is that of vital capacity. This is an estimate of the amount of air that can be taken into the lungs in one deep breath. It is assumed that an individual with a high vital capacity would possess a strong constitution and hence a strong resistance to disease. An ironical result of the hiring of a selected group of workers with high vital capacity readings occurred in a lead plant. T h e incidence of lead poisoning was higher in this group since the volume of inspired air containing lead dust was much greater than in the group with lower vital capacity. Nor can psychological criteria by themselves help us in determining physical efficiency. T h e individual is a total personality, composed not only of physical traits and abilities but mental traits as well. These are fused in normal life into automatic and integrated action. T h e term psychosomatic has been coined to define this welding of all man's capacities into one dynamic unit. T h e separation of the capacities into their component elements, such as alertness, intelligence, endurance, awareness, and memory is of theoretical significance only. Nevertheless, this theoretical evaluation has assumed important practical significance because of the mistaken identification of those individual traits with the total reaction of the individual. It is assumed that one or more of these traits will provide the clue to human behavior; that they will uncover the mystery of human personality. Tests for the determination of individual traits are of limited usefulness, although they have assumed an undue importance in educational and industrial life. High and low scores are helpful in encouraging or discouraging a man from entering vocations. However, we are obsessed with the desire for a Rosetta stone that would unlock the mysteries of individual character.

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There are many fallacies underlying the use of aptitude tests as measures of physical fitness. First, by the use of the test we embrace the fallacious mechanical concept that underlies the use of physical traits, namely, attempting to compare the body with a machine. Second, the selection of a comparatively few traits out of many thousands is an inadequate and unrepresentative sample of the total physical and mental personality. Third, it is difficult, if not impossible, in clinical practice to separate native ability from the influence of acquired experience. Man is born with certain anatomic traits (size, form, color) and physiologic mechanisms (circulation, respiration, cerebration, metabolism). This is his native equipment. Out of these native abilities or capacities develop his acquired abilities, modified or influenced by education, training or experience. When we say men are equal we mean their native abilities are very much alike. This means that the potentialities of great performance lie within us all. This, then, is the drama of America, that the equal powers of every individual are pitted against the social opportunities to achieve his goal. Success or failure is the result of the myriad of intangibles, the social and emotional accidents resulting from living and from development. T h e position in the family constellation, the physical and mental product of heredity, the early psychological and social environment, the political and geographical accidents of history are only a few of the factors which modify man's native ability. T h e result of these influences is expressed as the individual's acquired ability. We have described the difficulty in evaluating general working capacity or general physical fitness. Though this difficulty obtains for general working capacity we can nevertheless evaluate the ability to perform specific physical acts. Out of this has evolved the idea of matching the physical characteristics of the worker and the job, a concept which is the basis of the whole selective placement movement and which owes its origin to the development of job analysis. T h e object of job analysis is to break down a given occupation into its component elements, in order to ascertain the skills required for the effective execution of that job. As a natural corollary, it was seen that no analysis would be complete without a consideration of the physical demands present in each job. These

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were carefully weighted and appraised, so that today an accepted or standard form has been evolved for the determination of the physical requirements for any job. This consists of two sections, one on physical activities and one on working conditions. Both effect the fitness of a worker to carry out continuous and efficient production. A group of from 27 to 31 physical activities are listed, covering practically every ordinary physical act of the person in performing work. So, too, are all the most important working conditions which might affect work listed. T h e object of this analysis is to match the demands of work to the capacities of the individual. In this respect the whole plan is laudable. It has been used in many organizations, especially the Kaiser Shipyards, with considerable practical value and benefit. It is of immense advantage in personnel work, since it places the emphasis where it belongs— upon the physical and environmental aspects of the job rather than on the limitations of the applicant. It also emphasizes the fact that no job requires all of the physical and mental capacities of human beings. J o b analysis was not originally concerned with the needs of the physical handicapped, but the latter have received the benefits of the practical application of this development in placement evaluation. Given the case of an amputation of the leg above the knee, it is obvious that the individual will be unable to perform specific tasks like climbing a ladder or jumping from a height, or if he can do them at all, the performance will be so poor or so hazardous to himself or others that common sense would prevent his undertaking it. On this basis, then, we have, not a positive estimate of his capabilities, but a negative estimate of his limitations. By itself, this information is of little value in determining work capacity, but when available skills correspond to the demands of the job we have a valuable technique for placing the worker in industry. In other words, work capacity has no meaning unless coupled with the physical demands of the job. T h e two form the opposite sides of the medal of worker-job relationship. Because of the dominance of mental traits and abilities, the relationship should properly be called one of physico-mental demands and capacities. T h u s the question of fitness can be answered by reference

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to its objective, when the standards of physico-mental demands of work, play, or military service are matched to the physico-mental capacities of the individual. In some cases job analysis has been used to describe the physical demands of the job, but no record of these demands has been kept. T h a t is to say, detailed job descriptions are not available in writing nor are personnel policies or employment procedures prepared or used. Frequently, the personnel officer or employment officer is so familiar with these demands, because of long experience, that he knows intuitively the suitability of an applicant for the job. He has had a good or bad experience with an amputee, an epileptic, a paralytic, and this experience will definitely influence his decision. On the other hand, a longstanding emotional prejudice or the desire to conform to company policies may be the deciding factor, rather than any attempt to match the worker to the job. Industry has made serious attempts to set up certain criteria and methods to facilitate the placement of the handicapped. Lists of jobs were prepared by the Civil Service Commission for each disability group, such as the one-eyed, one-armed, and onelegged workers. Consulting such a list greatly simplified the problem of putting the disabled worker in a job suited to him. Such lists have an educational value in helping to convince a skeptical employer. T h e y indicate that very many jobs do not require completely able-bodied workers. This is of particular value not only to personnel men but to supervisors and foremen. However, the lists have distinct disadvantages as well. In the first place the patient's disabilities are emphasized and not his capacities. Secondly, all one-eyed men and all one-armed and onelegged men are grouped in a single category, although actually their physical capacities vary widely. They live not only with their disabilities but with their residual structure and function. Furthermore, by identifying workers with a specific job category, the lists limit work opportunities, instead of providing information that would enlarge them. Jobs bearing the same title may nevertheless vary significantly in physical demands, thus creating a false estimate of the actual demands to be met. In the last analysis the placement officer realizes that these lists cannot serve as short-cuts, because he is dealing not with an abstract situation

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but with a live individual with hopes, desires, interests, and a definite need which must be satisfied. Lists of jobs cannot in any way intimate the emotional demands of the many personal relationships arising out of the work environment. Because of these shortcomings an attempt was made to deal with both workers and jobs in terms of the physical and environmental factors required—standing, lifting, hearing, working outside, and working in high places. An attempt was made to match the factors required by the job with the factors possessed by the worker. One method of making this comparison was the use of a rating scale. One rating scale classified all the physical demands and capacities into arduous-moderate-light. Another classified them into great-moderate-little-none. Still another used a time frequency scale of constantly, frequently, occasionally, never. Other variations included above average, average, below average, none. Still others use numerical and letter scales of A , B, C, D, and 1, 2, 3, 4. One can see how the method of evaluating specific physical fitness has been oversimplified. But there are other disadvantages to these rating scales. In the first place the evaluations are purely subjective and therefore not reliable. Secondly, qualitative and quantitative factors are mixed while the quantitative units are not established. For example, the definition of occasional lifting may mean once a day, one third of the working day or five times a day. L i f t i n g fifty pounds once a day and lifting forty pounds for the full work period would both be classified as " g r e a t " in physical demand. Some attempts have been made to make these scales useful by the addition of considerable interpolative material with definitions and descriptions giving disability information. Other attempts to modify the scales lead the authors and readers into a maze of abstract medical mathematics that has neither practical nor theoretical significance. It was seen that in order to avoid the pitfalls and fallacies of these scales and lists, and in order to give a more accurate picture of the actual job requirement, it would be necessary to break down a job into its qualitative and quantitative components. T h i s has been accomplished in the development of one scale in which the physical factors have been reduced to such detailed quantitative units as to give reality to the matching.

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F o r example, the physical factors of the j o b are resolved into such activities as sitting, standing, treading, walking, climbing, jumping, running, stooping, crouching, kneeling, crawling, reclining, twisting, fingering, handling, reaching, throwing, lifting, carrying, pushing, pulling, resting, seeing, color vision, depth perception, hearing, talking, feeling, smelling, and tasting. But to describe the qualitative term is not enough. T h e duration, intensity, and frequency of the physical facts are important. By an actual description of the work involved a complete specification can be written for the j o b and the patient's capacities analyzed to see if they can meet the requirements. It should be emphasized that the methods of placing the handicapped worker on a j o b are essentially the same as placing the nonhandicapped. Disability does not divide the population into two halves, with everyone in each half identical. Rather, disability is a scale ranging from no physical disability to total physical disability, with all manner of variations between the poles. No worker, however well he is physically, can do every j o b . And there is no person, physically handicapped or not, who, cannot do some j o b . T h e problem is to match the individual's entire work potential (including mental abilities, personality traits, education, experience, motivation, interest) with the j o b . T h i s , then, is the technical side, but it would be a mistake to overlook the many compensatory factors, the emotional factors, the deep prejudices, the psychological urges and motivations that modify the future of hopelessness and futility even in the severely disabled into a future of hope and unlimited potentialities. No, the human personality cannot be put into fixed molds of work capacity. T h e limits are not prescribed by the fine mathematical calculations of the engineer but by the élan and the spirit. T h e fitting of the disabled person to the j o b is a major responsibility of the rehabilitation officer, but it must be predicated not on the disability but on the range of human capacity of which the applicant is the lucky heir.

PART III

Rehabilitation in Practice

Chapter XII T H E MENTALLY AND EMOTIONALLY DISABLED

R

E H A B I L I T A T I O N of the mentally and emotionally disabled is essentially a new trend in public health and in general social action. It has been largely stimulated by two recent developments, the influence of the war and the inclusion of the mentally disabled in the physical restoration services made available to the civilian handicapped by the Barden-La Follette amendment to the Federal Vocational Rehabilitation Act in 1943. Heretofore, the benefits of this act applied only to those with physical defects.

O n e must not overlook the prominent part played by the whole mental hygiene movement in improving the lot of the mentally and emotionally disabled. From its early days in 1843, when the phrase "mental hygiene" was coined by Sweetser as a kind of polite advice to potentially nervous people, to the modern concept of constructive help advanced by Dorothy D i x and Clifford Beers, it has gone through an evolution of constant though halting advances. Yet its value was limited by the failure to educate the public in the importance of mental disease in the national economy and welfare. Money and legislation were also lacking to implement the techniques and methods for changing old conditions. T h e impact of the war and the Federal Rehabilitation Act make possible the potential utilization of this large group of disabled who have suffered from ignominy and from public inertia for so long. T h e traditional attitude has been even worse toward the mentally disabled than toward the physically deformed. Even mild emotional disorders evoke a marked degree of social repugnance and hostility. T h e sufferers are variously labeled as queer, different, sad sacks, rebels, goldbrickers, nonconformists, petulant complainants, pseudo-querulents, sea lawyers, and, as a group, emotionally unstable. T h e s e are not medical diagnoses. T h e y are social judgments based on behavior which is "dif-

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ferent." For a time it was feared that the label "neuropsychiatrie" might prevent a veteran from finding a job. Fortunately the gloomy predictions of some prognosticators were dispelled by the availability of many jobs and the quick absorption of the "neuropsychiatrie" veterans into industry. But what about the man with more serious mental disease, one that required prolonged if not permanent hospitalization and removal from his family and community because of his abnormal behavior? What has been the social attitude toward him? T h e outlook for the group with severe mental disability has been so hopeless that cure was rarely expected and incarceration appeared the only plan of treatment. T h i s is a barbaric attitude inherited from previous centuries, an attitude from which only a few states seem to be emerging. T h e idea that many can be rehabilitated as productive members of their community has only recently been developed. Newer forms of treatment and a better insight into some of the causes of mental derangement are holding out hope for a more optimistic future. Some of these techniques were developed in the war; many of them had been devised much earlier, but had not been thoroughly tested. T o day we know that with intensive treatment and with adequate organization of medical and rehabilitation services many lives can be restored to usefulness. Viewed from the standpoint of numbers alone, the problem of mental disease in this country is enormous. Of all our hospital beds in this country, more than half are occupied by patients with mental disease. More than 30 percent of all disability pensions paid by the Veterans Administration to veterans of World W a r I I are payable because of psychiatric disorders. Selective Service during the war disqualified 856,000 men for the same cause, while more than a million were later discharged because of psychiatric illness or because they could not adjust themselves to military life. It is estimated that about 6 percent of the population or about 8 million people suffer from some form of mental illness and that one out of twenty people will require hospitalization at some time in their lives. T h e r e are many explanations for this constantly increasing burden. T h e tendency is for oversimplification, as we seek refuge in simple explanations such as increasing urbanization, increased

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longevity, specialization, mechanization, social insecurity. Whatever the explanation, the problem is so important that the Federal Government plans to spend millions for research into the causes, diagnosis, and treatment of mental disease. Furthermore, the program contemplates financial help to individuals, hospitals, and schools working in the field, and to help states with their mental hygiene programs. T h e problem from the standpoint of numbers is staggering. But what about the cost of maintaining a program of custodial care and treatment? And what about the cost to the national economy in the loss of individuals from the productive labor market? What about the stigma and social prejudice that affects not only the individual but his family as well? Can we rehabilitate these people and make them self-supporting, self-reliant, and employable? Can we reduce the tremendous burden of public assistance and custodial care of the mentally ill, a burden which threatens to engulf us? T o these questions, rehabilitation, the infant tool of social medicine, frames an affirmative answer. We have learned that fundamentally, mental stability is measured by one's ability to live with his environment. This ability is conditioned by biological and social factors having their beginning in racial history and operating through every moment of the individual's existence. Unlike animals and insects, man is born weak and helpless, prey to the harmful forces of nature, unable to cope with the ordinary problems of existence. He must pit his energies against the forces of his own environment in a struggle for survival. He knows nothing of the world about him, but by means of his instincts and drives and the physiological functions of breathing, digestion, metabolism, and the sensitivity of his nervous system, his life is soon translated for him in terms of the satisfaction or denial of his needs. In the beginning, the solution of day-to-day problems are automatic and reflex, on the same level as the fixed pattern of instincts which determine the action or behavior of lower animals and insects. But soon he emerges to a new position, where his superior brain provides him with the capacity to communicate bycries and speech. Still later he develops the ability to evaluate and interpret his experience. His first consideration is himself. Hunger and excretory func-

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tions are made known to h i m through p a i n f u l sensations. T h e s e are tensions or disturbances affecting the most powerful of all his instincts, his ego, power drive, or idea of himself. Communicating his needs by sounds and cries, he discovers his relationship with an outer world which may satisfy or deny his needs. His w o r l d is completely dominated by himself, his own wants and interests. As new values and experiences appear, they are accepted or rejected in so f a r as they support or maintain his idea of himself. If this central idea is disturbed, he is frustrated, his feelings are hurt. T h e s e emotional disturbances are expressed by tensions. H o w these tensions are resolved and how he reacts to these frustrations shapes his whole f u t u r e and personality. As the individual develops, the elements of each new experience become compressed into an idea which is registered and stored in the brain. T h e s e ideas meet the impact of other ideas and are themselves modified by new experiences. T h e solution of day-to-day problems is accomplished by intuitive correlation, that is by the quick and automatic mobilization of ideas, the condensed expression of his own experience, accumulated and stored for emergency use. T h e s e ideas, concepts, or values are not always complete. M o r e frequently, they are only fragments, signs or symbols. Y e t these symbols, fragmentary as they are, serve as the interpreters of experience and the springs to action. T h e y are the tools which unlock the mystery of each new experience by providing the connecting link with some previous experience. T h e intuitive flash of genius, the insight into a new relationship is based on something that has gone before. In the genius, there is developed to a superior degree the ability to reach quickly and effectively the steps in a series of mental acts, connecting one idea with another. Expressed in another way, that individual has the superior ability of selecting from a mass of relevant data the precise figure which is the clue to the solution of an unsolved problem. Man's whole life, then, can be viewed as a series of problems which he must face f r o m day to day and which he must solve if he is to preserve his integrity and self-consistency. Mental health, normal behavior, and emotional stability are synonyms for the consistency and unification of his personality organization. T h e tensions and disturbances in that organization, whether mani-

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fested by emotional or bodily symptoms, are the expression of mental unrest that results from the difficulty in solving his problem. T h e s e symptoms are of two kinds: the one reveals the existence of the struggle; the second reflects the tendency to build u p substitute performances which allow him to escape this struggle and come to terms with the demands of the outer world in the best possible way under the given conditions. T h e symptoms may be transient or prolonged; they may be protean in character, representing every system in the b o d y — t h e head, the stomach, the lungs, the heart, and other organs. B u t the most frequent symptoms are related to the vasomotor and nervous system. T h e s e symptoms are characterized by anxiety states, phobias, depression, guilt reactions, inability to concentrate, mental confusion, irritability and "startle reactions." For the most part, these feelings and sensations are transient, f o r the h u m a n personality is incredibly tough. Certainly, the mere presence of such symptoms is not sufficient to warrant the diagnosis of psychoneurosis. However, when they are prolonged and intense and interfere with the patient's routine pursuits of life, he is apparently faced with an emotional problem beyond his tolerance and his personality organization is in turmoil. In a very small percentage of cases these symptoms may even become irreversible. In military life they are expressed in the exhaustion of the soldier with combat fatigue; in the nightmares and insomnia or the feeling of guilt of the boy w h o was saved while his buddy alongside of him was killed. But many of the milder symptoms occurred in boys who never saw combat. W h o are the people who broke down in military life, who could not stand up against the rigors of combat or the routine of military life, with its special world of drill, uniforms and regulations, a world where a lifetime of habits have to be changed, where individuality is lost and identification comes only f r o m the group? W h y should a man who has been a successful lawyer in private life suddenly develop peculiarities that immediately stamp him as undesirable for military service? Actually, there is nothing peculiar about these reactions. A man who is about to give his first lecture may be too excited to sleep for days in advance. H e will tremble, lose his appetite, exhibit heart palpitation. Similarly, fear of tuberculosis or cancer may give rise to all

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sorts of uncomfortable sensations. All these are signs of mental reaction within the range of normal, because many individuals in the same situation react in the same way. Mass suggestion, panic conditions, and hypnosis are of this order. T a k e the case of Jones. He had never seen combat. But he came into the service with personality traits and attitudes which made him sensitive to regimentation. In civilian life he would probably never have seen a psychiatrist. But in the service he developed psychosomatic symptoms; headaches, backaches, inability to work—all excuses of the mind for his inability to adjust himself. These symptoms are real to the patient but their cause is mental conflict and not physical weakness. Jones's trouble was not cowardice or fear of combat, but simply his inability to adjust to the idea of himself as a number instead of a name. In every war there are thousands of cases like Jones; fortunately, good military psychiatry is able to help most of them. And who are those who break down in civilian life? They are those who cannot resolve the difficulties of facing problems of ill health, financial reverses, unrequited love, domestic infelicity, or vocational maladjustment, threats to their scheme of life. What happens to these people, whether civilian or military? Those whose heredity or early personality development has been defective, or whose problem has exceeded individual tolerance, break down to become chronically maladjusted and even in a few cases to require institutional care. T h e majority, however, make satisfactory adjustments. While the percentage of rehabilitated cases of mental illness is not as high as that found in physical illness, the formerly hopeless attitude is no longer justified. Many psychoneurotics and neurotics, and even some psychotics, can be rehabilitated to useful lives. When properly placed, they have good production records; in certain types of work, they may be better than normal: the obsessivecompulsive type is suited to detail work. How do they resolve their difficulties? What techniques are used? Why are some cases successfully rehabilitated, and others not? T o answer these questions completely would be to solve the riddle of human behavior. Partial answers are furnished by the various schools of psychology. Despite many flaws in these systems, they have brought advances in our thinking and under-

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standing of mental activity and human behavior. T h e r e have also been advances in the young science of psychiatry. Psychiatrists are cognizant of the influence of heredity, physical constitution, and disease, of the loves and hates and frustrations in the richly receptive period of childhood, the social contacts in childhood and family life, the effect of habits and social customs in the community in which the person lives, his habits, hobbies, and beliefs, the challenge of puberty, and early adult life in which he shapes his personal and economic goals. All these psychological hazards the psychiatrist evaluates and interprets, as he tries to bring to the disturbed personality insight and understanding. Through analysis, through suggestion, through narcosynthesis, through repeated interviews, through group therapy, he ferrets out undisclosed childhood conflicts, bringing them to the surface and rationalizing them and making them fit into the patient's experience. T h e process requires varying periods of time and a variety of techniques. T h e psychiatrist must coax, persuade, assuage, threaten, argue, psychoanalyze, interview, sedate, stimulate, medicate, give occupational therapy, group therapy, physical therapy, psychotherapy and shock therapy. These methods have been used before. While it is true that the general principles of treatment and the specific techniques are not new, rehabilitation differs from previous methods in the planned, as opposed to unorganized, attempts to mobilize all resources of the patient and the community. In the military services this work was well organized on two levels, for the acute and for the chronic case. In the former instance rest, sedation, assurance, and individual psychotherapy generally within the milieu of the battle area was carried on. Those who did not yield to this type of treatment were evacuated to centers where a more comprehensive service could be offered. Here improvement was obtained through physical conditioning, diversional and occupational therapy, and through group meetings as well as individual analysis. Diagnosis, treatment, and rehabilitation went hand in hand. In civilian life the neurosis must be handled similarly: diagnosis, treatment, and rehabilitation must go hand in hand. Such a plan envisages at least a place where these services can be rendered. T h e nearest approach, at present, is the mental hygiene

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clinic. Unfortunately there are too few of these and many are not equipped to carry out a complete program. They are nevertheless the nucleus around which can be built the structure of a complete and coordinated rehabilitation service. T h e Veterans Administration, cognizant of the value of organized action in the handling of emotional or incipient mental illness, has established mental hygiene clinics in regional offices to render out-patient neuropsychiatric treatment, particularly in minor psychiatric illness, and thus prevent the development of more serious phases of mental disease. In this program, group therapy—the simultaneous treatment of a number of veterans suffering from similar mental or emotional disturbances—is emphasized. However, individual treatment is available where required. T h e principle of rehabilitation treatment is recognized by the employment of a team consisting of a neuropsychiatrist, a clinical psychologist, and a psychiatric social worker. There is a growing number of tax-supported acute psychopathic hospitals where mentally ill patients receive intensive treatment before being sent to the regular state institutions. T h e per diem cost in the former institutions may be ten times that of the cost per diem in state hospitals, but the long-range cost is less, since long-term commitments in state hospitals are often prevented. For example, less than 1 4 % of admissions to the Colorado Psychopathic Hospital go on to the state institutions. These short-term institutions produce the kind of results that are achieved by the best type of private hospital, where the excellent therapy raises the cost beyond the reach of most families. T h e kind of a job best suited to the man with a psychoneurosis can only be described in a general way by saying that it should be within the limits of his physical and mental powers. All jobs that involve considerable nervous tension, as from speed or other pressure, should be avoided. If a man is intelligent he should not be given work fit only for a moron. If lie is clumsy, delicate work is contraindicated, and if he is a skilled craftsman his time should not be wasted in unskilled labor. He should be put at work in which he has a strong interest; his interest will sustain him through fatigue, and even through nervous tension and other hardships. But if he dislikes his job and is bored by it, it will only

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further increase his resentment and cause tension. Fatigue and other minor hardships become intolerable. A key man in the management of the neurotic in civil life is not the psychiatrist but the vocational counselor. In the Veterans Administration, in state rehabilitation bureaus, in state and Federal employment bureaus and among the personnel men of industry is lodged the greater responsibility of assisting the vocationally maladjusted person, the man out of work, the marginal worker, the unskilled worker, the physically handicapped worker, the psychoneurotic. T h e vocational counselor cannot send every client to a psychiatrist; there are not enough to go around. In many of these situations he must take the psychiatrist's place; but lacking the training, he must necessarily be limited in effectiveness. Yet, the trained psychiatrist is not always needed. Common sense may be all that is necessary. Besides, a psychiatrist unfamiliar with the culture of a specific industry would be less qualified than a counselor with intimate knowledge of that industry in all its human as well as its production aspects. There are those who claim that only trained psychologists are equipped to treat the multitudinous miseries of mankind; that the vocational counselor should receive training in gaining insight into the special relationships which exist between the client and himself; that he must be trained to understand the problem of cooperativeness and uncooperativeness; the nature of encouragement and criticism; that he must learn to recognize certain characteristic reaction types which may call for some special handling. Certainly here is a challenge to the vocational counselor. Can he meet it? T h e many problems he must help to solve and understand are revealed in the following case. A young man of twenty-two was one of nine children. Both parents had been college graduates. T h e father was a chemist, but not a very good provider, and he and the mother separated. When the son was fifteen both parents died. T h e boy quit school at the end of the ninth grade to go to work. He took several odd jobs—as waiter, bell hop, and mimeograph operator, and later worked as an apprentice patternmaker in a steel foundry for 60 cents an hour. Later he got a much better job in a shipyard.

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In January, 1943, he joined the Navy as an apprentice seaman and, in the eighteen months that he was overseas, served in some of the thickest of the Pacific fighting. His ship escorted the carrier Hornet to a point where the Doolittle planes took off for Japan. He was in the invasion at Attu, Kiska, Tarawa, Bougainville, Kwajalein, and two other islands, and in addition to these campaigns, took part in the bombardment for the second front in New Guinea. He was also in the air attacks on the Philippines and later joined the Halsey Task Force 58 in the bombardment of Truk, the Marianas, and Palau. After Kiska, his tonsils were removed and under the influence of sedatives, he became emotionally upset, disoriented. In dreams he heard his dead parents exhorting him to leave the brutalities of life and join them. While in this trancelike state he made several attempts at suicide. He apparently recovered and returned to the States where on leave he married a nurse. On return to duty he was assigned to the wards at the U.S. Naval Hospital, Mare Island, where he showed sufficient proficiency to be admitted to the surgical school for corpsmen in July, 1944. Under the strain of operating-room responsibility, his mental symptoms reappeared, with epigastric burning, nausea, loss of weight, nervousness, nightmares, and depression. He was hospitalized in November with a diagnosis of anxiety neurosis. As a patient in the hospital he sought the services of the educational officer. He wanted to go to school, stating that his ambition was to be a doctor. On the basis of his educational background this seemed rather far-fetched. However, he asked leave to take some tests. These showed an average I.Q. and a high interest in personal, social, scientific, verbal areas of vocational interests with a good manipulative pattern. On the basis of his limited qualifications he was advised to give up the idea of medicine and return to pattern-making at which he had shown steadily productive activity. He felt, however, that even though he had been successful in that work he would never be satisfied or happy because he couldn't help people. Yet he needed a job to support his family. We see here a conflict in ambition, drive, desires, and, intelligence, with accompanying emotional instability. How should he be placed? It was suggested that he investigate an opening in the

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Y M C A . A f t e r an interview he was engaged as a shop teacher and supervisor. H e r e he f o u n d vast opportunities for his talents and interests. T h e security was good, while his ability counted more than formal education. T h i s patient still needs counseling and psychiatric supervision. T i m e alone will tell how successful his adjustment will be. T r e a t m e n t , diagnosis, vocational guidance, and selective placement go hand in hand in the rehabilitation of the psychoneurotic. Placement is of paramount importance. What happens to psychoneurotics on the job? Many are irritable and try to rationalize their unrest. T h e y may be sullen, angry, on edge, causing a strained feeling between them and their fellow workers. B u t if the foreman is an intelligent and kindly person, or perhaps a friend of the family, he may diplomatically settle any difficulty that may arise. T h u s the foreman takes over the function of the buddy, the chief, or the sergeant of military life. A thirty-two-year-old veteran found it difficult to adjust to army life because he was constantly thinking of his family back home. H e eventually returned to his j o b jittery and nervous, only to find in a comparatively short time that, without the intervention of doctor or treatment, all his symptoms had disappeared. His scheme of life had been reorganized. H e was again a worker, and work was the medicine that cured him. In a cotton mill, an emotionally disturbed veteran was transferred several times because of inability to get along with other workers. A j o b was f o u n d in the stockroom where he was given some measure of responsibility and where the only other employee was a much older man. A father and son relationship developed that soon eliminated friction and tension. A neglected phase of mental hygiene in industry has to do with the establishment and the maintenance of proper relations among the personnel. As a rule, workers are hired in an informal way and are quickly thrown into the maelstrom of work activity with no more than a casual introduction to a foreman or supervisor. Each little g r o u p is left to work out its human relationships by trial and error. Certainly there would be less confusion if some system were established to indoctrinate the worker in the policies of the company, the steps in the manufacturing processes of which he is a part; to provide for the selection and

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training of foremen in leadership, as well as for the placement of employees, the adjustment of work arrangements, and group talks to the men. At present these talks are chiefly confined to safety measures, but the scheme could be expanded to include other matters of concern such as health, new advances in operations, and new products made by associated plants. T h e worker would be proud to identify himself with the advances made by his company. W e have been discussing the role of the psychoneurotic. Do the same techniques and principles apply to the psychotic? Can we hope to bring these people back to working capacity again? T o do this we need not only adequate techniques but also adequate medical organization. T h e machinery of psychiatry will be of little value without coordinated planning and organization. T h e two most important types of psychoses are the schizophrenic (dementia praecox) and the manic depressive. T h e schizophrenic retires to a world of delusion, may lack energy, and may be abnormally suspicious. T h e manic depressive alternates between states of excessive activity and depression. Many psychotics whose symptoms have apparently subsided are discharged from mental institutions on probation. This exposure to a possibly unfavorable family or industrial environment throws upon them a great mental strain and may precipitate recurrences and relapses. A good example of what can be done to rehabilitate psychotics is the program in Ohio. A chain of receiving hospitals is contemplated, where new cases may be sent for diagnosis and a brief period of intensive therapy, without the stigma of court commitment and incarceration in an asylum. T h e first of these hospitals opened in November, 1945, at Youngstown, with a capacity of eighty patients and a staff of sixty, including two physicians, a psychologist, two social workers, and fourteen graduate nurses. In the first three months of operation, 71 out of 89 patients were discharged as capable of a trial at readjustment to the outside world. T h e advantage of the plan is obvious. For something less than three hundred dollars per patient for six weeks of intensive treatment, the state receives a high ratio of returned citizens. Custodial institutions, in spite of their deceptively cheap daily rate,

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in the long run spend much more per patient and in the end fail to restore as many of their patients to society. Successful placement of the mentally handicapped individual depends largely on finding the proper working environment. Generalizations other than this cannot be made. Each case must be considered individually, with full consideration of medical findings and recommendations. W e are dealing with a group whose outlook has always been poor and whose ultimate road usually led to the insane asylum. T h i s is not invariably the case; adequate early treatment may prevent more serious disability. Furthermore, many individuals are victims of administrative and organizational inefficiency. In the placement of former psychoneurotics and psychotics the program in California has been unique. W i t h the cooperation of the United States Employment Service, many psychotics and neurotics have been placed in employment after careful evaluation of their condition and work opportunities. But in this instance the vocational counselor must be part of a team in which the role of the psychiatrist is dominant. T h e executive, for example, who returns to the same milieu with the same tensions and tempo will only find himself precipitated into another episode. It may be even necessary to start him on the road to rehabilitation by commencing as a dishwasher. Farm work always is an acceptable way of bringing people back to normal. W o r k thus may be the best therapy to prevent the return of symptoms. T h e psychoneurotics and the psychotics do not make u p the sum total of those with mental illnesses who require rehabilitation services; the homosexual, the chronic delinquent, the petty offender, the grotesque and pathological liar, the swindlers and kleptomaniacs, the alcoholics, the problem children and "wise guys," the addicts and psychopaths; each group requires special handling and special assistance from the psychiatrist. A m o n g the many mental and emotional misfits the chronic alcoholic is not only a public health problem but also an important problem for industry. T h e effects of alcoholism on industrial absenteeism, turnover, accident and production rates have not been statistically determined, but the general indications are that the chronic alcoholic adds to these problems. Cer-

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tainly the man who does not have the power to self-control is a serious work hazard. T h e s e m e n are emotionally as sick as the psychoneurotic; their d r i n k i n g is a symptom of deep-seated disorganization and maladjustment. Work capacity is seriously affected primarily because of the unreliability rather than the physical impairment of the group. Although the employer cannot assume responsibility for the treatment of these cases, he is, however, able to assist them by educating all employees regarding alcoholism and its effects on working capacity. Alcoholics A n o n y m o u s was organized to provide help to the alcoholic through group therapy by restored alcoholics themselves. T h e record of " A . A . " has been so outstanding that a similar organization has been started for drug addicts. M a n y psychiatrists refer patients to " A . A . " during the process of analysis. W e have discussed the psychoneurotic and psychotic groups, in which the personality changes and disorders arise from functional disturbances rather than structural or organic changes in the brain. In another group of persons the disturbed function of the brain and central nervous system is the direct result of inj u r y to the brain. A n injury of this kind, in war or in civil life, may leave the victim with only minor disabilities. Even those with major structural changes carry on effectively. M a n y , however, may show the severe mental symptoms of diseases of the brain. Individuals with brain injuries may be hypersensitive to noise, heat, bad air. H o w shall we adjust them to employment demands? T h e best system of management is one which attempts to prepare each man to continue in his former work. In determ i n i n g the choice of a vocation it is necessary to consider the special impairment, the original skill, and also the character of the m a n and the type of work he did before he was hurt. Obviously, miners, masons, and house painters are seldom able to return to their former occupations, whereas an artisan in a small business is relatively likely to do so. In one large series of cases, *j3 percent remained in the former or a similar vocation, 17 percent went to a new type of work, and only 16 percent remained jobless; a large number of persons following intellectual pursuits remained in their former professions but failed to measure u p to their original efficiency. In another series of severe head injuries followed over a long period

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of time, it was found that 20 percent became almost normal workers, 32 percent retained about one half to two thirds of their normal working capacity, 30 percent had a working capacity below one third, while 18 percent did nothing and earned no money. Among the sequelae of brain injuries, epilepsy is one of the less common, generally occurring about two years later. If it occurs earlier than this, in not a few cases there are no later recurrences; if it occurs after one or two years, the epilepsy may remain permanent as a result of scar tissue in the brain. But while epilepsy may result from injury, this is by no means an important cause. A n ancient disease, it is surrounded by a good deal of superstition, myth, and ignorance. Many outstanding persons have been its victims: J u l i u s Caesar, Mohammed, Lord Byron, Flaubert, Swinburne, and De Maupassant. It has always excited the prejudice of the public and has been surrounded by an aura of shame and degradation. It is still associated in the minds of many persons with insanity and feeblemindedness. T h e disease is marked by sudden loss of consciousness, brief or prolonged, and sometimes accompanied by convulsions. T h e chances of cure are slight, but seizures can be reduced in frequency and intensity, and life expectancy is good. There are four types. Grand mal affects probably 65-70 percent of the cases. It is characterized by the well-known convulsive seizures generally followed by a period of relaxation or deep sleep. Some have a warning impulse, others have no warning at all. T h e attack may be violent enough to cause the person to fall. In petit mal, which attacks 20-30 percent of all epileptics, the symptoms are slight. T h e loss of consciousness may last for a few seconds, yet the person may not fall, and may even continue what he has been doing. Jacksonian seizures are characterized by convulsive seizures affecting one side of the body only, beginning at the foot and working up the arm. About 10 percent of the cases are thus affected. Finally, there are the psychic seizures, or psychic equivalents, affecting about 7 percent; here there is no loss of consciousness or any seizure, but there are short periods of amnesia during which the patient may mumble incoherently and drop articles on the floor or wander aimlessly about the street. It is obvious that a person suffering from any of these forms

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of epilepsy would constitute a hazard to himself and to his fellow workers in a crowded place, or near hazardous machinery, or in a position of control over the safety of others, as in driving a bus. Yet are we to continue the traditional prejudice toward these men? Are they not employable? Certainly it would be a great injustice to bar an individual from an employment who has one seizure in three years. But it would be just as great an injustice to deprive other epileptics from employment if we can demonstrate that they have a working capacity. This they have, but something must be done to reduce the hazards of their special disability. Modern tools have helped to mitigate these hazards. In the first place the advances of diagnosis and treatment have done much to reduce the disability from epilepsy. By means of the electroencephalograph we are in a better position today to determine the diagnosis of epilepsy. With newer drugs we can reduce both the frequency and the severity of the seizures. Our second tool is the employment of the principle of selective placement. T h e hazards of mechanical devices, moving objects, high places, cramped quarters, or exposure to burns are to be given careful consideration in making job placement. Furthermore, there is no need to discard the fundamental principles of vocational guidance in making this determination. After a true ap praisal is made of the patient's capacities, aptitudes, and interests, alternative objectives are chosen in accordance with the environmental restrictions imposed by the disability. For those whose warning of an attack is sufficient to enable them to leave their work and lie down, there is an even wider latitude in the choice of jobs. Although about half the number of epileptics experience a warning "aura," it is not infallible and there is always the possibility of a seizure without it. T h e r e are a few other practical considerations. Great harm can result from a hidden case of epilepsy. While concealment has always been a matter for personal adjustment in view of the serious obstacle to employment, the attitude is dangerous not only to other workers in the place but also to the entire cause of rehabilitating epileptics. T h e r e is a definite place for them, but they must be completely honest about their condition. T h e employer must know of it at the time of hiring. Undoubtedly some will still

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practice discrimination, but through continued education of the employer this practice may be overcome. It can be shown that, by making minor concessions, he will gain a faithful and productive employee. T h e successful utilization of individuals with unusual skill will thus add to the sum total of the productivity of the country. A great deal of attention has been directed recently to the problem of drug addiction, particularly among young persons. Addiction is always accompanied by severe mental and physical sequelae, and the only hope of restoring addicts to society is through hospitalization. T h e Federal government maintains two centers, one in Kentucky and one in T e x a s , f o r narcotics addicts, but facilities are grossly inadequate to handle the increasing number of cases. T h e r e are several organic diseases for which the outlook is less hopeful. Encephalitis, multiple sclerosis, muscular dystrophy and Parkinsonianism are examples of severe neurological disorders, progressive in character and severely disabling. Encephalitis is an inflammation of the brain leaving disabling defects in about 60-70 percent of the patients. It is most frequently characterized by a slowing u p of all muscular and mental activity and generally accompanied by tremors, tics, spasms, speech defects, and occasionally behavior disorders. Nevertheless, the victims are often placeable in sheltered employment. As a rule they cannot adjust to competitive employment but they are useful where no special schedule of productivity has to be maintained. Multiple sclerosis is a serious disease, affecting all parts of the nervous system, causing severe tremor and muscular disability later followed by defects of speech and vision, and by paralysis and even mental changes. It is a unique feature in that there may be periods of remission during which all the symptoms disappear as at the wave of a fairy wand and full working capacity is restored. Unfortunately, the symptoms and the disabilities recur. Muscular dystrophy is a disease of unknown origin that results in gradual paralysis of the body. T h e life expectancy is short, but patients may live with this disease f o r years. T h e r e is no cure. Parkinsonianism is a disease of the brain characterized by impairment of muscular coordination and by a persistent and

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constant tremor. Generally it begins with the fingers and hand. If it remains one-sided, retraining of the other side will sometimes mean complete adjustment for the patient. This was seen in a sixty-six-year-old physician who could no longer write prescriptions with his tremorous right hand. He was taught to write with the left hand and was able to resume his practice for a long time. Many persons who are termed mental defectives because their intelligence falls markedly below the average are able to make good adjustments in society. Those falling very far from below normal often meet with difficulties at work. Many have already f o u n d for themselves an occupational niche in keeping with their limitations. For the guidance officer faced with the problem of placement routine, intelligence testing and aptitude testing is important in at least prescribing the limits of the patient's working capacities. Rarely are there any limits as far as physical demands go. T h e limits are generally in the field of comprehension of complicated processes and restrictions in the area of responsibility. Automatic and repetitive processes are in general compatible with even moderately severe limitations of mental equipment. Agricultural work is also of valuable assistance, and the Goodwill Industries have employed a sizable n u m b e r of the feeble-minded. Tailoring and garment industries especially in nonmachine operations are also suitable. In evaluating the physical demands of the job, particular attention must be paid to the ability to work with and around others, to the danger from mechanical and electrical hazards which the applicant may not understand, and to work speed which may exceed his capacity. We have thus seen the potentialities of the mentally and emotionally disabled and how by organized treatment and management and by providing work opportunities they can be brought into our national working economy. Aside from the tremendous reduction in the cost of treatment and custodial care it should be emphasized that they form a distinct source of untapped manpower.

Chapter XIII THE ORTHOPEDIC PATIENT

T

HE physically handicapped have for centuries been symbolized by those disabled by orthopedic defects. B u t the character of crippling deformities has been changing. T h e hunchback, the victim of Pott's disease (tuberculosis of the spine) is no longer the symbol of the crippled and d e f o r m e d . W e see less of deformity and more of disability. Poliomyelitis, with its concomitant paralysis and loss of function in the young, and arthritis in the older groups have taken the place of the traditional orthopedic deformities. T h i s changing picture is d u e to many causes, among them the specific advances in medicine and surgery and more particularly the organized programs of public health and welfare. B u t other general factors have also been in operation, not the least of which are improved social and economic conditions. T h e s e are reflected in the reduction of the incidence of many diseases contributing to the development of deformity and disability as rickets, tuberculosis, arthritis.

Attention has already been directed to the needs of the crippled child. M a n y an adult cripple is a product of crippling in childhood. In some cases the original disability has been prolonged by neglect; in others it was so severe that despite long and expert treatment it has left severe residual effects. Poliomyelitis, osteomyelitis, scoliosis, congenital deformities like harelip, cleft palate, club foot or congenital dislocation of the hip leave their marks in deformity and cosmetic defect. B u t adults have other hazards to face after adolescence and maturity, hazards which may also result in severe deformity and disability. T h e s e are the diseases of adult life and the accidental injuries of the machine age, accidents which occur on the street and highway at home or at work. Adults crippled from all these causes constituted 50 to 75 percent of the cases, rehabilitated by state rehabilitation agencies over the past thirty years. Until 1943 much of the rehabilitation included only vocational guidance and training and placement. T o d a y we know

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that the rehabilitation is not complete unless physical restoration is included. Regardless of the nature of the orthopedic defect or disability these fundamental principles must be observed. Complete physical restoration must be explored to make certain that the handicapped person has been brought to the best possible physical condition. Once this has been achieved, and indeed even before or during the process, exploration or analysis of the individual's vocational assets through the tools of vocational guidance and counseling must be carried out and a vocational objective selected, one which will be in keeping with his mental and physical and vocational capacities and aptitudes and interests. Vocational training is planned to utilize his capacities with a view to placement in satisfying employment. T h e training and placement of the individual with an orthopedic handicap is generally not difficult, since in the majority of instances the disabilities are static; that is, more or less fixed and unchangeable. T h i s permits the guidance officer some opportunity to predict the success or failure of the individual on the job in so far as the physical capacities of the individual will match the physical demands of the job. T h e most common and disabling type of orthopedic disability among adults is arthritis. This is a name given to a great many conditions, so that it is difficult to evaluate its role in the total problem of rehabilitation. Arthritis means, primarily, inflammation of a joint; but a joint consists not only of the bony segments which go to make it up but also of the many structures which are an intimate part of the joint complex: the synovial membrane which lines the joint cavity, as the mucous membrane lines the mouth; the heavy capsule or fibrous tissue envelop which surrounds the joint; the ligaments which maintain stability; and the many muscle attachments closely fitted to the joint so as to provide the function for which the joint was intended, namely, movement. Usually all the structures around the joint participate to some degree in the inflammatory process, and the degree i f repair which nature exerts to combat the inflammation will also depend on the nature of the tissue involved and the nature of the causative factors, whether bacteria, injury, or metabolic disturbance. When the inflammation is acute the joint sometimes suppurates, or forms pus; destructive changes may develop which

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will permanently disable the patient. But these acute and suppurative cases of arthritis are not those we refer to as the common cause of crippling and disability. T h e latter are commonly called chronic arthritis to distinguish them from the acute cases we have been discussing. Now the chronic cases also require differentiation. Generally they are lumped altogether as if the course and evolution of each type were the same. But they are not. While there are many classifications of chronic arthritis, for simplification and clarification it is best to consider only the two main types that produce disability. One of these is essentially not a disease at all but the result of mechanical wear and tear to which the joint or joints are subject. It may affect the spine, or one or more joints of the arm or leg, but will respond quite rapidly to mechanical treatment. It does not spread to other joints and is the least disabling of the two types. T h e condition is essentially one in which the joint is unable to withstand the demands of excessive weight, prolonged standing, flat feet, or old injuries, which produce unstable or deformed parts and throw unusual strain on neighboring joints. Since the cause is essentially mechanical the treatment is also mechanical. Weight reduction, the application of arch supports, a back brace, or light leg braces or supports correct the condition and permit the individual to resume his former occupation. In rare instances operation has to be performed. This type of arthritis, then, can be considered a static defect, since the condition is not progressive, is confined to specific parts of the body, and is amenable to simple orthopedic treatment and correction. In this same category are the cases of low back pain due to postural strain. A small number of these cases are associated with sciatica and derangement of the intervertebral disc. In a number of cases operative removal of the ruptured disc is necessary. However, in the majority of cases, rest of the joint by splints and braces and correction of the muscular and mechanical factors are the remedies required. From the standpoint of the physical demands of work, the chief factor is the impairment of the lifting and carrying capacity. This is one of the most important physical demands in industry and in the routine pursuits of life. For example, in a survey of 617 jobs in the shipbuilding industry lifting and carrying capacities up to 100 pounds were required in all

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but 10 percent of the jobs. What is important is not the medical diagnosis of fractured vertebra, or osteoarthritis of the spine, or herniated intervertebral disc, but the patient's ability to lift and carry weights. In another study of 1,300 positions in 60 government establishments, and in private industries with government contracts that covered a wider class of occupational requirements, it was found that only 15 percent of the jobs require no lifting. These industries included an air-craft factory, an arsenal, an ammunition depot, a clothing depot, four navy yards, and a quartermasters' and engineers' depot and office. T h e selective placement of this type of physically handicapped worker must take into consideration, therefore, the special occupational limitations resulting from his defect. T h e second type of arthritis is in a different category. T h e defect is no longer static, but dynamic and progressive. Although the joints are the seat of the disease, the whole body is involved. T h e basic factors are many and varied. In many instances lowgrade or chronic infection is responsible; in others, metabolic changes such as those produced by gout; in still others, neurovascular disturbances and obscure psychological factors. While mechanical factors are present also, since these skeletal parts are automatically subjected to mechanical strain, their influence is only incidental. It is true that orthopedic treatment in the form of rest, splinting, and immobilization is of value, but it is not enough. T h e whole body has to be treated. Now the progressive and dynamic and changeable character of the disease is its most striking feature and represents the most important obstacle to successful rehabilitation. T o be sure, many of the victims develop successful powers of repair, so that for all intents and purposes they are cured and adjusted. But these are unusual. T h e majority live on the edge of exacerbation, while a moderate number go on progressively to complete disability. T h e Arthritis and Rheumatism Foundation has been set up as a research and educational organization to deal specifically with the problems of these diseases. Obviously it is difficult to plan an integrated rehabilitation program for this group. Yet a large number can be successfully adjusted and made partially productive. T h i s means selective placement. Work tolerance can be evaluated in a curative work-

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shop similar to that for tuberculosis cases. All cases of systemic disease will benefit by such a technique. In this manner the limits of working capacity are determined without aggravation of the underlying condition. It must be remembered, however, that the strong emotional factors influencing the course of chronic arthritis can operate not only in the work place but also in the home and elsewhere. Although complete control of these factors is impossible, we must be aware of their influence. Recent years have produced great advancement in the chemotherapy of arthritis. New drugs, such as the famous cortisone and A C T H (adrenocorticotropic hormone) have produced startling remissions of symptoms. Important as these drugs are, however, they are not miracle drugs: difficulties in obtaining raw materials, consequent high cost, necessity for constant use, and undesirable side-effects are problems that still must be solved. However, some of the early results show great promise, and the future holds possibilities. Paralysis from disease and injury is frequently grouped with orthopedic defects. T h i s grouping is logical, since the chief disability is that involving the extremities. T h e man who has suffered a cerebral hemorrhage or stroke is disabled because of a one-sided paralysis or hemiplegia. T h e specific lesion is in the brain where, through hemorrhage or thrombosis, the portion controlling the action of the opposite side of the body is put out of commission. A brain softening, involving the specific centers that control motor power, results in disability. T h e degree of disability following a stroke varies from minor involvement to serious and irreversible paralysis. Some improvement is possible through physical therapy, muscle training, and occupational therapy. Through compensatory development of the powers of the rest of the body, many of these individuals can be restored to working capacity at selected jobs. Among the many disabilities of adulthood those due to injury loom large in the experience of the average surgeon. T h e improvement of emergency treatment and the advances of surgical techniques have helped to reduce the disability period and prevent severe residual deformity. But we have already seen the lack of continuity that is responsible for the prolongation of disability. Some injuries are so serious as to leave severe deformities that

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require surgical correction. Fortunately the surgeon is equipped with a large armamentarium of methods and techniques, so that scarcely a deformity need go uncorrected. Among the many types of complication following fracture is the failure of the bones to unite. This is sometimes due to muscle and soft tissue which is interposed between the bone ends or due to local infection. After the infection is controlled or the muscle is removed, satisfactory restoration of function can be obtained by splinting the bone with a bone graft. This has become an established procedure in orthopedic surgery today. T h e orthopedic surgeon has a large source of experience to draw on. He can stabilize a flail joint or make a stiff joint movable. He can transplant muscles to take the place of weak or paralyzed muscles. But all this is of little value unless associated and coordinated with other forms of treatment that will develop wasted muscles and move stiff joints. Here too continuity of treatment must be emphasized. Formerly, the outlook was hopeless for those who suffered spinal cord injuries, with partial or complete paralysis attended by loss of use of the legs and frequently by loss of control of bowel and bladder. Military medicine, through its integrated approach toward the solution of the problems of these paraplegics, has brought hope and light into their lives. Today, under adequate training these men need not consider themselves disabled, for they can be trained to be independent and self-sustaining. This is one of the great miracles of war medicine. Among the many who contributed toward the realization of this program, the work at the Institute for Crippled and Disabled deserves acknowledgment. By breaking down the physical demands of daily living into its component units ways and means were devised of having the paraplegic learn to master the movements necessary to be independent. T h e y learn how to get into and out of bed, attend to toilet activities, dress themselves, eat and drink, get into a car or other vehicle, travel to their job, sit at desk or workbench for six to eight hours, and return home without help. Many of these activities are learned while the patient is still in bed or a wheel chair and unable to maintain the erect position. Later he learns how to use crutches and braces, learns to climb and descend steps,

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ramps and curbs, develops endurance and speed and the ability to get on and off vehicles. With constant training and practice the entire picture has changed for the paraplegic. Even in the presence of loss of control of bowel and bladder, he develops, through habit training, regulation of these functions which permits him to get about without difficulty or embarrassment. Reference has already been made to the case of the student injured in a football game who went on to become professor of engineering at a local school. In another instance, a worker fell off a scaffold, sustaining a broken back and paraplegia. A year later he appeared before me for an evaluation of his compensation claim. I certified him as totally and permanently disabled. Six years later he appeared at the New Jersey Rehabilitation Clinic without the crutches and braces he wore when I last saw him, but shuffling awkwardly from side to side attempting to balance himself. "What are you doing here?" I asked. " I am looking for a job." "Looking for a job? I thought I had certified you as totally and permanently disabled. What can you do?" " I am a structural ironworker," he answered. "Yes, I know, you were a structural ironworker." " N o , " he replied, " I am a structural ironworker." "What do you mean?" "Well, I have been working as a structural ironworker for the past two years." "Oh, I understand," I said, "you mean you are one of those who checks material as it is brought into the building that is going up." " N o , " he said, " I am one of those who shinny up in the air for twenty stories," and with that he presented me with credentials from his employer certifying to his work record and his ability to carry on as a structural ironworker. His employer had gone out of business, and wherever the ironworker presented his credential no one would hire him because he was a cripple. Of the many orthopedic handicaps that present themselves for rehabilitation service the amputation case is of especial interest. During World War II 18,000 amputees resulted from military casualties. During the same period 120,000 civilians lost their limbs because of congenital deformity, accident or disease. Although the Army and Navy organized a comprehensive plan and program for the rehabilitation of these amputees no organized program was available for the civilian amputee.

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Some of the problems that confront the civilian amputee can be appreciated by the following experiences. A sixteen-year-old boy with a below-the-knee amputation suffered in an automobile accident at the age of four had never been furnished with a prosthesis. His doctor and the neighbors had advised the mother to wait until he grew up. In the meantime, he had gone to school, stigmatized as a cripple and unable to participate in many of the activities with the rest of the children; most important, he had lost valuable years of practice in the use of a prosthesis. Another young man who lost his leg in an industrial accident four years earlier presented a below-the-knee stump seven inches long, in excellent condition. H e had been fitted with an excellent leg. As a rule only one stump sock is worn between the stump and the bucket of the artificial leg. Occasionally another sock is added if some further shrinking has taken place but if shrinking continues, instead of adding more socks, either a liner is added to the artificial leg or a new bucket is made. T h i s boy had received no instruction from the l i m b manufacturer. As the limb shrank he continued to fill in the space with socks until at the time of examination he was wearing twelve of them. T h e r e had been no one to assume the responsibilty of instructing him in the proper use of his leg. T h e s e problems reveal the traditional one-dimensional approach toward meeting the problems of the amputee. T h e limbmaker is interested in his profit, the surgeon in his operation, and the inventor in his pipe dream as he attempts to create a deus ex machina. T h e citizen displays a spasmodic interest only when he identifies himself with the collective public conscience, stirred out of its lethargy by contemporary dramatic events. T h e r e is no one to help, advise, assist, or guide the amputee through his Odyssey of adjustment. Rehabilitation thus becomes a metaphor and not a reality. If we are sincere in our desire to remove the physical, mental, and social obstacles to the adjustment of the amputee, then the problem must be met by a three-dimensional approach. A n example of what can be accomplished through this threedimensional integrated program is seen in the case of a young coalminer w h o suffered a broken back in a mine accident. Paralyzed from the waist down, he developed bed sores (decubitus

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ulcers) so severe as to require amputation of both legs at the hip. Formerly, this severe double disability would have seemed hopeless. However, through the cooperation of the orthopedist, plastic surgeon, internist, occupational therapist, physical therapists and limb-maker, the young man was rehabilitated. It was necessary, first, to repair the bed sores that still remained on his back. T h e n he was given physical conditioning to strengthen the trunk. Following fitting of the artificial limbs, he was taught to walk with the aid of crutches. T h e internist solved some of the bladder and bowel problems that attend paraplegia. Finally, he was ready for vocational counseling. It developed that Ed had always wanted to have a business of his own, preferably a small restaurant. He invested his disability benefits in a business of this type, and today, five years after his accident, he owns and manages a very successful lunchroom in his home town. In some ways, his vocational adjustment is better than it was before the accident; Ed is doing work he really enjoys. There is the child amputee who has suffered an amputation because of injury, congenital deformity, or malignancy. He requires a prosthesis not when he grows up but at an early age. School physicians and teachers can be informed of the desirability of early use of prosthesis. Furthermore, he requires close supervision in order to anticipate the rapid alterations concomitant with changes in growth. He requires very little training since his adaptability is great. Most of the outstanding limb wearers are those who have been fitted early in life. Furthermore, the early restoration of function and appearance removes the stigma of defect and fosters complete social adjustment. All adult amputees have problems in common, but each group requires special consideration according to age and the nature of the disease or injury which necessitated the amputation. T h e veteran, for example, belongs to a homogeneous age group. He is young and plastic and under normal circumstances should make a satisfactory adjustment. Furthermore, he has been the recipient of a comprehensive plan of treatment at service amputation centers which should facilitate his adjustment. This treatment was provided not after he was discharged from the hospital nor after demobilization as in previous wars but was administered in an organized manner from the time he was hurt.

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What about the civilian amputee who loses a limb as a result of accidents, vascular disease, or malignancy? With the exception of the Office of Vocational Rehabilitation and associated state rehabilitation agencies there has been no official interest in his welfare. From these agencies, 7,582 amputees have received service during 1950, but certainly this does not approach the need. T h e control of this adjustment has been left largely to the doctor and the limb-maker. T h e latter plays by far the more important role since the doctor is only too inclined to delegate the entire responsibility for the choice of limb, manufacture, after care of stump, fitting and training in its use to the limb-maker. It requires no great imagination to appreciate the necessity for an integrated three-dimensional program in which the doctor, the limb-maker, and an official agency will all participate. A few rehabilitation centers for civilians exist which provide this type of service, but they cannot treat even a small percentage of the amputees who require their services. T h e basic fundamental features of such a program include five major points: psychological preparation of the patient, adequate surgery, after care of the stump, procurement of the prosthesis and training in the use of the limb. T h e first step in the rehabilitation of the amputee is not the prosthesis but the psychological preparation. T h e resolution of apprehension and the prevention of serious mental reaction may be facilitated by early contact with the patient by a trained social worker or rehabilitation officer. This can be done through consultation with the surgeon even before operation and may help allay apprehensions of the patient toward his future. If for various reasons, this service cannot be rendered before the operation it should be done as soon afterwards as the patient's condition will permit. In military hospitals physical conditioning, occupational therapy, education and vocational services were the solvents of fear and anxiety. T h e rehabilitation committee is the nucleus. One of the most valuable contributions of the service amputation centers was the development of programs of aftercare and preparation of the stump for the wearing of a prosthesis. This plan included the systematic shrinking of the stump, the prevention and the correction of contracture deformities, the exercise of

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the muscle that controlled the stump, and exercise of the whole body to improve balance and general control. As a result, the fitting of the stump was expedited and adjustment to the limb facilitated. Even in the case of bilateral amputations above the knee, exercise of the abdominal muscles permitted better and earlier development of balance and control in walking. T h e procurement of prosthesis is a complex problem. During the war, there was considerable criticism from the public as well as service personnel that the limbs being furnished were unsatisfactory in material, design, and fit, and were totally inadequate to meet the needs of the amputee. This view was, of course, largely influenced by the fact that industry had made tremendous strides in war production; new materials and processes had been introduced, and there appeared to be no mechanical or engineering problem that could not be solved. What was overlooked was the fact that limb manufacture presents not merely a mechanical problem but also a biological problem. Furthermore, the fact that more than 3,000,000 amputees had been satisfactorily fitted by private industry and had been brought to social and economic competence was completely ignored. What was needed was further improvement in existing devices and the selection of those that best stood the test of daily performance. A long-range program of research and development is now under way under the auspices of the National Research Council. In the meantime, private industry is the chief source of aid to the veteran or civilian amputee. T h e Veterans Administration maintains one shop for the manufacture of artificial limbs but permits the veteran free choice of limb from any manufacturer. T h e many factors here involved include manufacture, price, fitting, and servicing. Heretofore, the amputee's relationship with the limb manufacturer had been one of simple purchase and sale, a purely business relationship. No professional considerations were involved. Many limb manufacturers have taken a great pride in their product and in their moral obligation to assure the amputee a maximum amount of quality and service. On the other hand, there have been others who have been guided by the dictates of business and trade practices. T h e abuses of these practices need not be gone into here. But it is apparent that some control is indicated. T h e American Board for Certification

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of the Orthopedic A p p l i a n c e and L i m b Manufacturers' Association has recently set u p a licensing system whereby the professional level of the entire prosthetics industry will be raised. Oral, written and practical examinations will be given, and those limb makers who pass will be officially certified by the board. T h i s will eliminate the inexperienced or u n q u a l i f i e d operator, and encourage f a i r trade practices and more thorough training. T h e use of standard specifications established by some national body like the B u r e a u of Standards, the National Research Council or the A m e r i c a n Board for Certification w o u l d provide the amputee assured materials, design, and fabrication that will measure u p to m a x i m u m standards. T h e true criterion of an artificial limb is its fit and utility. T h e evalution and approval of the limb is the final step in the control procedure. T h i s presupposes special qualifications on the approving authority be he doctor or limb-maker. Unfortunately there are too few who can q u a l i f y as experts in this field. A small n u m b e r of surgeons trained in the service amputation centers d o have this experience a n d are the nucleus around w h o m can be built a system of certifying surgeons. Fitting is the beginning rather than the end of the road of the patient's adjustment to his prosthesis. T r a i n i n g and instruction are paramount. T h e y are r e q u i r e d by all but the few who seem to adapt themselves almost automatically to the prosthesis. O n e can immediately detect the individual who has had training and one who has not. T h e unhappy experience in the adjustment of artificial arm wearers can be attributed not only to the f a i l u r e of the prosthesis but the lack of instruction. T h e use of a m p u t e e instructors is an additional psychological stimulus. T h e r e is need for a place where this instruction can be given. Since there are no special civilian amputation centers available there is need for the development of more rehabilitation centers where a service can be offered similar to that provided in military establishments. T h e s e centers must be made available to veterans and civilians alike. A n o t h e r group of orthopedic defects that requires serious consideration includes the mutilating and severe cosmetic defects that require plastic surgery. Some of these, like harelip and cleft palate, are the results of congenital abnormalities. Others, like

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cancer of the lip or scars of the neck, are due to burns and accidental injuries. In either case the full restoration of function must be made available to reduce the cosmetic effect of the deformity. In this respect plastic surgery has made great contributions in the management of severe facial disfigurements. We see, then, how the orthopedic handicap follows the pattern of other types of disability in response to rehabilitation services. There must be assurance that all the measures of physical restoration have been explored and carried out. There must be a full appraisal of the individual's vocational aptitudes, interests, and capacities; a job must be selected to match them. Vocational training designed to capitalize the good points of the patient must be carried out looking toward the long-term rather than short-term goals. Finally, placement must be made in accordance with the social and economic factors as well as the engineering factors so that his talents will yield him greatest possible reward and lie himself will provide a full measure of productivity for his employer.

Chapter XIV T H E BLIND AND THE DEAF

T

HE blind have received organized and extensive attention from both public and private agencies. Originally these services were made available only to those who were totally blind, but this arbitrary concept is changing, and the near blind are now included in the category of those handicapped by severe visual defect. In general the definition of blindness has been modified to include those whose vision is of no practical value for education or earning a living. T h u s this definition would include not only the totally blind but those with some light perception, though not enough to have any value for employment. R o u g h l y speaking a person with less than one-tenth vision or with an eye condition which makes industrial work unsafe without special protection is considered industrially blind. C h i l d r e n w h o have 20/200 vision are educationally blind. T h e r e is however a large additional group of adults and children whose vision ranges from one-tenth to one-third normal. Special consideration must be given them if they are to adjust themselves successfully in the workaday world. Estimates of the civilian blind in this country range from 240,000 to 280,000. T h e Russell Sage Foundation made a thorough survey, revealing 1.7 b l i n d persons in every 1,000 inhabitants. If we apply this formula to the population of the United States we obtain approximately 240,000 blind persons. T o this n u m b e r should be added the 1,200 blind casualties of W o r l d W a r II and those w h o were blinded in the Korean W a r . W i t h i n the last ten years the incidence of infant blindness has increased due to a recently identified condition known as retrolental fibroplasia, which is found to predominate a m o n g prematurely born babies with low birth weights. T h e cause, prevention and cure of this condition is at present the subject of extensive medical research. T h e partially sighted—those whose defect is severe enough to require special attention such as special classes—have been esti-

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mated at 3.25 in 1,000, or 450,000. T h i s number does not include those with the failing vision of advancing years. No discussion of the rehabilitation of the blind would be complete without at least a brief mention of the importance of prevention. Since 50 percent of the cases of blindness are caused by disease and about 17 percent by accidental injuries, we must seek our objectives in these two fields. T h e employment of all medical and surgical methods, both preventive and curative, is essential in preventing serious visual disability. Accidentprevention campaigns require universal support to reduce the number of injuries which may bring on irreparable loss of vision. In this regard the use of goggles should be urged wherever the eyes are exposed to special hazards. Much resistance to the wearing of goggles can be overcome by equipping them with lenses corrected to the patient's vision. Glaucoma is a serious disease of the eyes which will cause total blindness if not diagnosed and treated in its early stages. Since it is amenable to medical treatment, an important part of the blindness prevention program is to make the public aware of glaucoma's warning symptoms and of the importance of seeking prompt medical attention. T h e National Association for the Prevention of Blindness has been active in keeping the public informed of blindness prevention measures. Sight-conservation classes are a valuable part of the program to reduce the disability in the partially sighted. Providing glasses would seem an obvious resort, yet not until recently has it been considered a part of the state's responsibility. T h e federal-state program now permits expenditures for this purpose as a necessary aid to render a handicapped person employable. It would seem logical that educational authorities should accept this responsibility just as state commissions accept responsibility for providing prosthetic appliances for crippled children. All these efforts require emphasis and continued private, public, and professional support. T h e first American legal reference to the care of the blind appeared in 1650 in the colony of Maryland, when a special tax was levied for the benefit of the blind, the maimed, and the lame. Since that time, most of the states have included the blind in their poor relief systems. In the general evolution of public

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care, they have been mentioned as objects of consideration along with the other types of physically handicapped persons. In some states they were specifically included in the classes whose support by relatives is required by law. Eventually the trend was crystallized by creating special authorities or commissions charged with the responsibility of caring for the needs of the blind. In some states residential schools have been established, and in some areas blind children are sent to outside schools. In many states schools for the blind are maintained by private organizations and are supported by endowment funds, though some may receive appropriations from the state and subject to its general authority and supervision. Public school day classes are also found in almost a fourth of the states, organized as part of the local educational system. Long before the development of the rehabilitation movement in this country, state agencies were charged with the special responsibility of the problems of the blind. Here again, public organized action and responsibility were substituted for private charity and philanthropy. However, the stimulus provided by private agencies was the spark that stirred the public to action. Outstanding among private agencies in the field is the American Foundation for the Blind. T h i s group does not serve blind clients directly, but it maintains an extensive research and educational program, provides a small but excellent sheltered workshop, a library of printed and Braille books, and a special department where all types of tools from kitchen gadgets to complicated engineering and musical instruments are adapted for use by the blind. For a long time public agencies for the blind carried out their responsibilities in their limited field without much consideration of their functions as part of the greater problem of the physically handicapped. Because of this narrow concept the aims and objectives were also narrowed. Only a limited success in the rehabilitation of the blind could be anticipated. In the past fewyears there has been a trend away from this narrow concept. T h e blind are now considered a part of the problem of all the physically handicapped persons and therefore a solution to their problems is given a broader consideration under the broader aegis of rehabilitation agencies. In those states where this happy

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marriage has taken place, the whole orientation is different. It is toward full employment of the blind, where the capacities, aptitudes, and interests of the individual are given consideration in the selection of a job objective in the manner of true vocational guidance. Prior to the passage of the Barden-LaFollette Bill (1943), few blind people profited from the services under vocational rehabilitation. With funds and personnel inadequate to meet the needs of the less severely handicapped, there was little inducement for rehabilitation agents of the several states to solicit the more difficult job of rehabilitating the blind, and few blind people applied. Procedure for the training and placement of other types of handicapped were not well adapted for serving blind people. With training costs high, and the results in placement discouraging, it is not surprising that such rehabilitation service as blind people received was secured from commissions for the blind or private agencies specializing in their problems. But with the passage of the Barden-LaFollette Bill, all this was changed. This law provided that in states where the agency for the blind was authorized to give vocational training and rehabilitation, administration of the rehabilitation service must also be under the control and supervision of the agency. Even prior to this, some of these agcncies had developed special placement techniques, so that, with added federal funds to make possible thorough training and adequate personnel, the work of placing blind people in industry was given a great impetus. At the present time, practically all states provide facilities for the vocational rehabilitation of blind people. In a considerable number of these, the work is done through the state agency for the blind. But the states in which the law is administered through a service for all the physically handicapped have in many instances profited from the experience of the more highly specialized agencies elsewhere. World War II created a fertile field for the placement of blind people, especially in industry; the report issued by the Washington Society for the Blind contains positive and valuable testimony to the proficiency of blind people whose jobs were carefully selected. In some instances, large numbers of blind

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people were taken on by particular corporations without careful selection either of the jobs to be filled, or of the blind people to fill them, and these employees were not adequately supervised. However, in states better organized to carry on a constructive program of placement, only such jobs were selected in which, by test, blind people were able to produce as efficiently as a sighted person of average ability. Furthermore, only a few blind people were placed in each factory, so that each blind person could stand on his own merits as an employee and be credited accordingly. Statistics are not available to indicate the number of blind people who were laid off after V-J Day. However, in instances where figures are available, it seems indicated that up to 50 percent or 60 percent of the blind people employed in industry during the war continued in their jobs after conditions began to right themselves. It seems likely that this percentage will increase gradually. Placement officers serving blind people seem convinced that since jobs for them are chosen only according to their merit and productive capacity, and since the philosophy has developed that careful supervision should be maintained over the job opportunity once it has been established, the future of blind people in industry should be much brighter than it has been over many years past. Numerous other laws passed in recent years have done much to ameliorate the conditions of the blind. T h e passage of the Social Security Act in 1936 with its Title X providing for financial assistance for blind people has made such assistance according to the individual needs of the applicant available to blind people in every state of the Union. T h e development of the Talking Book, by which literature is recorded on phonograph records for the use of blind people, and subsequent federal legislation providing for government subsidies for the publication of the Talking Book records and the production and maintenance of Talking Book machines, has meant much in the education of the blind and in the leisure time activities of many shut-in blind people. T h e Pratt-Smoot Act which obligates the Federal government to purchase, when

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possible, the output of workshops for the blind, has enabled many shops heretofore supported by subsidies to maintain themselves on a basis of reasonable wages and substantial production. T h e Randolph-Shephard Bill opens federal buildings to blind people operating vending stands, thus creating a very large number of opportunities; the successful operation of these stands has given rise to an extensive nonfederal program of similar opportunities throughout the country, with consequent gratifying returns to blind people. T h e r e has developed an increasing demand for Federal aid to state agencies for the blind, primarily for the shut-ins and for those who must be given special instructions before they can adjust themselves to employment. Such "home teaching," including instruction in Braille, typewriting, handicrafts, home duties, and in general, social adjustment means much to blind people in orienting themselves to their new condition. T h e r e has also been some demand that the Federal government participate in the campaign for the prevention of blindness. Any rehabilitation program must take into consideration the total and specific needs for vocational and economic adjustment. T h e total needs include discovery, registration, medical and custodial care, pensions, and relief. T h e vocational needs are employment for those who can compete with sighted persons and workshops or independent enterprises for those who cannot compete with the sighted person. T h e number of occupations open to the blind are necessarily limited by the physical demands of these jobs. But even when these demands can be met, the blind face the same prejudices that hamper the crippled and disabled who seek employment. A few sporadic demonstrations of the effectiveness of blind workers in industry have failed to stir the enthusiasm of employers. T h e Ford Motor Company has consistently employed blind workers. T h e T i m k e n Roller Bearer Company employs them for the inspection of roller bearings with a tolerance of one twenty-five millionth of an inch. Blind employees also perform sound tests, which are the final inspection of the assembled bearings for smooth and noiseless operation, and file testing by which each cap and cone is tested

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for hardness by use of a file. T h e blind worker differentiates by feel as to the softness or hardness of the steel. T h e blind then fall into the same categories of productivity as the other types of physically handicapped persons. Some of them are or may become wholly productive; others are or maybecome partially productive; and still others are prevented by complicating physical and economic and social factors from even partial productivity. Full productivity presumes ability to work in competition with sighted persons, as in operating a dictaphone or a screw-threading machine or serving in a variety of inspection jobs in factories. Partial productivity may mean a sheltered workshop or a small independent enterprise in which certain concessions—a newsstand, a tobacco, candy, or soft-drink counter—have long been reserved for the blind. T h u s the blind or partially sighted person can be trained to carry on certain work. Those who have lost their sight before having had any work experience naturally have a more difficult time. Nevertheless they can be successfully trained and employed. In World W a r I, St. Dunstans in England blazed the trail for the rehabilitation of the war-blinded. T h r o u g h a comprehensive program of rehabilitation it brought emotional and economic satisfaction to more than i,ooo blinded men. Social intercourse and physical training were stressed, and the intellectual qualities of the blinded veterans were considered in directing vocational training towards a specific objective that would provide a livelihood. Braille and the use of the typewriter were usually the initial steps. T h e basis for a modern plan of rehabilitation was therefore already in practical use. In the United States the same idea was applied to the needs of blind Army veterans at Valley Forge General Hospital in Pennsylvania and at Dibble General Hospital in California, while the U.S. Naval Hospital at Philadelphia undertook a similar program for the Navy, Marine Corps, and Coast Guard. T h e first step was psychological adjustment to produce confidence in the revival of social living. T h e intermediate period brings with it academic training in basic skills as preparatory to vocational training. At Avon, Connecticut, a convalescent branch was estab-

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lished for advanced training. Lessons in typing, clerical work, metal and woodwork, music, skilled trades, factory work, and agriculture were a few of the types of training offered at Avon. T h e Federal government allows a blinded veteran after discharge $280 per month. Some of the states have enacted legislation granting additional state aid to the blinded veteran. When indicated, "Seeing Eye" dogs may be provided. T h u s we see the changing picture of effort on behalf of the blind. But what about the tremendous psychological adjustment of the adult with the handicap of sudden and complete blindness? T h e r e is the "sudden panic, the swift despair, the reassertion of intellect over the emotions, the tentative first steps, the deluge of sympathy from kindhearted but uncomprehending friends. There are the challenges too of society's fixed patterns and the rigid formula of action of public and private agencies which tend to force the blind toward institutionalization." T h e chief disappointment is the failure to utilize the past experience and the intrenched social and vocational interests of the client by training him for the occupation which he as an individual is best suited. T h e trend in the past has been for standardization of training, so that the blind person drifts automatically into the sheltered shop for the manufacture of brooms or mops, when his talents cry out for development in constructive fields. Shall he submit to the accepted axioms of work for sightless people or shall he be a nonconformist and blaze a trail for himself, one consistent with his lifelong interests, hopes and aspirations? This is not only a challenge for the man but for the counselor or rehabilitation worker. About 15,000,000 people in the United States are hard of hearing; that is, some degree of hearing is present. Through the organized efforts of Leagues for the Hard of Hearing the public is being stirred to action on their behalf both for the child and the adult. In contrast to the hard of hearing the deaf are without usable hearing; some have never heard the voices of others or learned to speak naturally. Most of the 90,000 of this group live in a segregated world. T h e hard of hearing, on the other hand, live and work alongside those with normal hearing. T h e amount of hearing loss

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varies considerably from individual to individual. T h e majority of these patients are victims of childhood diseases like scarlet fever, diphtheria, or complications of acute infections. In the older-age group, otosclerosis, a progressive deafness due to changes in the structure of the ear mechanism, is the major cause. Of the three million deaf children, many struggle along as best they can, stigmatized as stupid at home and school, shunted about in games as in the classroom because they are not as quick as the others. T h e y die a dozen spiritual deaths a day. Some of them are made to feel inferior so often that they accept the judgment in a self-evaluation that may remain fixed. Older boys and girls may become discouraged and drop out of school to take their chances in the labor market, where they find themselves handicapped not only by their defect but also by their lack of training and education. Any program for the hard of hearing must, therefore, begin at the beginning. Compulsory hearing tests should be given once a year in all public schools. Some states now have laws making such tests mandatory. T h e service should be extended to all the states. When cases of impaired hearing are discovered it is of equal importance to see that competent medical attention is provided. But nowhere in the country is provision made for this kind of follow-up for all children. T h e public prejudice toward children with defective hearing is also reflected in their grim attitude toward the adult with a hearing defect. T h e latter frequently find themselves grinned at in shops and humiliated in restaurants. They are the victims of a hundred mistakes because of misunderstanding imperfectly heard phrases or words. Change the public attitude? This is hardly probable;—but equip the hard of hearing individual with the means of improving his sound reception and you solve his major problem. Physical restoration, then, is again the first and foremost step. Progressive deafness, for example, can be cured or permanently arrested in the majority of cases if it is found and consistently treated early enough in childhood. Otosclerosis is gradually yielding to a delicate operation on the ear mechanism which provides a new window connecting the middle and inner ear. But the

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most important contribution of physical restoration lies in prosthesis or hearing devices. Perhaps the best way to describe the modern hearing aid is to picture it as a small portable radio which picks up sound waves, and transmits them, suitably amplified to the impaired ear mechanism. T h e use of these devices is producing radical changes, both psychological and vocational. T h e considerable initial resistance to wearing these devices has been gradually overcome, until today about 500,000 people are using them. These devices cannot, of course, do the impossible. Where the hearing loss is 80 percent or more they do not function well. If the auditory nerve has been damaged or destroyed a hearing aid produces only distorted sounds. Furthermore, not all people use them with equal facility or success. In the majority of cases they have to be supplemented by lip reading. Voice and speech training are also important, although it is not necessary in cases of unilateral hearing. T h e importance of an integrated program in which all these elements were carefully considered and followed can best be described by reference to the Army and Navy efforts in this field. T o the millions of civilians already affected, the war brought added numbers of men suffering aural disability from high explosive shells, land mines, roaring planes, tropical fevers, and starvation in Japanese prison camps. It has been estimated that a quarter of a million servicemen will develop diminished hearing acuity. Many of these cases are not apparent now but will show up later. T h e Army and Navy established rehabilitation centers staffed and equipped with every device for the retraining of these aural casualties. They enlisted ear specialists from the medical profession, lip-reading teachers from the schools for the deaf experts in speech correction, sound engineers, psychiatrists, and psychologists and vocational guidance men. Never before were so many talents brought together as a team to solve the physical and social problems of one group of war disabled; altogether, 10,000 specialists were recruited for the Army program and 3,200 for the Navy. T h e program was built around a new concept of hearing loss and adaptation. First, the degree of hearing acuity was deter-

ig2

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mined by means of an audiometer. If the hearing loss is unilateral —in one ear only—no aid is required. If it is bilateral and less than 30 decibels, no aid is required, but above that point, aid is indicated. T h e actual point varies with individual sensitivity, but as a rule conversation is carried on at an intensity of 30-50 decibels. Some appreciation of the intensity of sound at this level can be gained by comparison with a pneumatic drill; this works at a 90-decibel intensity at a point ten feet from the ear. T h e sound of a train on an overhead trestle reaches the 100-decibel level. A hearing aid usually gives a 30-40 decibel improvement. In the selection of an aid, several standard devices were available in the Army and Navy centers. T h e hearing-loss pattern, or audiogram, is the basis of selection. Many subtle acoustic differences must be considered, and the final choice is narrowed to several aids which are first tested in a sound-proof room and then in ordinary routine practice in the hospital and out-of-doors. T h e instrument promising the greatest individual help is finally chosen. It was found that the proper fitting of the earpiece is important; an individually molded earpiece is more satisfactory than other kinds. It was also discovered that the new vacuumtube devices were a great improvement over the old carbon type, and that air conduction is better than bone conduction. Group instruction is the next step. It comprises listening to the instructor's voice and to various sounds on records, practicing special test words that are usually missed, listening to speech against different backgrounds of sound. It is followed by speech instruction, in which muscle mechanics are explained as a preliminary and lip reading is taught as a supplement. T h e Veterans Administration has taken over much of this work. It is desirable that similar programs be made available to the civilian. T o this end it has been suggested that the entire Army and Navy aural rehabilitation program be applied to the civilian hard of hearing. A few rehabilitation centers, hospitals and universities have set up programs along these lines, chiefly for children, but present facilities are still far from adequate. After effective physical restoration has been accomplished by means of hearing aids and speech training, many individuals are

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enabled to return to their former employment. T o assist those who for various reasons prefer to change their work, the general rules of vocational guidance are followed. A series of jobs and alternatives are selected on the basis of individual capacities, training is given, and placement becomes a matter of suiting individual capacities to the demands of the new job. T h e American Hearing Society in Washington was organized to promote these broad objectives through an excellent program of public education in the field of aural rehabilitation. T h e group puts out an excellent publication and many informative booklets. Individuals with a speech defect do not form a distinct group. T h e y are considered here because they suffer from a disability which interferes with their employability. T h e stutterer who cannot transmit a message accurately is certainly not efficient; to his physical handicap is added an emotional tension caused by the difficulty in getting his message across. Those who have a harelip, a laryngectomy, a cleft palate, or a severe lisp, to say nothing of a heavy foreign accent or some laryngeal affection that reduces the voice to a whisper, all require rehabilitation services. Speech correction and training are important for them. T h e latest estimate, known to be incomplete, of deaf-blind persons in the United States is more than 2,000, and approximately 900 of these have a total hearing loss. T h i s severely handicapped group constitutes a difficult community problem which is being handled directly by home teachers and counselors of local and state agencies, and indirectly through consultation with the Department of Services for the Deaf-Blind of the American Foundation for the Blind. Of the total number, less than 200 are children under 20 years of age. Although no institution has been established for the sole purpose of educating young deaf-blind individuals, residential schools for the blind and for the deaf in four states have created special departments for training doubly handicapped pupils. T h e employability of this group is naturally very low; however, a few deaf-blind persons have found work in industry. At least one has been graduated from a regular college. During World War II, Ford employed a few at the Willow R u n plant.

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and some have found work at the Industrial Home for the Blind in Brooklyn, New York. Another doubly handicapped group deserving special consideration includes those persons who have lost their sight and both arms. This disability, resulting usually from explosions, is not as uncommon as one would think. T h e problem of rehabilitating these people is vast, but it can be accomplished. Since the hand is the eye of the blind, blinded bilateral arm amputees have an especially difficult problem of perception. Therefore, it is not advisable to fit both stumps with arm prostheses. T h e dominant stump is fitted, and the patient receives training in the use of the prosthesis. An operation is performed on the other stump which divides the forearm into two finger elements, providing a measure of prehension without destroying tactile sensation for Braille reading and orientation. T h e patient is then given the usual course of training for blind persons, in orientation, Braille reading, travel and vocational and personal adjustment. Cooperation between the orthopedic surgeon who cares for the arm disability and the blind counselor is essential for the rehabilitation of this difficult group of cases. T h e successful adjustment of these patients is a tribute to the limitless capacity for compensation that is inherent in each of us. One young man from Greece was brought to the United States after losing his sight and both arms in an explosion while fighting with the guerillas. When he had arrived, it was discovered that, in addition to his physical disabilities and language handicap, he had numerous psychological problems. He received counseling to sever him from his mother, to whom he had a neurotic attachment, during the course of his physical rehabilitation. Cineplastic and Krukenberg surgery was provided, and a prosthesis was fitted to his dominant arm. T h e local agency for the blind sent a partially-sighted worker who taught the young man Braille, orientation and travel. He is now back in his own country with his physical and psychological difficulties improved. Another patient with this double disability wrote an excellent training manual, The Blinded Bilateral, which is being used to assist other sightless arm amputees. Rehabilitation of the blind and the deaf is carried on, more or less completely, in other countries. Many have provided for

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physical rehabilitation and vocational adjustment through government agencies; others through activities within private industries and agencies. Recently, experts from the United States have assisted in the development of programs in other countries directed toward the rehabilitation of the blind and hard of hearing.

Chapter XV MEDICAL AND SURGICAL INVALIDS

T

HE great American tragedy has not been written. It has been lived by the sufferers from severe chronic defects. For these severely handicapped men, women, and children, the promise of redemption lies buried in the conscience of the public. It has been estimated that twenty-five million persons, or one out of every five in this country, have chronic disease, and that one and one half million of this number are totally disabled and five and one half million are partially disabled. T h e Commission on Chronic Illness, which released these figures, believes that the estimate is too conservative, since there is evidence that the National Health Survey's figures are too low for tuberculosis, diabetes and cancer. If these millions of chronically disabled persons could be provided with special facilities and services, at least 20 percent could be partially or totally self-supporting, while 10 percent could be completely self-supporting. It may seem a contradiction in terms to speak of the severely disabled as totally self-supporting; nevertheless, the paradox is an illusion. T h e human body is incredibly virile. Through its safety factor it counteracts heavy assaults upon structure and function, enabling the individual to carry on despite serious impairment of heart, lung, or kidneys. Most chronically ill persons live on the edge of their incapacities. As long as the struggle between the demands of the job and the capacities of the worker is balanced, however slightly, in the latter's favor, he continues to work. By appropriate treatment and physical restoration, physical capacities are improved, but the essential factor which makes for successful work adjustment is the lesser physical demand. T o direct the handicapped person in a field which will make the most use of his talents and at the same time provide the least encroachment on his physical capacities is the aim of competent vocational counseling, training, and selective placement.

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T h e rehabilitation of the chronic disabled follows the principles and methods established for other types of disability. First, we must be assured that the m a x i m u m improvement has been obtained by medical treatment. It is immaterial whether we name this process medical care or physical restoration. T h e important consideration is to assure the patient the benefit of those medical services which will permit the m a x i m u m use of his physical capacities and thus permit him to meet the physical demands of the occupation for which he is fitted. Secondly, it is important that he return to his former occupation, if this is at all possible. If it is not, the selection of a new j o b should be made on the basis of his skills, interests, and aptitudes, in accordance with the best principles of vocational guidance. T r a i n i n g should be advised except in those instances where age or the pressure of economic factors are unfavorable. T h e application of these principles vary to some extent with the specific type of disability. A classical type of chronic disease is tuberculosis. T h e needs of the case of pulmonary tuberculosis are those of all chronic disabled: medical care d u r i n g hospital or sanatorium treatment, follow-up after discharge from the sanatorium and suitable placement u p o n dismissal from the sanatorium as an arrested or healed case. N o t enough attention has been paid to the possibility of utilizing the long period of hospitalization for the preparation of the patient for ultimate employment. Professional interest and orientation has been directed primarily toward case finding and medical treatment. O n l y recently has there been increased consideration of the patient's vocational future, and even this attitude has been directed to his needs after discharge from the sanatorium. Resistance to the development of rehabilitation programs within the sanatorium are the result of the traditional prejudice toward interference with the time-honored rest cure. Physical or mental activity d u r i n g this period has always been interdicted. It mattered little that mental anxiety concerning home conditions or future economic outlook disturbed the patient. It was assumed that the patient at physical rest was also at mental rest. Moreover, other unhealthy conditions following in the wake of the rest cure were reflected in habit patterns that later interfered with a smooth and successful adjustment. Early anxiety

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frequently subsided into an apathy that sometimes took the form of resistance to physical conditioning or convalescent training after discharge. Certainly, hospitalitis is no respecter of persons or diseases, and those suffering from pulmonary tuberculosis are subject to the same enervating effects of mental inactivity as the victims of other diseases. Programs of physical and vocational rehabilitation can be fitted to the needs of the individual case in the sanitorium. Occupational therapy, physical conditioning, educational work can be planned according to the condition of the patient. Preparation for a place in civil life after discharge is a mental stimulus toward recovery. T h e program can be fitted in with the program of medical and surgical treatment and adjusted to the special nature of the treatment such as rest treatment, pneumothorax or thoracoplasty. Although bedrest is still accepted therapy in the treatment of tuberculosis, and probably will never be entirely displaced, recent advances in surgery of the chest for tuberculosis offer promise of reducing the period of complete disability from this disease. In carefully selected cases, thoracic surgery has shortened the hospital stay from several years to several months. T h e important goal of treatment in pulmonary tuberculosis is the arrest of the disease. We speak of arrest rather than cure because complete eradication is rarely achieved. What occurs is a sort of armed truce between the reparative powers of the body and the activity or virulence of the tuberculosis organisms. Because this balance is critically small, the individual is subject to relapse. Recurrence may be due to incidental respiratory infection or exposure to another large dose of tubercle bacilli. However, recurrence from these causes are less common than those due to what has been called a lowering of the patient's resistance. T h e factors underlying human resistance to disease are not too well defined. While biological processes are dominant, there are also social factors—income, condition of work, improper housing, and inadequate nutrition—which influence the patient's resistance. It has always been assumed that tuberculosis and poverty went hand in hand; that crowded living quarters facilitated exposure to the tubercle bacilli that were being expectorated by those ill with active pulmonary tuberculosis; that reduced stand-

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ards of living and lowered nutrition, long hours of work, exposure to dusts and fumes, excessive physical and mental strain, were additional factors undermining the body's ability to deal with the tubercle bacillus. Of these factors, the role of physical strain has been least understood. Yet this is a vital factor that must be evaluated in the determination of the proper type of employment. If the physical demands of the job are such that they will tend to cause a relapse then the patient is poorly advised. How shall we evaluate the patient's ability to withstand strain? We have already discussed the difficulty in evaluating physical fitness and working capacity. These analyses were concerned primarily with individuals suffering from static defects. The evaluation of the physical fitness of working capacity of individuals with dynamic defects or recurrent illnesses like tuberculosis is even much more difficult. Yet some idea of a patient's fitness must be obtained if we are to help him in his adjustment and avoid a breakdown in his health. T h e testing of work tolerance has become a fairly wellestablished procedure in the rehabilitation of the tuberculous. Vocational counselors who are charged with the rehabilitation of tuberculous individuals have in the past depended on the estimate of the attending physician, based on his clinical evaluation of the patient. While this estimate is absolutely necessary, it must be weighed in the light of an actual demonstration of the patient's working capacity in a test situation as in a workshop or center. Here the work can be graded according to intensity and duration. We can then say that a patient has a two-hour, fourhour, or six-hour work tolerance. By this we mean, that he has the ability to perform continuous and productive work for specific periods without fatigue or the aggravation of symptoms or the later development of complications. For many years the Altro and Reco Workshops in this country have carried on a program for determining the work capacity of individuals handicapped by tuberculosis. These shops have also served as a means of sheltered employment, and the different processes of the tailoring industry have been used as the basis of work demands. These shops were originally established for arrested cases of tuberculosis alone. But it is not necessary to segregate the tuberculous in order to determine work capacity

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and work tolerances. If the case is not active there is no reason why this determination cannot be made in any curative workshop. Usually after a patient is discharged from the sanatorium there is some delay before he returns to employment. If he has not had the advantage of a rehabilitation program within the sanatorium he feels that he is not yet sufficiently recovered to warrant returning to his former occupation on a full-time basis. He is beset by many other qualms, about his earning capacity, about his relationship with former or new personnel on the job. These anxieties cannot be resolved in every case, but adequate preparation is a great stimulus toward confidence and self-assurance. A modern program in total rehabilitation of the tuberculous has been established by the Veterans Administration at Oteen, North Carolina. This program, described in Chapter 5, might well become a model for civilian tuberculosis centers, since it provides the complete range of rehabilitation services in addition to medical care of the disease. In the placement of the tuberculous we must remember that the disability of an arrested case of pulmonary tuberculosis differs from that of an amputation case in that the defect is hidden. Outward evidence of disability is not apparent so that employer prejudice is not a problem. However, as soon as it is made known to the employer that the patient has had tuberculosis, reluctance to hire the worker is encountered, primarily because of the employer's ignorance concerning the nature and hazards of the disease. Enlightened management has taken a more progressive view by fitting the worker to a job within his tolerance. One of the popular beliefs or myths concerning the employment of the arrested case of pulmonary tuberculosis is the necessity for placing the individual in an outdoor job. But farmers, motormen, laborers, postmen, and others engaged in outdoor work may develop tuberculosis. Veterans of the last war who engaged in chicken raising frequently found that the physical strain and irregular hours offset the advantage of outdoor life and frequently caused a relapse. Specialists recognize that what the arrested tuberculosis case does during the eight hours he is employed (except when he is employed in specially hazardous work) is of less importance than what he does with the remaining six-

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teen hours of the day. Those remaining hours have to be utilized fruitfully so as to conserve health and vitality through proper rest and wholesome recreation. What actually happens to people who are discharged from sanatoria? One study of 125,000 patients revealed that the majority resume their previous occupations or continue training for the careers originally planned for. T h e difficulties of the extuberculosis patient have been therefore much exaggerated. In cases where early discovery has been followed by prompt treatment and age and environmental factors are favorable, he will return to his studies or former occupations. T o restrict these individuals in their work opportunities would be a serious mistake. Yet restriction and prohibition of industrial employment is too widely practiced. In the first place evidence of a good work tolerance under modern conditions should assure a return to complete productivity. Furthermore, factory work under modern conditions does not involve undue heavy manual labor. Surveys show that industrial workers show no greater incidence of tuberculosis than the rest of the nation, except in special industries like stonecutting. T h e tuberculosis patient who changes a vocational life pattern to which he is habituated has been badly advised. He is certainly less handicapped than the deformed cripple who must face the deep-rooted prejudice of the public. But he nevertheless is faced by a difficulty, one that is largely psychological. T h e skeleton in his closet is the idea that he can never work again. T i m e disproves this erroneous belief. These ideas, however, are also held by employer and by fellow employees. T h e attitude is yielding only slowly to the force of education. T h e National Tuberculosis Association, originator of the famous Christmas seal, is an organization which has assisted many persons with tuberculosis to return to a reasonably normal and active life. Providing certain basic conditions of rest and nutrition are met, there are few occupations in which healed victims of tuberculosis cannot engage. There is a group of tuberculosis patients who, owing to the extent of their disease, personality difficulties, advanced age or other handicaps cannot be advantageously placed in industry. Some are employed in sanatoria; only a few are found in sheltered employment. For this partially productive group, exten-

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sion of sheltered work opportunity is needed. For the group of unfortunates who are unemployable, pensions are recommended. In some countries village settlements have been established for them, as the classical one at Papworth, England. Here patients live with their wives and families while earning a living at special tasks. While these village settlements are valuable in controlling the after-treatment of the patient, it is questionable that they can provide security for tenure of employment for an indeterminate period. T h e essential object of the village settlement is to bring the active stage of the disease to a state of arrest for a period long enough to reduce liability to relapse to a minimum. But the settlement should not become a center for the employment in perpetuity of arrested cases. T h e fulfillment of a rehabilitation program for the tuberculous through federal-state action has been slow to develop, first because of the traditional emphasis on orthopedic cases rather than handicaps from chronic disease. T h e passage of the BardenLaFollette amendment in 1943 has renewed interest in the needs of the chronically ill. Many types of programs are being undertaken. Some are conducted independently by the various state agencies. Others are carried out by state bureaus in cooperation with specialized tuberculosis agencies that are already in the field, that understand the problems of the tuberculous, and are prepared to provide or undertake rehabilitation services in an organized way. In New Jersey, for example, a cooperative agreement exists between the State Rehabilitation Commission and the New Jersey Tuberculosis League, whereby the state assumes rehabilitation services for discharged patients having a fourhour work tolerance. An extension of this agreement permits the purchase of tools and equipment for in-sanatorium patients, provided that the projects are prevocational. T h e New Jersey Tuberculosis League is concerned with the rehabilitation program within the sanatorium, while the State Rehabilitation Commission picks it up after the patient's discharge. There is thus a continuity of treatment and service. There are other chronic pulmonary disorders that require consideration. They cannot be gone into detail here except to name them and briefly review their problems. Bronchiectasis is a chronic lung disease caused by congenital dilatation of the bron-

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chial tubes, whereby small and progressively larger blind pockets act as a trap for mucus and other collections of matter. Infection may supervene and the symptoms of chronic cough and expectoration is frequently mistaken for tuberculosis. However, the condition is not in the same category, since it is a more or less stationary condition confined to the lungs and does not involve the rest of the body. However, the presence of cough and expectoration is a frequent bar to employment, especially in industrial environments where irritating dusts or fumes may aggravate the condition. Treatment is difficult because of the multiple character of the lesion and its inaccessibility. Working capacity is not necessarily reduced, but some attention must be given to avoid placement in unfavorable work environments. Asthma is a common disorder due generally to an allergy but characterized by variable attacks of difficulty in breathing. Here again the worker is guided into work consistent with his interests and aptitudes, but consideration is given to the work environment which will be least likely to produce or aggravate these attacks. In these and other pulmonary conditions the successful work adjustments will depend on providing the worker with complete medical care and an analysis of his work capacities and the matching of these with the physical demands of the job selected on the basis of his interests and skills. Emphasis then is on the positive side of utilizing his capacities rather than on the nature of his illness and its associated disabilities. There are an estimated 9,200,000 cases of cardiovascular renal disease in the United States. Subdivided by types of disease, there are about five million cases of heart disease, four million cases of hypertension and 950,000 cases of nephritis. These figures add up to more than the total, since some individuals have more than one condition. Mortality statistics give heart disease as the greatest single cause of death in the United States. T h e incidence of disabling heart disease is extremely high, and this group is one of the most important sources of chronic disease in the United States. Under the ordinary conditions of life, the normal heart uses only a small fraction of the total available energy, the balance of unused power being held in reserve to meet unusual demands or accidental demands which accompany strenuous or prolonged

2C>4

M e d i c a l a n d Surgical Invalids

physical effort. T h e reserve of muscular power constitutes a factor of safety for use in emergency only. As a result of infection, syphilis, arteriosclerosis, and kidney disease, this reserve or safety factor is gradually encroached upon until the cardiac muscle is no longer able to maintain the circulation during the rest. T h e diminution in the functional capacity of the heart may begin slowly or suddenly and is characterized by symptoms referable to the lungs, circulation, kidney, stomach, and the nervous system. Between these two extremes of a normal and fully decompensated heart lies the large group of cases of organic disease of a moderate or serious degree, without symptoms. These cases are referred to as compensated, indicating that enough reserve muscular power is present to meet the demands made upon the heart despite the serious n a t u r e of the organic lesion. In coronary disease for example, the circulation to the heart muscle has been damaged. T h e integrity of the muscle will depend on the development of collateral circulation. T h e conditions will vary in individual cases so that it will be difficult to make a decision. O n e must be guided by the cardiologists findings. T h e X-ray and electrocardiograph findings are helpful in reaching a conclusion. Frequently patients ignore the physician's warning to lead a modified life and in a short time are dead. Others live on to a f r u i t f u l career. In this respect one cannot ignore the inexorable facts of statistical evidence. A large number of those with coronary disease have a severely limited life expectancy. It will be a personal matter for the patient to decide if he will die in his boots or completely modify his way of life. Many attempts have been made to evaluate the stability of the chronic heart case in relation to the demands of work. T h e classifications of the American Heart Association have been long in use as an index of work capacity. These classifications however are essentially clinical, in that they refer to the restrictions of physical activity rather than the positive aspects of working capacity. Five classes are established, ranging from full physical activity to complete physical inactivity. Certainly heart disease impairs the efficiency of the worker, reduces his output and earning capacity. But many men and women who are admittedly handicapped by heart disease can, under proper supervision and

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control, carry on suitable work and continue to earn wages. Under favorable conditions where the physical demands of the job do not exceed the patient's tolerance, most persons suffering from chronic heart disease maintain a fair degree of earning capacity. From our point of view, patients fall into three groups: those who can be made totally productive, those who will be limited and therefore partially productive, and those who are totally unproductive. Classification according to working capacity is of greater value for our purposes than one based on the pathological or clinical terminology as (valvular disease, congenital heart disease, endocarditis or coronary heart disease). T h e woman who has been bedridden but who is given an opportunity to operate a mail order business in her home and thereby earns more than $50 a week is a productive worker and not a case of chronic myocarditis. On the other hand, the man with a mild angina pectoris who becomes so apprehensive about his condition as to give up all attempts to work is totally unproductive and disabled, not because of the nature of his disease but because of the way in which he has reacted to it. Numerous studies have revealed the presence of large numbers of these "cardiac neurotics." Suffering from little or no organic disease, they nevertheless suffer from psychoneurotic symptoms so severe that productive work is impossible. Occasionally, this condition is indirectly caused by an over-cautious physician. Modern cardiologists are strongly in favor of carefully selected work for the cardiac patient. Many of those whom we designate as totally productive will automatically make their own adjustments to full employment. Others will be apprehensive about taking such steps or will be advised by friend or physician to limit their activity. Here again, these estimates or recommendations will have a greater validity as they are verified by testing the patient's work tolerance in a workshop or rehabilitation center. Observation in the worktesting situation will determine the limits of activity which produce symptoms of pain or changes in the pulse, blood pressure, or general circulatory efficiency. T h u s they will reveal the necessity for supervision in an employment situation. However, the actual working capacity may be far beyond that estimated clini-

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cally, one that permits a much wider use of the patient's powers. Certainly the clinical and the performance test should be weighed together, but only experience will demonstrate how great the underestimation of working capacity has been. Furthermore, the full powers of the individual can be utilized even where these powers appear to be restricted. By careful selection of a job situation which will not demand physical effort or capacities beyond the tolerance of the individual the patient can still remain totally productive. How shall we go about making the job selection? One method would be list the jobs that cardiacs could do. For example, it would be a simple task to select a series of occupations such as jewelry design and repair, watchmaking and clockmaking and repair, proofreading and copyholding, drafting, bookkeeping, stenography and accounting, elevator and switchboard operating, watchmaking, ticket collecting, restaurant cashiers, packing and examining hairnets, hosiery and glove folding and wrapping dress patterns, labeling and finishing goods in drug supply houses, coloring lantern slides. In one study conducted by the United States Civil Service Commission this was the method followed. A list of positions was prepared based on the recommendation of the medical officer on his estimation of the minimal physical requirements of the job. In another study of the handicapped at work those jobs were listed that were held by cardiacs. But both methods fall short of helping the cardiac to adjust himself; both provide only minimal opportunities for him. They do not attempt to utilize his full potentialities based on a complete analysis of what those potentialities are. T h e physical disability should not dominate the judgment reached. Good counseling will reveal alternative selections, so that the disability does not become the deciding factor. For the unskilled cardiac, placement will be difficult since his past pattern of work activity has been one in which excessive physical effort has been required. Training will provide new opportunities for employment in fields where excessive effort is not required and where his potentialities as revealed by an adequate survey can be realized. For the man of middle age, a sudden attack of coronary heart disease may become a major catastrophe. He needs sound

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advice not only to provide new avenues for productive economic effort but also for emotional assistance in devising a design for living that can still give him real satisfaction. T h e majority of these individuals remain in former activities. A t first they assume only a modified program of activity. As they sense no harmful effects they expand their efforts until a full program of activity is achieved. In one particular field the adjustment of the cardiac has been almost completely overlooked, housework. T h e work of a housewife has not been explored by j o b analysis, yet if the physical demands of housekeeping, cooking, laundering, and caring for children's needs were carefully analyzed, it is fair to assume that in many cases it would exceed a sixteen-hour day in heavy employment. It would seem then that we underestimate the working capacity of the cardiac, as we have other types of disability. T h e therapeutic diagnosis is not correlated with the individual's functional performance. Only by an intelligent examination of physical and mental capacities and the selection of training and employment where these can be utilized fully and to the greatest satisfaction can we appreciate the hidden assets of adaptation and adjustment. T h e needs of children crippled with cardiac disease have already been discussed. O n e point requires repetition and reemphasis. Many of these children are handicapped by irregular attendance in school and in every case are generally lower in efficiency during the period of attendance. T o this educational difficulty is added the poor quality of instruction and the failure to receive training in trade schools. W h e n the disease is at all developed the children are excluded from all but a few light and simple tasks which give them small satisfaction and little financial return. T h e r e f o r e they become a burden to the family or community. O n e cannot speak about heart disease without considering one of its corollaries, namely vascular disease or disease of the blood vessels. T h e two most important are hypertension or high blood pressure and arteriosclerosis or hardening of the arteries. Although moderate increase of blood pressure accompanies increase of age, generally this slight rise causes no symptoms. How-

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ever, in the case of kidney disease or malignant hypertension, it becomes a serious menace to the patient's health and working capacity. Many individuals can work better with a higher blood pressure than under a regime of rest, purgation, diet and medication to lower it. T h e y are rarely kept from their work until a mild or severe cerebral hemorrhage or stroke stops them. T h i s is due to the gradual adjustment of the body over the years. In malignant hypertension and in kidney disease the onset is less gradual so that the individual cannot make a sufficiently rapid physiological adjustment. Symptoms of headache, dizziness, and shortness of breath and fatigue soon impair his capacity to work. In some cases of malignant hypertension some medical help is available through surgical removal of the nerves which are presumed to influence blood presure. In any case, the adjustment of the patient is essentially on a personal basis, but one in which close cooperation with the attending physician is indispensable. Arteriosclerosis is the inexorable process of changes in the blood vessels with age. T h e blood vessels thicken, lose their elasticity, become brittle from deposits of lime within the vessel wall, and thus interfere with the function of all the organs, dependent upon the blood supply. T h e process varies greatly, so that chronological age and physiological age are not always synchronous. As the process develops the entire body is affected, although none of the organs reveal the decline in vigor and virility as greatly as the brain. But the decrease in general physical and mental capacity begins long before the popular notion of what constitutes old age. In fact the decline begins even before middle age. Industry has used the 40-year period as the deadline for the beginning failure of productivity, with all its social and political implications. While this attitude is unreal and inequitable in a modern industrial system, we must nevertheless not close our eyes to the facts of physiology. T h e reduction of man's capacities with age must not be used as a club over his head, but should be utilized to perform a better job of selective placement. By placing the individual in a field of activity where through his tested knowledge and experience he can do his best job we are subscribing to the fundamental principles of good selective placement. Industry profits by the mental and vocational equipment he brings with him. T h e man still retains his

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usefulness and productivity, thus providing production for the nation, and status and satisfaction for himself. Kidney disease varies in character and extent, some of the cases being only slightly disabled as the body strikes a balance between disease and repair. Others go on to progressive disability and death. Certain surgical diseases of the kidney have a better outlook. Tuberculosis and hydronephrosis for example, are amenable to surgery, so that removal of the offending kidney will produce a fully productive worker if the remaining kidney is sound. This is another manifestation of the safety factor operating in every individual. Early ambulation has proved to be an important part of postsurgical care. Formerly, the patient was permitted to lie in bed for an unnecessarily long time after an operation, in the belief that rest was essential to his recovery. T h e opposite is more nearly the case; inactivity is weakening. Surgical patients are now encouraged to get up on the day after the operation, and, in minor operations, on the actual day surgery is performed. T h e hospital stay is shortened, the patient can return to work sooner, and, most important, some dangerous consequences of prolonged bedrest are averted. Gastric ulcer is a common disorder with long-standing effects on the patient's capacity to work. Individual variation in the ability to withstand pain determines in large measure the incapacity of the patient for industrial work. A large number of patients do carry on fairly normal activity, with comparatively little impairment of efficiency or working capacity. T h i s is especially true when active treatment and medical supervision is continued until the condition is healed. New types of medication have been found useful in healing ulcers and, when combined with psychotherapy to erase the psychosomatic cause of ulcers, greatly reduce the disability from this disorder. There are one million known diabetics in the United States, and the American Diabetes Association estimates that there are at least another million persons with unknown cases of this disease. In this disease, the pancreas is unable to produce sufficient insulin to regulate the amount of sugar in the system. Excess sugar is present in the blood and spills over into the urine.

21 o

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Invalids

Basically, treatment for diabetics consists of regulating the sugar intake through diet, and through artificial administration of the substance, insulin, which the body itself is unable to manufacture in sufficient quantity. For this patient the outlook both for life and active working capacity was at one time very dark. For children the prognosis was generally fatal. But since the advent of insulin the entire picture has changed. T h e child can look forward to growth into adulthood, while the adult can look forward to a life of full activity with little restriction of a major character. Yes, the diabetic need not consider himself disabled. He can undertake work without restriction in the majority of cases. As a matter of fact work with the expenditure of muscular effort is most desirable for the diabetic, since it helps him to burn up the excess sugar and in that respect reduces the amount of insulin required. Since 50 percent of all diabetics require no insulin there is no need of establishing any special restrictions to their working activity. Of the group who require insulin it may be said that restrictions are necessary in occupations in which the worker is responsible for the safety of others, as a mild dizziness or faintness, or even loss of consciousness, must be considered as a possible concomitant of shock from the excessive use of insulin. In the employment of the diabetic, prejudices have arisen from misinformation concerning the practices and routine requirements of the insulin taker. One of the objections has been the erroneous idea that time must be taken out for the administration of injections. T h e injection rarely has to be taken more than once a day and this is done generally before breakfast or, if it has to be repeated, after work. Improvement in the insulin itself has considerably reduced the number of injections previously required. Another question that frequently arises in the mind of the employer is whether special eating arrangements are necessary for the diabetic. They are not, except that the meal times must be regular. Once the pattern has been established it should be observed. Furthermore, there is no need for taking time out for specimens. This can be done at home, generally on a free day. Blood determinations are being used less and less for routine examination and even these are taken before breakfast on a fasting diet.

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We see then the tremendous potentialities for vocational and economic usefulness for this large group of chronically disabled civilians. Corrections of our misconceptions of the disease, improvements in medical technology, together with advances in treatment have restored them to a productive place in our society. While diabetes is never cured in a technical sense, there is no reason why the diabetic cannot become a continuous and productive member of society. What holds true for diabetics holds true for the whole gamut of chronic disease. Metabolic diseases such as gout, and gastrointestinal disease such as colitis and cirrhosis of the liver, leave their victims with enough residual working capacity to be utilized in at least partial if not total productive effort. T h i s productivity can be utilized if the principles of rehabilitation are followed: every medical and surgical technique must be exhaustively explored to provide a full measure of physical restora tion; the mental and vocational powers and experience must be analyzed to ascertain in what area they can be best applied. Vocational training in new or allied fields of work should be made available if return to previous employment is not feasible, and finally a selection of employment, whether partial or total, must be made by matching physical demands of the job selected and the physical capacities which the patient still presents.

PART IV

A National Program

Chapter XVI LEGISLATION AND ADMINISTRATION

W

E have seen that the efforts of charity and private philanthropy have provided only a limited solution to the problems of the physically handicapped. Nor can the work of fraternal and other voluntary organizations be overlooked in a survey of the agencies which have provided funds and services in an attempt to ameliorate the conditions of the crippled and disabled. Above all, the greatest service rendered by these groups has been the initiative and support they have given to legislation. Organized action through legislation was necessary to expedite the appropriation of large sums of money and to create permanent machinery for carrying out the purposes of the legislative measures. Naturally, the best legislation is ineffective without competent and sincere administration. T h e test, therefore, of the validity of any legal contribution is not only the scope of the law but the manner in which its purposes are carried out. Many types of legislation have affected the welfare of the crippled and disabled. Poor relief, old age pensions, and widows pensions all consider the physically handicapped person as an object of their ministrations, not as a crippled or disabled person, but as a case of indigency. T h e legislation which secured rights and benefits for the crippled and disabled person because of his special physical condition is a twentieth century contribution. Yet though a wide variety of legislation is now available, it owes origin not to the conception of the disabled as a single social or economic class but to the scattered efforts to meet the needs of special groups of disabled persons. These measures have been grouped into five general categories according to their application to the needs of five separate groups: the child cripple, the injured worker, the war disabled, the chronically disabled, and those disabled by blindness. T h e introduction of rehabilitation legislation in the United States represents the first attempt to treat all these groups as a unified problem, yet administrative and political considerations still pre-

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vent the realization of this aim. T h e r e is need for a reexamination of legislative enactments in order to make them consistent with modern trends. Until the latter quarter of the nineteenth century, virtually all efforts for the crippled child were exclusively in the field of asylum and care. F o l l o w i n g the example of private philanthropy, the first pertinent state legislation was for the establishment of state-owned and maintained institutions. Not until the law which went into effect in Ohio in 1 9 2 1 was there provided a decentralized plan with emphasis on family care rather than institutional care. It sought to fix upon the counties and the state the responsibility for the quality of treatment. T h i s was a good law, providing as it did f o r care, education, rehabilitation, and placement, and centralizing the efforts of various groups working in the interest of the cripple; private enterprises and interest were utilized to the utmost. Laws of this type were later adopted by thirty-five states. Legislation and administration for the care of crippled children was thus on a state basis until the passage of the Social Security Act. T h e W h i t e House Conference on child health and protection in 1930 had already crystallized the growing sentiment throughout the U n i t e d States for more adequate care of crippled children. T h e shortcomings of state-sponsored and administered legislation was evident. T h e need for the national government to participate in these schemes in some capacity became apparent. As f a r back as 1 9 2 1 the principle of government assistance to the states in the development and operation of its welfare and health programs had been established by the passage of the S h e p a r d - T o w n e r bill. T h i s act (Public Laws 1 9 2 1 , Chapter 1 3 5 ) was established for the promotion of the welfare and hygiene of mothers and infants and formulated the principle of grants-in-aid which m a d e it possible for the states to collaborate with the government in the control of a national problem. T h e law set aside $480,000 to be equally apportioned among the several states, on condition that each state legislature pass enabling legislation and appropriate a sum equal to the Federal grant for the maintenance of the services and facilities provided for in the Act. T h e Children's B u r e a u of the Federal Security Agency was

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made responsible f o r the administration of the provisions of the Social Security Act and for the examination and approval of state plans for federal-state cooperation. T h e Bureau also maintained a staff of medical, nursing, and social personnel to advise the states and serve as a stimulus toward improvement of services and the maintenance of high professional standards. But actual administration of the program has been left to the states. T h e method of administration varies considerably. Responsible agents in the various states include the departments of health, departments of public welfare, crippled children's commissions, departments of education or state universities. In 1951 the Congress appropriated $31,500,000 to the Children's Bureau of the Federal Security Agency for maternal and child health services, services for crippled children, and public child welfare services. T h e bulk of these appropriations represent grants-in-aid to public and non-profit voluntary organizations, including grants to universities and other institutions for research and training activities. T h e Children's Bureau, now under the direction of Dr. Martha M. Elliot, carries on an extensive educational program in child welfare activities. It would seem that the machinery has been well formulated and developed and yet there are serious gaps. T o o few states have enacted legislation for reporting crippled children to the authorities. Such a simple device as the registration of congenital cripples at birtli should find widespread adoption. Despite adequate educational facilities in many states, arrangements for a follow-up in order to supervise the important period of transition to adolescence and adulthood are woefully inadequate. It is apparent that despite the effective work of existing official and private agencies, the care of crippled children is still far from the goal for service that will transform the crippled child into a potential productive citizen. It took the United States a long time to accept the principle of social insurance. W h i l e the European Continent had been experimenting with it from the last quarter of the nineteenth century, it was not until 1 9 1 1 that the principle was accepted here as the alternative to public relief and private charity for injured workmen; the enactment of workmen's compensation legislation

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in all but one state and by the Federal Gov ernment confirmed its validity. Even so, there are serious gaps in the present system of laws. Provisions for full physical and vocational rehabilitation are limited. Compensation awards, for example, both for temporary and permanent disability, are frequently inadequate in estimating the degree of vocational incapacity suffered by disabled workmen. T h e use of lump-sum awards for the rehabilitation of the severely disabled is given little consideration, and special funds for second-injury cases still wait for establishment in many states. These inadequacies point to the necessity of bringing workmen's compensation laws up to a modern standard, the criterion of which is the ultimate rehabilitation of the worker and his reestablishment in employment. T h e basis of this standard is unlimited medical benefits, both as to time and amount; inclusion of artificial appliances; the preparation of schedules of benefits for temporary and permanent disability, in accordance with surveys indicating the extent of the vocational handicap; the inclusion of the principle of computation of lump-sum awards, now too loosely provided for purposes of settlement only and not as an aid to rehabilitation; the inclusion of second-injury clauses in all compensation laws; and the provision of compensation for life in the case of total disability. In the latter case some inducement should be made to the employer to encourage him to advance the money for rehabilitation, so that the worker will not be penalized for his disablement. In this way, the employer and the injured worker both benefit. In the Canadian system, pensions are provided without regard to earning capacity, so that there is every inducement to develop earning capacity and rehabilitation. These inadequacies represent defects in the laws themselves. T h e y can be partially counteracted by good administration, and they can certainly be exaggerated by poor administration. Shortsighted concentration on the settlement of claims defeats the fundamental purpose of workmen's compensation. A new orientation is needed, one directed toward rehabilitation rather than mere litigation. In this respect the personnel of the industrial ac-

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cident commissions will need the cooperation of the insurance companies and the medical profession. T h e history of governmental effort on behalf of disabled veterans has already been reviewed; it remains here only to point out the legislation which becomes the basis for the policy and procedures that the Veterans Administration are called upon to carry out. In W o r l d W a r I, basic legislation was enacted to take care of the needs of disabled veterans of future wars. T h e Veterans Administration was authorized to establish rules and regulations that would care for certain contingencies construed to be within the scope of the statutes as passed by the Congress and approved by the President. Public Law 2 of the 73d Congress, approved on March 20, 1933, and often amended thereafter, provided pensions and compensation for the disabled veteran. T h i s law (which is also basic regarding pensions for disabled World War I I veterans) applies to any person who has been in active service, and has been disabled as a result of disease or injury, or aggravation of a preexisting disease or injury incurred in the line of duty in time of war, provided he was honorably discharged and the disability is not the result of his own misconduct. T h i s provision was liberalized by an amendment of J u l y 13, 1943, and established the principle that induction in the armed forces shall be construed as prima facie evidence of sound health, unless the record at its inception noted the defects, infirmities, or disorders. On J u n e 6, 1933, President Franklin D. Roosevelt issued an executive order to establish ten grades of disabilities, as far as possible on the impairment of earning capacity. These schedules have been subject to considerable fluctuation. As of the winter of 1 9 5 1 the scale of pensions paid monthly and according to the percentage of disability is as follows: Percent

Dollars

Percent

Dollars

10 20

15.00 30.00 45.00 60.00 75.00

60 70 80

90.00 105.00 120.00 135.00 150.00

30 40 50

9° 100

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These increased amounts were established only after considerable agitation on the part of the national veteran's organizations. A fair and equitable analysis of even these increased grants will prove that they are insufficient to permit the disabled veteran an accepted standard of living. Under Public Law 877, additional benefits are payable to disabled veterans with dependents. A rate chart has been developed which specifies the allowance for each additional dependent. While this legislation is more liberal than the original legislation for disabled veterans with dependents, the schedule provides assistance that is still inadequate to meet the needs of disabled veterans. Legislation has not kept pace with rising living costs, and the disabled veteran and his family would have a difficult time maintaining themselves according to the current standard of living unless there were some additional income to supplement the benefits. If, as a result of service-incurred disability, the veteran has lost the use of a foot, hand or eye, the previous rates or schedules are increased by $42 a month; if he has lost two hands or two feet or one hand and one foot, he receives $240 a month; if he has lost two extremities and has been rendered so helpless as to require the assistance of an aid or attendant, he may receive $282 a month; total blindness or the loss of two extremities so close to the hip or shoulder that the wearing of a prosthesis is impossible will render him eligible to receive $ 3 1 8 a month. Finally, if the veteran qualifies for two or more rates as outlined above, he may receive up to $360 a month. Under the present legislation, no amount over $360 per month may be paid for additional service-connected disabilities. T h e equitability of these pensions will always be controversial. On the one hand, veterans organizations will constantly, and with some justice, be pressing for increased rates to enable disabled veterans to achieve a better standard of living. On the other hand, growing public objection to increased federal spending will act as a damper to any legislation aiming toward increased allowances. As of 1 9 5 1 , Congress has made over to the Veterans Administration more than four million dollars for the current fiscal year. This amount is for the various health, welfare and education

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programs of the Veterans Administration, which now is more or less responsible for the 18,828,000 living veterans. T h e scope of Veterans Administration activities is indicated by the following data: In 1951 there were 2,377,029 active pension and compensation cases. In addition, there were 687,947 active compensation cases covering death benefits to survivors of veterans. A total of 1,223,346 veterans were in education and training programs and 55,546 disabled veterans were receiving vocational rehabilitation. More than 100,000 Veterans Administration patients are in hospitals. Congress has approved legislation to make veterans of the Korean conflict eligible for many benefits on the same basis as Veterans of the Second World War. T h e y have the same right to hospital and medical care and may qualify for disability compensation and pensions; their survivors may receive death compensation and benefits, and burial benefits. At the present writing, the one important exception is the law governing education and training benefits. World War II veterans, of course, are no longer able to take advantage of these benefits under the G.I. Bill of Rights unless they are already enrolled in some educational program. A special House committee is studying the strengths and weaknesses of the veterans educational program as it operated for veterans of the Second World War, and there is little doubt that similar legislation will be enacted within a short time for the veterans of the Korean conflict. T h e past decade has seen the enactment of numerous legislative provisions concerning veterans, covering such matters as housing, cars and equipment for certain classes of disabled veterans, financial allowances, educational assistance, priorities, etc. It is impossible to present all these laws here, even in summary, but a brief review of the most important laws of this nature might be significant to indicate the liberal trend of this type of legislation. On December 19, 1941, the 77th Congress enacted Public Law 359. This provided for the payment of the amounts previously mentioned to disabled officers and enlisted men while in armed

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combat, extra hazardous service, or while the United States is engaged in war. Again to circumvent the errors that caused confusion and perpetrated injustice to the World War I disabled veterans, passage of the Voorhis Act of December 20, 1941, prescribed specific procedure in the Veterans Administration relating to the determination of Service Connection of disabilities. The Act specifically provides that in default of any official record regarding the origin of disability, lay evidence is permissive for resolving every reasonable doubt in favor of the veteran. Veterans of all wars under certain conditions prescribed by regulation are entitled to existing Veterans Administration facilities, hospitalization, and domiciliary care. An amendment of March 17, 1943, grants hospitalization, domiciliary care, and burial benefits to those who served in the Women's Army Corps, Women's Reserve of the Navy and Marine Corps and the Women's Reserve of the Coast Guard. By the Act of May 23, 1944, Congress repealed many acts that provided artificial limbs and appliances, stipulating that any retired officer or enlisted man who has lost a limb or the use thereof in the line of duty in military or naval service at any time, may be provided with an artificial limb or other appliance found by the Administrator of Veterans Affairs to be reasonably necessary in medical judgment. "Seeing-Eye" or guide dogs may be provided pensionable blind disabled veterans. Public Law 16 of the 78th Congress was approved March 24, 1943. This statute supplemented previously established federal laws and was enacted to extend benefits to the disabled in World War II. It provided vocational rehabilitation to those who served actively in the armed forces after December 6, 1941, to the date of the termination of the war. Further stipulations are an honorable discharge and a service-connected disability or aggravation of a preexisting disablement. T o secure training, it is necessary that the disability be construed as a vocational handicap. Training courses are limited to four years and the cost thereof is limited to $500 a year. Additional maintenance or subsistence allowances are granted for the period of training. The operation of this law is supervised by the Veterans Administration. The Administration does not establish schools for

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the purpose of extending vocational training. Training is given through approved public and private schools. Employment training on the job is permitted, if the trainer has been officially approved. T h e law is far-reaching, in so far as it recognizes as serviceconnected any further disablement incurred by the veteran during the training period, provided such injury is not due to willful misconduct and that the claim is presented within two years of date of injury or aggravation. T h e so-called G.I. Bill of Rights of World War II (Public Law 346, 78th Congress) was approved on J u n e 22, 1944. This Act, like Public Law 16, is administered by the Veterans Administration. For the first time in the history of American wars, the G.I. Bill granted educational training with subsistence alowance during the period of training. Honorably discharged able-bodied veterans who served in the armed forces 90 days or more were eligible. T h e Veterans Administration was permitted to pay for tuition, books, and supplies up to a total of $500 for an ordinary school year. (Under the terms of the original Act, an ordinary school year was held to be from thirty to thirty-eight weeks.) For a short intensive course in excess of $500 the entire charges may also be paid by the Veterans Administration. Vocational training under the terms of the G.I. Bill, unlike the disabled veterans' reeducational feature, is not under the supervision of the Administration. Both disabled and nondisabled veterans may secure a guaranty of loans for the purchase and construction of homes, farms, and business property; most of the states have supplemented this by the enactment of liberalized loan acts. Another section of the Bill that applies to the disabled and nondisabled is the Unemployment Compensation provision that permits weekly payments of $20 to unemployed veterans for a period not exceeding 52 weeks. T h e Veterans Preference Act, approved J u n e 27, 1944, grants precedence in civil service appointments under supervision of the United States Civil Service Commission. Preferentials are in the following order: honorably discharged disabled veterans; wives of disabled men who are themselves unable to qualify; widows of deceased ex-service men; honorably discharged service men and women who have served under war conditions.

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On September 27, 1944, the Federal Homestead Act was approved. T h i s law stipulates that veterans of World War II must have served ninety days; homestead entry must be made subsequent to discharge for two years' credit as to residence and cultivation time. In the field of patents, the period of residence prior to patent issue has been reduced, for disabled veterans, from three years to one. Congress enacted a law September 26, 1 9 4 1 , which provides that reserve officers in the U.S. Army who were disabled, diseased, or injured in line of duty are entitled to the same retirement pay as officers in the regular army. T h u s far we have considered legislation for the crippled child, the injured worker, and the disabled veteran. Legislation for the chronically disabled—the so-called "otherwise" disabled—has been less constructive. Old age pensions and mothers' aid pensions were the basis for present day public assistance laws. Philosophically, the disabled are considered among the indigent, and the emphasis continues to be financial assistance for subsistence rather than for rehabilitation. T h e largest federal grant-in-aid program continues to be for old-age assistance, aid to dependent children, aid to the blind and aid to the totally and permanently disabled. For the fiscal year of 1 9 5 1 , Congress voted an appropriation of $1,150,000,000 f o r grants to the states for these four programs. (At the time of this writing, the Senate had voted to increase the federal share of the cost of these four programs in order to encourage the states to increase individual payments; the House had not yet acted on this proposal.) T h e chronic disabled are still in the general class of those receiving public assistance and relief on the basis of indigency rather than physical defect. Invalidity pensions should be extended to this group. However, since Ave are concerned with the restoration to working capacity of as many as possible, our aims may be realized only through the expansion of rehabilitation legislation to the severely disabled. As for the blind, the brief survey we have made is significant in that it points to legislative remedies applicable also to the needs of other disability groups. Legislation establishing workshops, independent enterprises, and pensions for the blind are important. But more important is to create the favorable condi-

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tions to make the blind employable in normal times as they were in the war years. We come now to a new concept of social legislation for the physically handicapped—the concept of legislation for rehabilitation which views the problem as a systematic responsibility requiring integrated principles of administration. T h e evolution of this legislation to its present position has been reached through a series of advances and regressions, under the pressure of events and the steady demands of the disabled. In 1908, Paul Pastur, a public-spirited lawyer of Belgium with a keen understanding of human nature, convinced his fellow citizens that it was cheaper to retrain the physically disabled for self-support than to maintain them in idleness; that no state can remain economically healthy if a large group within it remains unproductive while at the same time consuming an appreciable share of the production of others. As a result of this irrefutable logic, a school for the crippled was established at Charleroi. It remained in effective operation until, in World War I, the Germans overran Belgium. T h e director of the school, M. Azer Basque, fleeing before the invasion, arrived in Lyons where Edouard Herriot, then mayor of the city, was pondering what to do about a labor shortage on the one hand, and an ever-increasing number of disabled French soldiers on the other. In M. Basque's arrival Herriot found the answer. T h e "Ecole J o f f r e " was established at Lyons and became the pattern for similar schools for retraining the disabled. Following the same idea, the American Red Cross in J u n e , 1 9 1 7 , established in New York the Red Cross Institute for Crippled and Disabled Men. This institute carried on an educational campaign, disseminating information on the care of the disabled in European countries, and established the New York schools for training cripples. T h e late Robert McMurtrie, the institute s director in those early years, was a dynamic character, a humanitarian by deep conviction, whose philosophy of rehabilitation was "the sky's the limit." Any method—orthodox, unorthodox, conservative or liberal—that could be devised to assure self-support for a crippled person was a legitimate procedure. Because of this liberal interpretation of rehabilitation on the broadest scale imaginable, McMurtrie was drafted to write a bill

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for presentation to the New Jersey legislature. One of the first state rehabilitation acts, the bill creating the New Jersey Rehabilitation Commission was enacted into law and approved April 10, 1919. It has stood the test of time. For practical purposes it is today the same law that was enacted in 1919. The New Jersey law, contrary to the federal act of 1920 or of any other of the respective state rehabilitation laws included in its provisions the right of the New Jersey Commission to reconstruct, physically, a crippled person whenever surgery would aid in increasing physical function. Credit for the inclusion of this important provision in the law is due to the late Colonel Lewis T . Bryant, the late Dr. Fred H. Albee, and Robert McMurtrie. It was not until 1943 when Congress passed the Barden-LaFollette Bill that the Federal government recognized physical restoration on a comparable basis. Federal legislation on behalf of the adult civilian handicapped had a peculiar beginning. In 1917 Congress passed the SmithHughes Law, known as the Vocational Education Act, which created the Federal Board for Vocational Education. T h e board was composed of the Secretary of Agriculture, the Secretary of Commerce, the Secretary of Labor, and the United States Commissioner of Education as ex-officio member, and three lay members appointed by the President with the advice of and consent of the Senate—one representing agriculture, one representing manufacturing and commerce, and one representing labor. The board approved any plan or program wherein federal funds were used, the use of such funds being limited to certain types of organizations publicly controlled and maintained, and certain types of vocational education of less than college grade. Born of the demand of organized labor for a program of vocational training to repair the damage done by the breakdown of the old apprenticeship system (under which a worker had an allround knowledge of his craft instead of being limited to a single operation that might become obsolete over night), this SmithHughes Law was destined to play an important role in rehabilitation. On June 27, 1918, Congress passed the Smith-Sears Vocational Rehabilitation Act, by which $2,000,000 was appropriated from the United States Treasury to help train the disabled veterans of

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World War I with the objective of self-support. T h i s was to be accomplished through special vocational training and reeducation, after the disabled veteran had received maximum medical care or surgery. T h e Federal Board for Vocational Education, created under the Smith-Hughes Law, was made the agent for administering the law until in August, 1 9 2 1 , the newly created Veterans Bureau assumed control. In World War I, the Smith-Hughes Law had proved a valuable preparedness measure in the diverting of skilled workers from nonessential into essential World War I work and in the grooming of drafted men for their new wartime duties. All the retraining machinery set up under this law was ready to function to the advantage of the disabled World War I veteran when the SmithSears Act became law. In 1920 the Federal government enacted a law providing for the vocational rehabilitation of persons disabled in industry or otherwise, and for their return to employment. This Act (Public Law 236 of the 66th Congress) had no connection with the legislation providing for the rehabilitation of ex-service men and women. Federal money was allotted to the states with the provision that each dollar of federal money was to be matched by a similar amount of state money. T h e maximum appropriation up to 1935 for vocational rehabilitation was about $1,000,000. T h i s has since been considerably increased. Other innovations are modifications so that funds could be allocated not only according to population and matching appropriations by the states, but also on the basis of the needs of the states. T h e attendant newspaper publicity stressed the vocational benefits to be obtained, but completely ignored the fact that in the case of disabled World War I veterans, physical reconstruction had already been cared for in the veterans hospitals. T h i s oversight on the part of the publicists, and the unwillingness of the educational group to broaden their vision and to see rehabilitation in its true perspective, was to lead to a long drawn-out controversy as to whether or not vocational rehabilitation should be preceded by physical rehabilitation in the case of the civilian handicapped, whose rehabilitation became the next consideration. Today the issue of physical restoration is settled by the enact-

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ment in 1943 of Public Law 1 1 3 . T h i s is the Barden-LaFollette Bill relating to the rehabilitation of disabled civilians. T h e Preamble expressly stipulates the promotion of vocational rehabilitation of persons disabled in industry or otherwise. T h e original Federal Law of 1920 also specifically mentioned an intent to care for the rehabilitation of workers injured in industry, and a similar provision appeared in some of the state laws enacted in 1919. In the early years of workmen's compensation legislation after the rehabilitation laws were enacted by the government and the respective states, effort was directed, especially in the industrial states, to comply with the Preamble of the law to stress the rehabilitation of injured workers. Yet this provision of the Act has certainly not received from industrial accident commissions the attention it merits. In the inception of rehabilitation, and for many years thereafter, certain employers were reluctant to reemploy even workers injured in their own establishments, alleging that such reinstatement was contrary to the provisions of compensation insurance policies of which they were carriers. In recent years insurance companies have tried through widespread publicity to dispel this idea. Counselors in rehabilitation bureaus now have assurance that the insurance carriers will not raise any objection to the employment of persons physically handicapped. T h e civilian handicapped are indebted to the disabled veterans of World War II, because it was in their behalf that insurance companies issued the favorable pronouncement. T h e 78th Congress which enacted Public Law 1 1 3 realized that insufficient funds had been appropriated by the states to care for the needs of those registered for rehabilitation service. T h e Congress, too, had before it concrete evidence that, notwithstanding nation-wide organization to promote safety in industrial establishments since the enactment of workmen's compensation legislation in 1 9 1 1 , the toll of injured workers increased year after year. T o Congressman Barden and Senator LaFollette of the 78th Congress and to the members of the House and Senate Committees on Education and Labor, credit is due for the decision to permit matching federal with state funds for physical reconstruction. In the inclusion of physical restoration in the 1943 federal

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law, the Senate and House committees exercised due restraint. T h e national lawmakers desired to avoid the controversial issue of socialization of medicine. T h e rules and regulations specifically stipulate that only to those who are "found to require financial assistance" are rehabilitation bureaus authorized to expend funds for medical and surgical care and hospitalization costs. Furthermore, the service was to be made available only to those with static defects. As Public Law 1 1 3 was enacted during the World W a r II period, it contains a specific provision to care for war-disabled civilians. These are defined as merchant seamen, members of the aircraft warning service and civil air patrol, the citizen's defense corps, and those injured in the line of duty. Fiscal provisions were liberalized by removing fixed ceilings on federal funds. T h e government assumes all necessary state administrative costs, and shares with the state, on a 50-50 basis, the costs for medical treatment, vocational counseling, and training. T h e cost of rehabilitation services to war-disabled citizens is the full financial responsibility of the Federal government. Undoubtedly the most significant forward step achieved by this law is the recognition of physical restoration in the rehabilitation scheme. T h e integration of medicine, surgery, psychiatry, physical therapy, occupational therapy, and vocational training, now available to the nation's handicapped assures the implementation of a perfectly rounded service. Only one state in the union —New Jersey—had the foresight to include all these services in its law of 1919. After the enactment of Public L a w 1 1 3 , the Federal Office of Vocational Rehabilitation stated in brief outline, that rehabilitation covers nine integral factors, all or part of which may be required for successful adjustment. 1. Early location of persons in need of rehabilitation to prevent the disintegrating effects of idleness and hopelessness. 2. Medical diagnosis and prognosis, coupled with a vocational diagnosis as the basis for determining an appropriate plan for the individual. 3. Vocational counseling to select suitable fields of work, by relating occupational capacities to job requirements and community occupational opportunities.

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4. Medical and surgical treatment to afford physical restoration and medical advice in the type of training to be given and in the work tolerance of the individual. 5. Physical and occupational therapy and psychiatric treatment as a part of medical treatment, when needed. 6. Vocational training to furnish new skills, whenever physical impairments incapacitate for normal occupations or whenever skills have become obsolete because of changing industrial needs. 7. Financial assistance to provide maintenance and transportation during training. 8. Placement in employment to afford the best use of abilities and skills in accordance with the individual's physical condition and temperament, with due precautions against further injuries. 9. Follow-up on performance in employment to afford adjustment that may be necessary; to provide further medical care if needed; and to supplement training if desired. T h e following services are provided without cost, irrespective of the economic status of the individual: physical examination, vocational counseling, training, and placement. However, medical treatment, transportation, maintenance, occupation tools, and equipment are only furnished by rehabilitation bureaus when well-established economic needs exist. T h e federal office establishes standards, gives technical assistance to the states, certifies federal funds for grant in aid to the states and furnishes special assistance by regional offices. T w o councils accord professional guidance to the Office of Vocational Rehabilitation— the Rehabilitation Advisory Council and the Professional Advisory Committee. Similar committees in each state provide comparable service on the state level. T h e Federal Rehabilitation Act of 1943 far outstrips the 1920 law in breadth of concept. None who have faith in the human engineering phase of rehabilitation concede, however, that Public Law 1 1 3 is the last word. T h u s we see that rehabilitation legislation has been enacted providing the machinery and the necessary financial support to carry out the constructive aims of this legislation. In the administration of the provisions of these acts the Federal government

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and the states work together as partners in a great social enterprise. T h e federal agency administering vocational rehabilitation was formerly in the United States Office of Education of the Department of the Interior. At one time it was suggested that this department be placed in the Department of Labor. It is now in the Federal Security Agency. T h e work of the federal agency embraces cooperation with the state boards by devising rules and regulations to act as guides for carrying out provisions of the act, making the required cooperative agreements with the private and public agencies looking toward the advancement of rehabilitation services, examination and approval of state plans and the determination as to whether or not federal money is being employed by the states in accordance with the act, making all necessary financial arrangements with adjustments between the federal treasury and the several states in the allotment of funds and making investigations, surveys and reports. N o review of legislation for the physically handicapped can overlook the work of the Kelley Committee in Congress. This committee, officially designated as the Subcommittee on Aid to the Physically Handicapped of the House Committee on Labor, worked for two years, hearing almost five hundred witnesses in open hearings, traveling to four cities, reviewing communications from hundreds of persons experienced in serving the handicapped as well as from the physically handicapped themselves. T h e Committee reported to the 79th Congress in October, 1946, that the extent of aid furnished by official and private agencies was still far from adequate and certainly not evenly distributed. It recommended an expansion of the existing services sufficient to remove the inadequacies, but suggested further a new instrument to meet increasing obligations. T h i s instrument was to be a Federal Department of Public Welfare that would reach down to the needs of the physically handicapped in each community, similar to the way in which the Department of Agriculture extends its help to the needs of the farmer in his community. T h e Committee also emphasized the special needs of the severely disabled and the special services, including rehabilitation centers and sheltered workshops, which were required to make them partially or completely employable. Aside from the specific benefits to be derived from the concrete proposals made to the Con-

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gress, the Committee gave the physically handicapped in this country their first opportunity for organized expression. Future benefits from organized action can thus be anticipated. Though the Federal government is responsible for the supervision of the activities of the state rehabilitation bureaus and provides the money and administrative standards for the efficient operation of these bureaus, the fundamental responsibility for the specific work rests on the states themselves. This means that the state must have a well-developed organization manned by qualified personnel with a constructive scheme or plan for achieving the aims of rehabilitation. T h e liaison between the state agency and the Federal government has for a long time been carried on by the state board of vocational education. T h e state board may delegate its responsibility to a commission or other type of agency, which in turn establishes an organization headed by a state director. T h e duties of the latter are to distribute the case load to the case workers, establish and maintain accounting and statistical records, set up methods of procedure, prepare necessary forms, report to responsible officers on the agencies, activities, and expenditure of funds, and make studies looking toward the constant improvement of the state program. In the final analysis, the service rendered to the physically handicapped person is performed by the case worker or rehabilitation counselor or agent, whose task is manifold. He must survey the applicant and determine his eligibility for and susceptibility to rehabilitation service. He must carefully evaluate the applicant's needs and prepare a plan of rehabilitation to include physical restoration, vocational guidance and training, and a job objective. He must put this plan into operation and supervise it so that the aims of the plan can be fulfilled. Every state in the Union (and also Alaska, the District of Columbia, Hawaii, and Puerto Rico) now has a rehabilitation program. A n d every state in the union has the opportunity through the medium of legislation to salvage its crippled and disabled and utilize their great productivity. Rehabilitation legislation is thus a unified and integrated concept of dealing with all groups of the disabled. In this respect it is a distinctly American contribution to the solution of their problems.

Chapter XVII A NATIONAL CHALLENGE AN examination of the problem of the crippled and the disj t X a b l e d has revealed their importance in our national economy. The number of the disabled, however estimated, is so large that it demands our urgent attention. I believe that at least twenty-five percent of the world is physically handicapped. When we consider the extent of disability in the United States, and add to it the countless millions in other countries who have been disabled by war or famine or both, the figure appears conservative. This desperate situation requires more than our attention. It cries out for organized action. The obstacles have been severe. Most serious has been the force of social prejudice and its corollary, the myth of physical inferiority associated with visible deformity. We have been deluded too long by this false concept of physical fitness for we have learned how, by the powers of compensation and the constructive utilization of residual functions, the average man can do the average job. Past estimates of physical fitness have not been made on scientific grounds. They have been constantly distorted by psychological, emotional, and social factors. We have seen too, that a large source of man power has been wasted because of the false beliefs concerning the relationship between outward appearance and ability to work. We cannot afford to waste these powers any longer. Profligacy is not only a sin, it is national suicide. The development of a rational approach to the problems of the physically handicapped must begin with an entirely new concept of their role in our economy and in our national life. We must refuse to accept the verdict of hopelessness and pessimism pronounced by charity and philanthropy. T h e new concept is one which realizes the tremendous productive potentialities in every individual, regardless of his physical defect. It emphasizes too the unified manner or pattern with which the individual responds to the daily demands of living. It appreciates how re-

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sourceful he is in calling upon his residual capacities to make a successful adjustment. T h i s is the type of thinking which is required to offset our emotional prejudices and our atavistic truculence toward the crippled and the disabled. T h e physically handicapped have suffered not only because of their inferior position in society but also because of the lack of any organized attempt to improve their position. T h e fragmentary efforts on their behalf by charitable and religious groups provided little of constructive value in establishing them as responsible and independent members of the community. A beginning has been made through public rehabilitation agencies and the development of new and powerful private agencies with progressive aims and objectives. However motivated, these agencies cannot be effective if they ignore their relationship to the general health requirements of the nation. T h e need for an organized health program to maintain the efficiency of this nation is a matter that has been seriously debated in recent years. It has become a serious public issue, and one which may change the entire system of medical practice in this country. T h e primary concern, however, as noted in all the public discussion is with the distribution of medical service or, as it has come to be known, the cost of medical care. It has been proposed that compulsory health insurance will provide a better distribution of medical care, especially to the underprivileged third of the nation. W e are not concerned with any change of existing practices in order specifically to improve the position of the crippled and disabled. T h e i r medical needs are being and can be secured under the present system of medical care. We are concerned with the fact that in all the public discussions of improved medical care little attention has been directed toward any program which would reduce the number of disabled. Prevention has been considered in various legislative schemes but only in the narrow sense of preventing the spread of infectious diseases. T h e n u m b e r of crippled children, the victims of industrial and traffic accidents, the war casualties and the large n u m b e r of those permanently disabled by chronic disease are a serious threat to the capacity of a nation to meet the demands of an emergency such as war. They are also a threat to its efficiency as a productive

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nation in times of peace. O u r selective service and military experience proved our vulnerability in this respect. W e cannot ignore these findings. W e cannot be content or smug on the basis of past performances. W e face new problems. W e cannot wait to be aroused again by dynamic nations and seething populations emerging from the chaos of the war with increasing strength as they utilize the advances of modern machinery, organization, and transportation. W e cannot wait for catastrophe to impose its usual poignant lessons. Preparation must begin now. H o w can we improve the efficiency of our man power? How can we mitigate the loss to the national economy from the large number of those suffering from physical defects? Shall we seriously consider the impractical solutions offered to us by eugenists? W e need a more rational solution. Obviously, the efforts of health agencies, both public and private, and the advances of medicine and surgery should do much to reduce the number of physically handicapped persons. T h e safety movement has done much to keep the toll of traffic and industrial accidents down. Nevertheless, there has been a constant increase in the number. T h e r e are two special reasons why this is so: In the first place the majority of handicapped persons do not receive adequate treatment; and, secondly, even when the treatment is adequate by medical standards, it is not organized toward restoring him to employment. W h e n I say that the majority of the physically handicapped do not receive adequate treatment, I am not referring to the distribution of medical care, for the problem is not an economic one. Many other factors are involved, educational, social and political. W h e n a child suffers an amputation at the age of four and must wait until he is eighteen before he is fitted with an artificial leg because his physician or his mother believes he should wait until he has reached maturity, he is a victim of an inadequate knowledge on the part of the mother and physician. T h i s has nothing to do with the cost of medical care. W h e n hemiplegics and paraplegics are permitted to remain permanent invalids for lack of knowledge concerning the ability to adjust themselves that has been provided by newer techniques developed, this has n o t h i n g to do with the cost of medical care. W h e n a child with a c l u b foot is prevented from receiving treatment

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because of the shame of the parent or the inefficiency and arbitrary attitudes on the part of administrative personnel, the child becomes a potential liability to the family, community and the nation. But this has not been due to the inadequate distribution of medical care. T h e majority of the physically handicapped do not receive adequate care because of the lack of public and professional knowledge of their possibilities and because of the ignorance of facilities that are already available to help them physically and mentally. One would expect that the combined efforts of public and private agencies would be enough to meet the need both in making the handicapped aware of existing facilities and bringing the facilities to them. T h e development of mobile clinics in rural sections is a valuable step in this direction. How can we develop a system which will assure the individual an opportunity of being physically rehabilitated and at the same time act as a constant reminder of his responsibility to keep himself physically fit? Perhaps we can take a cue from one of the most constructive pieces of legislation in this regard. I refer to the compulsory registration of deformed children at birth. This law has now been in operation in most of the states for many years. It provides public responsibility for the detection of the deformity at an early date when so much more can be done to correct it. Machinery is thus set in motion to bring the matter to the attention of the state department of health; it is then referred directly to the official agency responsible for care of crippled children, the crippled children's commission. T h e agent of the commission follows the case through, so that after the physician and parent are consulted they are assured of financial and professional assistance if needed. Until the child reaches maturity his name is filed with the commission and its services are made available to him. T h e early detection and correction of these defects is therefore a sound and practical principle. We need to expand the concept to include a better system of control and a continuation of the control into adulthood. Thus the benefits of the original idea of compulsory registration may be enlarged to meet the needs of all the handicapped. T h e recognition and detection at an early

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age of the many defects disclosed by the Selective Service examinations would have reduced the number of rejected and concomitantly increased the potential power of candidates acceptable for military service. How can this be accomplished? By the establishment of a compulsory universal health record. By this I mean that from birth to death, a complete record of the health of every individual in the country would be on file in the state departments of health. T h e birth record is already on file in most of the states. This service then would pick up from there and extend supervisory health service to the adult in the following way. Each year the state department of health sends to the parent or patient a request to have him or his physician report the record of any illness or examination for the year. T h e nature, duration, and complications would thus be recorded. Along with this request he would be urged to have his defects corrected by his private physician or by public facilities, if he is unable to afford private medical care. T h e individual is not compelled to have these defects corrected, but initial registration and annual reporting is compulsory. T h e patient or parent retains a copy of the health record. This can be carried in a concise and suitable form. It would include all the essential data of past illnesses. Such a device was in use in the armed forces. In the Navy for example, all personnel had a health record, which contained the findings on initial examination for induction and a record of later illnesses acquired in service. Additional physical examination made from time to time for promotion or other reasons were likewise recorded so that the record was a running account of the health status of the individual. These records accompanied all personnel to whatever stations they were assigned, while copies were retained in the central files in Washington. For civilian application this method could be utilized except that the central files would contain the original records and remain in the files of the state departments of health. Copies could then be made available to the physician on request of patients or to the patients themselves for quick reference. Such a record would be of inestimable value to the treating physician. It would constitute an accurate medical diary of the patient's past illnesses, thus providing the data necessary to evaluate the patient's complaints.

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Moreover, the universal health record would serve as a constant reminder of the individual's responsibility not only to himself but to his nation to maintain an adequate state of physical fitness. It is not enough to respond to the call of national duty in a time of emergency; when the call comes, a man should be physically fit to perform the required duty. Here then lies a great field for preventive rehabilitation. It has already been in operation industrially in one large plant, where the correction of preexisting defects detected on preemployment examination was made a necessary qualification to employment. In a similar way a large number of individuals rejected by Selective Service boards were referred to the New Jersey Rehabilitation Commission, who undertook to correct their defects and thus make them eligible for military service. T h e establishment of a system of compulsory registration and annual health reporting will be objected to as another method of regimentation. Witness the unpopularity of prohibition in the 1930s and wage and price controls at the close of World War II. Yet the filing of an annual health audit would be no greater task or requirement than the income tax report which he files now. T h e latter is a definite responsibility of the individual to share the cost of the country's fiscal obligations. It is his duty, as well, to be physically fit and thus contribute to the country's resources in health, man power, and productivity. T h e problem of bookkeeping should not be difficult. T h e Army and Navy carried out extraordinary jobs of keeping health records not only for the war period but for the military lives of the members of their regular forces, periods which in some instances have lasted thirty years and more. T h e task can be easily handled by the vital statistics division of state departments of health. They have made their beginning with the file of the birth certificate. I have not discussed the many additional advantages to be gained from this scheme. It is obvious that it would provide an accurate and complete source of information of the actual health of the nation. Thus there would be provided an annual health census with all the important applications to the economic and social needs of the country. T h i s then is the first step in reducing the incidence of

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physical defect: early detection and recognition. T h e second step is an organized and integrated service of physical rehabilitation. T h e latter has two phases, one within the hospital and the other outside it. Certainly every doctor is interested in rehabilitation. T h i s is what he means by the word cure, the full restoration of the individual to his former position in the family, community, and work place. H e knows that the majority of his patients achieve such a desirable result after his ministration, since the natural disposition to restoration is great and the healing powers of nature are most generous. H e is troubled about those with severe residual disabilities who are unable to return to employment, but he feels that he has discharged his responsibility when he completes his medical treatment. Any further responsibility, he feels, is the concern of the social and public health agencies. As Putti, the great Italian orthopedic surgeon remarked to me in answer to a query as to how he completes the rehabilitation of his orthopedic cases, he said, "Doctor, I am a surgeon, not a teacher." Yet some of this responsibility still belongs to the physician. H e does not have to be a teacher, but he must be aware of the enervating effects of prolonged hospitalization and how, by appropriate stimulation of physical and mental activity through occupational therapy and educational training, function can be improved and recovery hastened. T h e provision for this service of early ambulation, physical conditioning, occupational therapy, and convalescent training is still the professional obligation of the physician. T h e problem of prevocational and educational training within the hospital should be shared by the physician with those who are technically qualified to administer these services. T h u s medical care would come to mean a complete and integrated service, directed not only toward physiological cure but also restoration of the individual to his full vocational powers. T h e service must be a continuous one. Although many of those discharged from the hospital may return to employment, a still greater number, including those who already have had the benefit of rehabilitation service within the hospital, will require additional or supplemental service. T h i s must be distinguished from the loose and fragmentary service in vogue at the present. It must be replaced by a program designed to utilize the full time

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of the individual to prepare him to meet the physical and vocational demands of old or new employment. Such a service can best be provided by means of community rehabilitation centers. Every sizable community requires such a center. It is just as necessary as the schools or the police and fire departments. In these centers f u l l physical restoration would be pursued, but to it w o u l d be added the services of vocational guidance, training and selective placement, thus completing the cycle of service leading to full-time employment. Recognition of the potentialities of the physically handicapped, the early correction of physical defects, and complete physical restoration are not enough. N o r is it always sufficient to restore an individual with a physical handicap to his previous social and vocational position. His residual physical and mental powers must be developed to the m a x i m u m . T h i s is the core of the rehabilitation program. T h e techniques will vary according to the age of the individual and the nature of the disability, but the principle is the s a m e — m a x i m u m development of all physical and mental powers. W e must begin with crippled children, bend every effort to locate them and accord them the f u l l benefits of all the modern advances of medicine and surgery. T h e y must not be retarded in their education. Segregation should only continue for the severely disabled crippled children. As soon as possible the child should be put back into a normal school environment so that he does not suffer from the stigma of being different. Expansion of rehabilitation facilities within the school system is desirable to take care of the needs not only of those with obvious orthopedic defects but also those with borderline cardiac, pulmonary and other medical defects. Administrative deficiencies or apathy must not be permitted to delay the adjustment of these children. T h e dogmatic opinions of physicians or the reactionary attitudes of officials and agents can destroy the most ambitious programs. A n unusually intelligent girl who was a spastic paralytic with severe deformities (the result of lack of continuous treatment because she was constantly shifted back and forth between private and public agencies) was denied service by one agency because the mother failed to report to a clinic for two successive appointments. She was

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charged with being uncooperative. Such arbitrary action can only result in discouragement and even resistance on the part of the patient's family, thereby delaying ultimate recovery. It is the responsibility of the public official, whether nurse, doctor, or administrative a g e n t — a n d a challenge to his a b i l i t y — t o obtain cooperation and maintain it by adequate professional service and sympathetic understanding. N o t only public officials are guilty of failure to realize their full responsibility but in this respect private agencies, too, have assumed prerogatives that transcend their abilities and functions in the community. In this respect there is considerable rivalry and not a little unfair competition among the multiplicity of public and private agencies that attempt to speak for and gain control over the crippled child. Curiously enough organized medicine has had only a small share in the supervision of the policies and procedures that have been developed by these agencies. It is true that physicians serve in honorary or consulting capacities, but they do not truly represent the point of view of organized medicine in these positions. For example, in one agency the complete control of the treatment of infantile paralysis cases in the area was left to the supervision of two physical therapists, both of whom had been trained in the Sister Kenny method of treatment but at different clinics. T h e y assumed control of the follow-up care without orthopedic or medical supervision. Furthermore, one of the physical therapists advised a parent that her child was receiving improper treatment from the other, w h o had been trained at a different clinic. By feuding over the merits of their respective techniques and by neglecting to ask for or to urge the services of competent orthopedic consultation they were only confusing and bewildering the parents. In several instances the children were left with severe deformities that could have been prevented. A t the present time, state commissions for crippled children exercise official responsibility in their respective states. Nevertheless, they do not have complete jurisdiction, but can only volunteer their services of hospitalization, case finding, medical care, and education. T h e general administrative arrangement is fairly satisfactory for the younger crippled child. But as the child approaches maturity and questions of prevocational, trade, and

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commercial training are considered the program becomes less effective. T h i s is especially so since state agencies for the rehabilitation of adults are less well equipped to administer similar service to youths. It is therefore desirable that the services of agencies for children, young people, and adults be combined into an over-all program of physical restoration, education, vocational guidance and training, and selective placement for all the crippled and disabled regardless of age. T h e introduction of workmen's compensation into this country forty years ago ushered in a new era in the control of industrial accidents and their social and human waste. Devised as a substitute for the inadequate system of common law which governed the relationship of master and servant, it has passed through a long evolution and has emerged in its modern dress as social insurance. It was designed to remedy the evils of the old system whereby an injured worker might be left with a broken back, permanently disabled, a charge to his family and community and friends, with the burden of medical expenses borne by the worker or, if his circumstances did not permit, by the charity hospital and physician without payment. T h e employer, however, was subject to suits by unscrupulous employees and many an employer found himself insolvent because of excessive or unfair claims. T h e new legislation held out a broader promise, one in which there would be a reduction of accidents, just compensation to the injured, payment of hospital bills assured, and the employer protected against fraudulent claims. Has the promise been performed? Let us look at the record. T h e failure to provide medical compensation and rehabilitation benefits promised by the law to miners in Alabama, Kentucky, West Virginia, and Tennessee has caused the United M i n e Workers of America to demand new machinery whereby these fundamental rights and benefits could be obtained. T h e y have demanded a separate welfare and retirement fund, as well as a separate medical and hospital fund to be established by a 5 percent impost on every ton of coal produced, in order to secure the services denied them under existing workmen's compensation laws. T h e significant fact about this innovation is that the plan is operated by the union and not by the state industrial com-

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mission or the mine operators. Other unions are also giving consideration to the establishment of similar medical and rehabilitation funds to provide for more complete and adequate service than they claim is available under workmen's compensation. Apparently, there has been a failure on the part of workmen's compensation administration in this country to realize one of its major aims, the restoration of the injured worker to gainful employment. This goal has been lost sight of in the intense concentration on the day-to-day litigation which is the dominant feature of present compensation practice. Many administrators feel that rehabilitation of the injured worker is a responsibility of some other agency, that their function as administrators of workmen's compensation is to receive accident reports, investigate claims, settle disputes, hear cases both by informal conference and formal trial, grant awards and order compensation paid. But the ultimate restoration of the worker to employment is so dependent on the character of the medical treatment he receives and the amount of the compensation paid that responsibility cannot be shelved. Rehabilitation is not only a third phase of medicine but it is also a third phase of compensation practice, administration, and procedure. Certainly all the modern techniques of surgery and physical therapy are available under the medical benefits of workmen's compensation laws. At present, in many states, medical benefits included artificial limbs. But furnishing an injured worker with an artificial limb does not constitute rehabilitation. Unless he is trained in its use and given the necesary supervision during his period of physical adjustment it will be a long time before he will return to any work. A man of sixty-two had never engaged in regular employment other than in business for himself in small manufacturing and selling enterprises. He was manufacturing neckties and making $ 7 5 to $100 a week, when the war broke out. He felt it his patriotic duty to enter a war plant and was hired as a helper in a shipyard. While assisting his boss in putting a steel plate into place the plate fell on his leg, crushing it and necessitating an amputation. T h e patient was hospitalized for eleven months and though he was provided with a satisfactory artificial leg, he had been given no instruction in

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its use and care. F o r two years he attempted to adjust himself to his leg and to his new status as a cripple. W h o would employ a m a n of sixty-four with an artificial leg? A n x i e t y deepened into hysteria with bouts of weeping and persistent appeals to the insurance company for assistance. T h e compensation bureau had made an award of $3,900 dollars which was the statutory amount to which he was entitled. H e was not interested in money. H e needed the third phase of compensation, rehabilitation. A caref u l examination of the artificial leg revealed only minor changes that were necessary to give the patient comfort. H e was assured about his stump and prosthesis, and was given certain instruction in its use and care. It was proposed to the insurance company that $ 1 , 0 0 0 of the award be immediately commuted to permit him to set himself u p in a small necktie manufacturing business. When these facts were communicated to the man his entire manner changed. T h i s was the chance he needed to be a m a n again, independent, with an opportunity to express himself on the basis of his talents and experience. W e see then that rehabilitation is different not in technique but in principle. It means team work, as compared to the onedimensional approach in which the physician, claim adjuster, and industrial commission operate independently without any appreciation of the value of their joined efforts. Each of these agents has much to contribute, but the combined and integrated efforts would yield a greater harvest. H o w can these ideas be implemented? H o w can we fulfill the promises implied in the workers' bill of rights? T o do so requires primarily a change in attitude, with the emphasis of compensation administration shifting from litigation to rehabilitation. It is, therefore, recommended that compensation administrators renew their pledge to the workers by proclaiming rehabilitation as the goal of workmen's compensation legislation and that a campaign of education be carried out among all personnel engaged in compensation administration, including the commissioners and their staff, claim adjusters, and the medical profession. T h e y should be made aware of the vast facilities that now exist and can be utilized to assist injured workers in their return to employment. Accident boards and commissions can enlarge their usefulness

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in this direction by supporting community rehabilitation centers, by cooperating with private agencies and government agencies, such as the American Medical Association, the Veterans Administration, and the Office of Vocational Rehabilitation, on Federal and state levels. T o insure the effectiveness of this program it would be desirable to establish within each commission the position of rehabilitation officer, whose function would be to act as liaison officer for the public and private agencies and to coordinate all the activities of the commission dealing with specific rehabilitation problems. T h e introduction of these measures would renew public confidence in the long years of public service rendered by the administrators of workmen's compensation. H o w has the government fulfilled its responsibility to the more than one million disabled veterans of W o r l d W a r II? In the six years since the end of the war, a comprehensive program lias emerged to provide physical and vocational restoration for this large group. A f t e r W o r l d W a r I, rehabilitation was in its infancy; such service as was provided to the earlier veterans was fragmentary at best. T h e problems of veterans rehabilitation have been largely solved, although the program is still hamstrung by administrative difficulties. T h e Veterans Administration has been charged with the continuation of the physical rehabilitation program carried on in the armed services, and to that end it has established the machinery for the development of a comprehensive system of rehabilitation centers. B u t more important it has raised the standards of medical care within the hospital program by providing professional personnel that meet the highest qualifications. T h i s is done by offering financial inducements, establishing research and residence training within the hospital framework, and insisting that each hospital have affiliation with medical schools. O n e distinct innovation in medical care has been the utilization of the services of the physicians in the community. T h i s is a radical departure from past practice. T h e sick or disabled veteran can thus secure professional service from the physician and hospital of his own choice. T h e only restrictions involved are the qualifications of the doctor and the financial restriction imposed by a fee schedule established by the Veterans Administration in consultation with the state medical societies.

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T h i s arrangement creates, of course, the possibility of medical service to millions of veterans and opens up additional possibilities at a later date of services to their families. T h i s is government-operated medicine. B u t it is not my intention to evaluate the wider social implications. T h a t must be left for the future historian. Y e t out of these many public service programs of veteran's medical service, rehabilitation service, workmen's compensation, crippled children's service, and social security service may crystallize the f u t u r e form of medical practice in this countryMatching the program of physical rehabilitation is the program of vocational guidance and training. Here too there have been established wide opportunities and diversified assistance. A t first the program was slow in developing, from the lack of sufficient and qualified personnel. But as the program gained momentum, intelligent counseling and training opportunities were made available. It must be remembered that a mass program of this sort suffers from the weight and size of organizational and administrative problems. T h e program is good only to the extent that it meets the needs of the individual veteran. T h e r e has been little criticism and much praise for this phase of the program. One feature of the training program, however, has come in for criticism. T h i s is the on-the-job training which has been offered the nondisabled as well as the disabled veteran. Abuses have crept in on the part of the employer who took advantage of the Veterans Administration, and, in many instances, by nondisabled veterans anxious to obtain subsistence pay while training on the job. It can be expected that these abuses will be corrected as increased supervision and inspection services are developed. Not the least factor in the maintenance of a progressive program is the role of the veterans' organizations. By their vigilance and pressure they exert a continuous influence on the Veterans Administration to maintain a high order of efficiency. Many of these organizations are not entirely sincere, and the charge of exploiting the veteran for political ends cannot be completely denied. Some of the organizations, for example, are avowedly out for a bonus and for the maintenance and increase of pensions.

A National Challenge

247

But at least one has decried both bonus and increased pensions, urging, on the contrary, the development of full rehabilitation facilities in place of pensions. Certainly there is need for a reexamination of the pension system, not with a view to lowering rates but to making the system a realistic instrument of rehabilitation. This is done in Ontario, where pensions are automatically given to injured workmen but are so administered that they serve as an incentive to the recovery of the greatest possible degree of full working capacity. T h u s through public agitation and generous legislation a satisfactory basis for the rehabilitation of disabled veterans is now possible. For the mass this has been assured. For the individual the problem is only partly solved. T r u e rehabilitation can only be achieved on an individual basis. T h e framework is there; it must now be filled in by the test of performance in the individual case. But this performance is not only the ability of the individual to perform work; it is also the willingness of the employer to provide employment. Management, on the whole, is no less reluctant to employ disabled veterans than it is to employ disabled civilians. Rehabilitation for this group is not complete without employer education, so that the veteran will be accepted as an employee after his working capacity has been restored. An examination of this phase of the program will disclose that social prejudice is still at work. We need, too, a new concept of chronic disease. T h e medicine of rehabilitation can instill new hope for this large group. They must be included in our search for man power and their energies utilized. Sheltered workrooms and partial employment should be made available. W e must not lose sight of the fact that with careful counseling and analysis of their potentialities they may even become totally productive and fully self-supporting. T h e important aim is to provide them with work opportunities that do not exceed their physical tolerance and capacities. We cannot divorce employment problems of the chronically disabled from their other needs of hospitalization, convalescent care, and pensions. Pensions for the chronically disabled may be a new principle in American social insurance practice. It is based on sound experience abroad, and should be given careful con-

248

A National

Challenge

sideration to replace the present system of relief and public assistance for indigency. T h e new principle is that of pensions for incapacity to work. We have already discussed the various administrative agencies that exercise control over the problems of the crippled and the disabled. A further word is required concerning the state rehabilitation commissions operating in all the states with the financial and administrative assistance of grants-in-aid from the Office of Vocational Rehabilitation in the Federal Security Agency. For more than thirty years these commissions have had an educational orientation, largely because the emphasis was on vocational education and training of the physically handicapped. Until the Barden-LaFollette amendment of 1943 physical restoration was given a minor consideration in the total rehabilitation program. Despite the demonstration of its value in New Jersey from 1 9 1 9 on, there was considerable resistance to establishing or introducing physical restoration. T h e agents in the state program were, by and large, teachers, and they were geared to an educational philosophy. This was a one-dimensional program. But despite the introduction of physical restoration into the larger program since 1943, the heritage of the original program still persists. Medical service is still an unwanted stepchild. In the operation of the various state programs the medical aspects are submerged. T h e persistence of this attitude can only retard the fundamental hopes of those aiming at comprehensive service. We saw how in the New Jersey program emphasis on physical restoration provided return to jobs in the majority of cases, without the necessity of vocational guidance or training. As it stands now vocational counselors are trying to supervise medical work, interpret medical work, and act as psychiatrists. This is indeed a dangerous system. It is medical practice by laymen without professional supervision. In one instance the social work consultant reported that a man who later proved to have an abscess in his hip was suffering from a sexual perversion. His desire to be operated on was interpreted as masochistic. In another instance the vocational counselor reported that the client would not cooperate. T h e client was a girl with spastic paralysis who suffered from congenital dislocation of both hips and who had recently been operated on for stabilization of her hips to

A National Challenge

249

permit her to walk. All she asked was a little time to consider what courses of study she should follow. T h e counselor had no insight in the emotional and psychological factors complicating her disability. T h e continuation of the control of this large area of medical care by laymen justifies the claim of organized medicine of the poor quality of medical care that would result from widespread governmental control. For in the physical restoration program of state and federal rehabilitation, lies the nucleus of a program of public medical care even wider than that of the veterans. At the present writing not enough physicians and civilians are aware of their rights under the present legislation. There is also the restriction of physical restoration service to individuals with static defects. But it does not take much imagination to provide a flexible connotation for that term. For example, if physical restoration were interpreted to mean any or all medical services to make an individual employable, the floodgates would be open indeed. A word here is also required concerning the role of United States Employment Service. Under the name of the War Manpower Commission this organization was a dynamic force in maintaining an adequate labor supply. During the war period it also dramatized the effectiveness of the physically handicapped in the total manpower picture. T o that end it conducted demonstrations, research, and practical efforts to convince employers of the potentialities of the crippled and disabled. It was also responsible for the inauguration of the concept of selective placement of matching the physical capacities of the handicapped person to the physical demands of the job. This agency has now been transferred back to the states. It has retained a good deal of its dynamism and ideas and is already putting them into practice. It is already overlapping and trespassing on the programs of other official and private agencies by including within its scope not only placement activities but also training as well. There is no need for competition among these various agencies. There is need, however, for integration. T h e three essential services that have to be rendered are physical restoration or medical care, vocational and educational training and guidance, and finally placement. A new type of agency should be established in

250

A National

Challenge

each state which would not be tied to any one of these three objectives but would be constituted as an autonomous rehabilitation commission or agency with the three subdivisions of medical care—vocational guidance, education, and placement—organized and coordinated under its direction. Employment of the physically handicapped is such a special job that it should not be relegated to the general employment lists. T h e tendency in the past has been to place the physically handicapped last on the list to be given employment. A n agent of the rehabilitation commission should have the responsibility to see his client placed and should exert his personal efforts to make the placement after he has satisfied himself that the individual is ready for it. T o the cry for the compulsory registration and employment of the physically handicapped I would say that this would establish a vocational ghetto for the handicapped. T h e poorest jobs would be made available. A l l sorts of subterfuges would be set up. T h e resistance to this form of regimentation would only hurt the cause. However, the continuous development of associations of the physically handicapped can realize tremendous gains only by the force of their united pressure. Such groups as the National Rehabilitation Association are in an excellent position to improve the status of services being rendered. In addition to the well-known groups for infantile paralysis, heart disease and tuberculosis, there are also organizations for almost every type of handicap: cerebral palsy, multiple sclerosis, muscular dystrophy, diabetes, epilepsy, leprosy, blindness, deafness and speech defects. In addition to providing patient services and opportunities for medical research, these groups could be a valuable stimulus to increased public awareness of the problems of disability. If they could all unite, somehow, they would be in a position to exert tremendous power and service. It has been our thesis that public prejudice toward the disabled is so great as to constitute the greatest obstacle to rehabilitation. T h e fundamental and deep-seated aversion is so insidious and powerful that many outwardly sympathetic persons do not realize the basis of their inwardly truculent attitude. Rationalizations appear on all sides. Is there no way we can change this public attitude? Can we not demonstrate the value and effective-

A National Challenge

251

ness of these crippled and disabled persons? Can we not make reasonable people understand the important role they play in our national and international life? All these methods have been attempted. T h e record has been there for all to see. Yet the basis for the hostile attitude rests on so powerful an emotion that intellectual arguments and demonstrations are of little value. N o advertising campaigns can modify it. Thirty years of organized effort on behalf of the disabled have produced only limited results. T h e war periods were favorable not because of a change in attitude but because of need. Certainly we must continue this struggle against this monster of prejudice. Certainly we must arouse the general public and the professions to their responsibilities. But fundamentally and in the final analysis they cannot be trusted. T h e r e is only one real hope for the disabled— rehabilitation. T r a i n them and develop them so that they can stand on their own. Provide them with the physical and vocational equipment that will enable them to face the challenge of competition. It was Balzac who said that most of us are ordinary people seeking extraordinary destinies. T h e physically handicapped are extraordinary in that they seek but an ordinary destiny. This then is their challenge to us. Give us the opportunity to realize that destiny!

MAJOR CENTERS AND AGENCIES FOR THE HANDICAPPED

A directory of nonsectarian groups providing either direct services to the handicapped or professional services through member organizations. With few exceptions, only national groups have been included. An asterisk (•) indicates that the agency has regional, local, or state affiliates, which may be consulted directly for further information. * Alcoholics Anonymous, P.O. Box 459, Grand Central Annex, New York 17, New York Altro Workshops, Inc., 1021 Jennings Street, Bronx 60, New York * American Cancer Society, Inc., 47 Beaver Street, New York 4, New York American Congress of Physical Medicine, 30 North Michigan Avenue, Chicago 2, Illinois * American Diabetes Association, Inc., 1 1 West 42 Street, New York 18, New York * American Federation for the Physically Handicapped, 1370 National Press Building, Washington 4, D.C. American Foundation for Overseas Blind, 22 West 17 Street, New York 1 1 , New York American Foundation for the Blind, 15 West 16 Street, New York 1 1 , New York * American Hearing Society, 817 Fourteenth Street N.W., Washington 5, D.C. * American Heart Association, 1775 Broadway, New York 19, New York American Hospital Association, 18 East Division Street, Chicago, Illinois American Legion, National Rehabilitation Commission, 1608 K Street, N.W., Washington 6, D.C. American Medical Association, Council on Industrial Health, Council 011 Physical Medicine and Rehabilitation, 535 North Dearborn Street, Chicago, Illinois * American National Red Cross, 400 17 Street, N.W., Washington 6, D.C.

254

Centers and Agencies

• American Occupational Therapy Association, 33 West 42 Street, New York 36, New York. • American Physical Therapy Association, 1790 Broadway, New York 19, New York American Printing House for the Blind, Inc., 1839 Frankfort Avenue, Louisville 6, Kentucky American Public Health Association, 1790 Broadway, New York 19, New York American Public Welfare Association, 1 3 1 3 East 60 Street, Chicago 37, Illinois • American Rehabilitation Committee, Inc., 28 East 21 Street, New York 10, New York American Speech and Hearing Association, Wayne University Speech and Hearing Clinic, Detroit, Michigan American Vocational Association, 1010 Vermont Avenue N.W., Washington 5, D.C. • A M V E T S , 1 7 1 0 Rhode Island Avenue, Washington 6, D.C. • Arthritis and Rheumatism Foundation, 23 West 45 Street, New York 36, New York Association for the Aid of Crippled Children, 580 Fifth Avenue, New York 19, New York • Association for Physical and Mental Rehabilitation, 736 Graham Street, Memphis, Tennessee Baruch Center for Physical Medicine and Rehabilitation, Medical College of Virginia, Richmond, Virginia Bay State Medical Rehabilitation Clinic, 255 Charles Street, Boston, Massachusetts Bay State Treatment Training Center, 86 Sanderson Street, Springfield, Massachusetts Betty Bacharach Home for Afflicted Children, Longport, New Jersey Blinded Veterans Association, 2438 18 Street N.W., Washington 9, D.C. Children's Rehabilitation Institute for Cerebral Palsy, Cockeysville, Maryland Cleveland Rehabilitation Center, 2239 East 55 Street, Cleveland 3, Ohio Commission on Chronic Illness, 535 North Dearborn Street, Chicago 10, Illinois • Community Chests and Councils of America, 155 East 44 Street, New York 17, New York

Centers and Agencies

255

Community Workshops, Boston, Massachusetts Community Workshops of Rhode Island, Inc., 79-83 North Main Street, Providence, R h o d e Island Curative Workshop of Green Bay, 1001 Cherry Street, Green Bay, Wisconsin Curative Workshop of Milwaukee, Inc., 750 North 18 Street, Milwaukee, Wisconsin Delaware Curative Workshop, Inc., 16 and Washington Streets, Wilmington, Delaware Denver Rehabilitation Center, Denver, Colorado * Disabled American Veterans, 1423 East M c M i l l a n Street, Cincinnati, O h i o Employers Mutual Insurance Company Rehabilitation Center, Wausau, Wisconsin Federation of the Handicapped, 241 West 23 Street, N e w York 11, New York * F i f t y - T w o Association of the United States, Inc., 840 Eighth Avenue, New York 19, New York Fraternity of the Wooden Leg, 600 South Oak Street, Sapulpa, Oklahoma Georgia W a r m Springs Foundation, W a r m Springs, Georgia * Goodwill Industries of America, 1222 N e w Hampshire Avenue, Washington 6, D.C. International Society for the Welfare of Cripples, 127 East 52 Street, New York 22, New York Institute for the Crippled and Disabled, 400 First Avenue, New York 10, New York Institute of Logopedics, 2400 Jardine Drive, Wichita 14, Kansas * Kabat-Kaiser Institute, 2633 16 Street N.W., Washington 9, D.C. Kessler Institute for Rehabilitation, Pleasant Valley Way, West Orange, New Jersey Leonard W o o d Memorial (American Leprosy Foundation), 1 Madison Avenue, New York iq. New York Liberty Mutual Insurance Company Rehabilitation Center, 691 Boylston Street, Boston, Massachusetts

256

Centers and Agencies

Lighthouse of the New York Association for the Blind, 111 East 59 Street, New York 22, New York May T . Morrison Center for Rehabilitation, 1680 Mission Street, San Francisco 3, California Menninger Foundation, T o p e k a , Kansas * Muscular Dystrophy Associations of America, Inc., 21 East 40 Street, New York 16, New York National Braille Press, 88 St. Stephen Street, Boston, Massachusetts Natinonal Conference of Social Work, 22 West Gay Street, Columbus 15, O h i o National Epilepsy League, 130 North Wells Street (Room 715), Chicago 6, Illinois * National Federation of the Blind, 2652 Shasta Road, Berkeley, California * National Foundation for Infantile Paralysis, 120 Broadway, New York 5, New York National Hospital for Speech Disorders, 61-63 Irving Place, New York 3, New York National Industries for the Blind, 15 West 16 Street, New York 11, New York National Midcentury Committee for Children and Youth, Inc., 160 Broadway, New York 7, New York * National Multiple Sclerosis Society, 270 Park Avenue, New York 17, New York * National Paraplegia Foundation, Broad-Grace Arcade, Richmond 19, Virginia * National Rehabilitation Association, 514-516 Arlington Building, 1025 Vermont Avenue, Washington 5, D.C. National Research Council, Committee on Artificial Limbs, 2101 Constitution Avenue N.W., Washington 25, D.C. * National Society for Crippled Children and Adults, 11 S. LaSalle Street Chicago 3, Illinois National Society for the Blind, 3238 M Street N.W., Washington 7, D.C. * National Society for the Prevention of Blindness, 1790 Broadway, New York 19, New York * National Tuberculosis Association, 1790 Broadway, New York 19, New York National Vocational Guidance Association, 1424 16 Street N . W . Washington 6, D.C.

Centers and Agencies

257

New York State Rehabilitation Hospital, West Haverstraw, New York New York University-Bellevue Medical Center, Institute of Physical Medicine and Rehabilitation, 400 East 34 Street, New York 16, New York Orthopedic Appliance and Limb Manufacturers Association, 336 Washington Boulevard, Washington 5, D.C. * Paralyzed Veterans of America, 99 Park Avenue, New York 16, New York Pope Foundation, 197 South West Avenue, Kankakee, Illinois Portland Rehabilitation Center, Portland, Oregon Portsmouth Rehabilitation Center, 40 Merrimac Street, Portsmouth, New Hampshire Possibilities Unlimited, 1 5 1 5 Euclid Avenue, Cleveland, Ohio President's Committee on Employment of the Physically Handicapped, Department of Labor, Washington 25, D.C. Rehabilitation Institute, 3600 Troost Street, Kansas City, Missouri Rehabilitation Services, Inc., Sheltered Workshop for the Disabled, 200 Court Street, Binghamton, New York Rochester Rehabilitation Center, 233 Alexander Street, Rochester, New York St. Paul Rehabilitation Center, St. Paul, Minnesota * Salvation Army, 120 West 14 Street, New York 1 1 , New York Saranac Lake Rehabilitation Center, 100 Main Street; 5 Franklin Avenue, Saranac Lake, New York Seeing Eye, Inc., Morristown, New York Speech Association of America, 12 East Bloomington Street, Iowa City, Iowa * United Cerebral Palsy Associations, 50 West 57 Street, New York 19, New York United Mine Workers of America Welfare and Retirement Fund, 907 Fifteenth Street N.W., Washington 5, D.C. United States Government Army Prosthetic Research Laboratory, Walter Reed Army Medical Center, Washington 12, D.C. * Children's Bureau * Office of Vocational Rehabilitation Federal Security Agency, Washington 25, D.C.

258

Centers and Agencies

• United States Public Health Service, Washington 25, D.C., National Institutes of Health • Veterans Administration Department of Medicine and Surgery, Division of Physical Medicine and Rehabilitation, Prosthetic and Sensory Aids Service, Washington 25, D.C. United Nations (international services), International Children's Emergency Fund, Technical Assistance Administration and Department of Social Affairs, World Health Organization, New York 17, New York Volta Bureau and Volta Speech Association for the Deaf, 1537 35 Street N.W., Washington 7, D.C. Washington Rehabilitation Center, 708 Fourth Avenue, Seattle, Washington We, the Handicapped, Inc., 15327 Welland Avenue, Detroit 21, Michigan Woodrow Wilson Rehabilitation Center, Fishersville, Virginia

INDEX

Abilities, similarity in human, 7 ff., 10, 114, 123; interrelation and interdependence of physical and mental capacities, 101; acquired and native, 123, 144; welding of, into one dynamic unit, 143 Abnormality, public attitude

toward,

'9 Accident prevention, 45, 84; campaigns to reduce loss of vision, 183 Accident proneness, is physical defect a cause? 20 Accidents, working capacity estimates and disability evaluation, 5; injuries in children, 40; the injured worker, 43-55, 104, 228; number disabled by, w h o require rehabilitation service, 44; steps and evolution of treatment, 47; psychological and social reactions in wake of, 48; industrial accidents commissions, 52; highway: treatment of injuries, 84 {.; disabilities due to, 86, 173 ff.; lack of rehabilitation programs in industry, 110; new legislation, 242; see also Worker, injured; Workmen's compensation Achievement, term, 123 Acquired abilities, see Abilities Acquired deformity, term, 40 A C T H , 173 Act of May 23, 1944, 222 Adler, Alfred, 5 Administration, see Legislation and administration Adrenocorticotrophic hormone, 173 Aged, physiologic or normal, and pathologic old age, 88 ff.; in population and in working force, 89; decrease in physical and mental capacity, 89, 208; a definite part of group of chronic disabled, 90; need to subsidize vocational training for, 135; Federal grant-in-aid to, 224 Agencies, work of public and private, in behalf of blind, 184; competition among, 241; need for integration of,

and for a new type, 249; directory of major, 253-58 Aging, see Aged Agricultural workers, rehabilitating handicapped, 130 Alabama, failure to provide rights and benefits for miners, 242 Albee, Fred H., 226 Alcoholics Anonymous, 164 Alcoholism, 163 f. Altro Workshop, work capacity of the tuberculous, 199 Ambulation, early, important part of post-surgical care, 209 Ambulatory patient, exercise and occupational therapy, 94, 95 America, drama of, 144 American Board for Certification of the Orthopedic Appliance and Limb Manufacturers' Association, 179 American Board for Certification of the Prosthetic and Orthopedic Appliance Industry, 30 American College of Surgeons, treatment of accidental injuries, 85 American Diabetes Association, 209 American Federation of Labor, 17 American Foundation for the Blind, 184 Department of Services for the Deaf-Blind, 193 American Hearing Society, Washington,

'93 American Heart Association, classifications of, 204 American Hospital Association, 87 American Medical Association, 87; treatment of accidental injuries, 85 American Public Health Association, 87 American Public Welfare Association, 87 American Red Cross, 225; see also Red Cross Institute for Crippled and Disabled American Rehabilitation Committee, Inc., 108 Amnesia, 165

26O

Index

Amputation centers must be made a v a i l a b l e to v e t e r a n s a n d c i v i l i a n s a l i k e , 180 A m p u t e e , r e h a b i l i t a t i o n in s e r v i c e a m p u t a t i o n c e n t e r s , 59 64; a d j u s t m e n t t o c i v i l i a n l i f e , 64; a r t i f i c i a l l i m b s a n d o t h e r p r o s t h e t i c d e v i c e s p r o v i d e d , 67; r e h a b i l i t a t i o n in V . A . c e n t e r s , 69; C a n a d i a n a n d E n g l i s h p r o c e d u r e s , 70; n e w p r a c t i c e w i t h i n f r a m e w o r k of medical care for whole population, 7 1 ; f a i l u r e t o m a k e u s e of local agencies, 76; p h y s i c a l restoration, 102 f.; r e i n t e g r a t i o n o f w h o l e p e r s o n a l i t y , 103; p r o b l e m s t h a t c o n f r o n t c i v i l i a n , 175 ff.; t h e c h i l d , 1 7 7 ; n o o f ficial i n t e r e s t in w e l f a r e of c i v i l i a n , 178; p s y c h o l o g i c a l p r e p a r a t i o n , 178; l o n g - r a n g e p r o g r a m u n d e r w a y , 179; instructors, 180; b l i n d e d bilateral a r m a m p u t e e s , 194; see also Prosthesis A n k l e , f u s i o n o p e r a t i o n to g i v e s t a b i l i t y ,

99 A n x i e t y , s o l v e n t s o f , 178 A n x i e t y n e u r o s i s , 160 A p p e a r a n c e as i n d e x to p h y s i c a l fitness, 141 A p p l i a n c e s , o r t h o p e d i c , 30; see also Prosthesis A p p r e n t i c e s h i p t r a i n i n g , 137 If. A p t i t u d e tests, 96, 122 ff., 168; s e m a n t i c d i f f i c u l t y , 123; a d v a n t a g e s , 124 A r t e r i e s , h a r d e n i n g o f , 207-8 A r t e r i o s c l e r o s i s , 207, 208 A r t h r i t i s , 169, 170 ft.; t w o m a i n t y p e s , 1 7 1 ; a d v a n c e m e n t in t h e chemot h e r a p y o f , 173 Arthritis and Rheumatism Foundation, 172 A r t h r o p l a s t y , 97, 99 A r t i f i c i a l l i m b , see P r o s t h e s i s A r t s a n d CTafts p r o g r a m , 96 Assistance, financial: for the perman e n t l y d i s a b l e d , 82 A s s u m p t i o n of risk, 45 f. A s t h m a , 203 A t a x i a , 36 A t h e t o s i s , 36 A t t e n t i o n , c a p a c i t y f o r , 122 A u d i o g r a m , 192 A u d i o m e t e r , hearing acuity determined b y , 192 A u r a l c a s u a l i t i e s , see D e a f , t h e A u t o m o b i l e , great destructive force of t h e a g e , 84 ff.

Avon, Conn., advanced b l i n d v e t e r a n s , 188

training

for

B a l z a c , H o n o r c d e , 251 B a r d e n - L a F o l l e t t e B i l l , i n c l u s i o n of m e n t a l l y d i s a b l e d in p h y s i c a l restorat i o n services, 151; t h e b l i n d , 183; ren e w e d interest in c h r o n i c a l l y ill, 202; r e h a b i l i t a t i o n of d i s a b l e d c i v i l i a n s , 226, 228, 248 B a s q u e , A z e r , 225 B e d patient, given exercises u n d e r medical s u p e r v i s i o n , 94, 95; d i s a b i l i t i e s flowing d i r e c t l y f r o m p r o l o n g e d ina c t i v i t y , 101 B e d r e s t , in t r e a t m e n t of t u b e r c u l o s i s , 197, 198; a v e r t i n g d a n g e r o u s conseq u e n c e s of p r o l o n g e d , 209 B e d s i d e t r a i n i n g , f o r l o n g - t e r m cases, 133 B e d sores, 176, 177 Beers, C l i f f o r d , 151 Benefit schedules, workmen's compensation laws, 52 Birmingham Veterans Administration h o s p i t a l , 69 B l i n d , r e h a b i l i t a t i o n , 182-89; V e t e r a n s A d m i n i s t r a t i o n ' s p r o g r a m f o r , 68; d e f i n i t i o n of b l i n d n e s s : t h e p a r t i a l l y s i g h t e d , 182; i m p o r t a n c e o f p r e v e n tion, 183, 187; causes, 183; e d u c a t i o n , 184; p l a c e m e n t , 185, 186, 187 f.; F e d eral a i d to state a g e n c i e s f o r , 187, 224; c a t e g o r i e s of p r o d u c t i v i t y , 187; " S e e i n g - E y e " d o g s f o r v e t e r a n s , 189, 222; s u d d e n a n d c o m p l e t e b l i n d n e s s , 189; standardization of training: challenge f o r , a n d f o r t h e c o u n s e l o r , 189; t h e d e a f - b l i n d , 193; b l i n d e d b i l a t e r a l a r m a m p u t e e s , 194; l e g i s l a t i o n f o r c a r e o f , 224 Blinded Bilateral, The, 194 B l o o d vessels, disease o f , 207 B o d y , s a f e t y f a c t o r , 4, 6, 18, 46, 99, 114, 143, 196, 209; m i n d - b o d y s t r u c t u r e a n d f u n c t i o n , 5; u n i t y of p h y s i c a l p a t t e r n , 9; c a p a c i t y to o v e r c o m e d e fects o f disease o r i n j u r y , 32; p h y s i c a l c h a r a c t e r i s t i c s : n o t a n i n d e x to w o r k c a p a c i t y , 1 4 ) ; f a l l a c i o u s c o n c e p t o f , as a m a c h i n e , 143; see also M a n B o n e , t u b e r c u l o s i s o f t h e , 3 1 , 39; inflammatory c h a n g e s f o l l o w i n g osteom y e l i t i s : s u r g i c a l r e m o v a l , 39 B o n e g r a f t i n g , in u n u n i t e d f r a c t u r e s . 98, 100; to s t a b i l i z e w e a k s p i n e , 99; a n

Index established procedure in orthopedic surgery, 174 Borden Test, 122 Bowel and bladder, paraplegic's regulation of functions, 175 Brace manufacture, board to evaluate and certify, 30 Braces, need of paraplegics for special, 70 Braille reading for blinded bilateral arm amputees, 194 Brain, cerebral palsy, 35 ff.; injuries, 164; cerebral hemorrhage, 173 Bronchiectasis, 202 Brookings Institute, 17 Bryant, Lewis T „ 226 Bulbar cases of poliomyelitis, 32 Burns, 40 California State Vocational Rehabilitation Bureau, viii, 62; program for placement of psychotics and neurotics, 163 Canada, rehabilitation of injured worker, 55; limb-making factory: rehabilitation of amputees, 70; workmen's compensation. 218 Cancer, 86 Capacities, human, see Abilities Capsuloplasty operation, 98 Cardiac disease, see Heart disease "Cardiac neurotics," 205 Cardiovascular efficiency, test of, 143 Cardiovascular renal disease, number of cases in the U.S., 203 Carrying capacity, impairment of, 171 Case worker, service to the physically handicapped, 232 Census of crippled persons, 17 Centers for the handicapped, directory of major, 253-58 Cerebral hemorrhage, 86, 173, 208 Cerebral palsy, 35 ff.; Rh factor a cause of, 36; organization to carry out program of treatment, education, and research, 37 Cerebral tone, loss of, 101 Charity, traditional attitude toward disabled, 23 Charleroi, school for the crippled, 225 Children, with cardiac disease, 40, 207; handicapped should be schooled with the nonhandicapped, 137: influences of receptive period of childhood, 157; infant blindness, 182; education of blind, 184; deaf: compulsory hearing

261

tests and follow-up, 190; diabetic, 210; federal grant-in-aid to dependent, 224 crippled, 26-42; number in U.S., 17, 26; categories, 27; early discovery and treatment, 28 f., 30; education and training, 30, 34; need for special guidance and counseling, 31; Poliomyelitis (q.v.), 31 ff.; causes of deformities, 31 ff.; cerebral palsy, 35 ff.; congenital deformities, 38 t.; compulsory registration of congenital defects, 39, 217, 236; osteomyelitis, 39; acquired deformity, 40; gap between available facilities and use made of them, 41; services for, inadequate, 41, 217; public assumption of responsibility for care of, 42; the child amputee, 177; legislation and administration for care, 216 f.; rehabilitation, 240 ff. Children's Bureau, rheumatic fever cases, 41; responsibilities, 216; appropriation to, for child welfare services, 217 Chronic disabled, 81-90; legislation for, 82, 224; functional disabilities, 85; social and economic burdens, 88; vocational training in hospitals, 133; rehabilitation, 197 ff.; relief on basis of indigency, 224; pensions, 247; see also Aged; Arthritis; Highway accidents Chronic disease, need for extensive care, 86; national conference on: research projects, 87; special hospitals for, 87; medical and surgical invalids, 196si 1; number in U.S., 196; need for a new concept of, 247; see also Heart disease; Tuberculosis Cineplasty, pectoral, 83 C..I.O., guarded seniority rights of servicemen, 78 Cirrhosis of the liver, 2 1 1 Civilians, limited amount of physical therapy and convalescent training available to, 85; the amputee, 178; need for aural rehabilitation for, 192; legislation for care of adult handicapped, 226; rehabilitation of disabled, 227 f.; care of war-disabled, 229 Civil Service, records re productive performance of physically handicapped, 4; Veterans Preference Act, 223 Civil Service Commission, fiction of physical perfection, 22; lists of jobs for each disability group, 146, 206; civil

262

Index

Civil Service Commission (Continued) service appointments under supervision of, 223 Cleveland Rehabilitation Center, 109 Clinics, mobile, in rural sections, 236 C l u b foot, static disability, 3g, 81 Colitis, 211 Color, social handicaps of, 12 Colorado Psychopathic Hospital, 158 Combat fatigue, 155 Commission on Chronic Illness, 87, .96 Committee on Labor (House), 231 Community agencies, to assist the returning veterans, 75 Community rehabilitation centers, 111, 240, 245 Commutation of compensation payments, 54 Compensation, limitless capacity for, inherent in man, 194 Compensation, workmen's, see Workmen's compensation Compulsory employment legislation, 128, 250 Compulsory health insurance, 234 Compulsory health records, 237 ff. Compulsory registration of congenital deformity, 39, 217, 236 Congenital deformities, see Deformity, congenital Congress of Industrial Organizations, reemployment of veterans, 78 Connecticut, employment of disabled, 21 Contributory negligence, the injured worker, 45, 46 Convalescence, deterioration resulting from prolonged, 93 Convalescent training, 51, 64, 85, 95 Cooperative effort, contagious spirit of, 105 Coronary heart disease, 204, 206; see also Heart disease Corrective therapy, in Veterans Administration hospitals, 67 Cortisone, 173 Cosmetic defects, 100, 180 Criminal behavior, association of physical stigmata with, 141 Cripple, a term of derision, 11 Crippled, prejudice toward, 11, 12, 234; threat to capacity of nation to meet emergency, 234; see also Physically handicapped Crippled and Disabled, The, vii, viii

Crippled children, see Children, crippled Crippled Children's Commission, 236 Crippling diseases, 31 ff., 88; see further under names of diseases, e.g. Ataxia; Cerebral palsy Critical differences, theory of, 7 ff. Curative workshops, 107 ff., 100 Cure, meaning, 93, 239 Curvature of the spine, 40 Deaf, program of Veterans Administration, 68; rehabilitation, 189-95; physical restoration, 190; compulsory hearing tests, 190; hearing aids, 191, 192; programs of Army and Navy for, 191; group instruction: need for aural rehabilitation for civilian, 192; vocational guidance: placement, 193 Deaf-blind, 193 Decubitus ulcers, 176 f. Defects, obvious or hidden, static or dynamic, 13 Defense industries, as job providers for disabled veterans, 73 Definitive treatment of injuries, 84 Deformity, medieval attitude toward, 18; classical causes of crippling, 31; acquired, 40; reduction of diseases contributing to development of, 169; due to injury, 173; scarcely any need to go uncorrected, 174; plastic surgery to reduce cosmetic effect, 180; myth of physical inferiority associated with, 233; see also Children, crippled; Physically handicapped congenital, 26, 28, 82 f.; as cause of crippling, 38; compulsory registration of, 39, 217, 236 Dementia praecox, 162 Dependence, aim to change idea of, 23 Depression years of 1929 and after, unemployables, 17 Diabetes, 86, 209 ff. Dibble General Hospital, rehabilitation of blind veterans, 188 Difference, myth of human, 7 ff. Disability compensation, 72 Disabled, evaluation of disability, 5 f.; social cost, 17, 234; primitive attitude toward, ig; groups from standpoint of functional adjustment, 24; types of disabilities, 43 f.; industrial, who require rehabilitation services, 44 (see also Worker, injured); compensation for the permanently disabled, 53;

Index chronic, 81-90 (see further Chronic disabled); static disability, 81; reh a b i l i t a t i o n of t h e mentally a n d e m o tionally ill, 131 -68; d o u b l y h a n d i c a p p e d , 193 (I.; n u m b e r in U.S., 196; e x p a n s i o n of r e h a b i l i t a t i o n legislation, 224; F e d e r a l g r a n t - i n - a i d to totally and p e r m a n e n t l y disabled, 224; o n e - f o u r t h of world p o p u l a t i o n , 233; p r e j u d i c e toward, 234, 247; little attention directed toward r e d u c i n g n u m b e r of, 234; see also Physically h a n d i c a p p e d ; Veterans, disabled Disabled A m e r i c a n Veterans, 79 D i s c r i m i n a t i o n , see P r e j u d i c e Disease, w o r k i n g capacity estimates a n d disability e v a l u a t i o n , 5; c r i p p l i n g , 31 ff., 88; c h r o n i c , 86-89 (see also entries under C h r o n i c ) ; paralysis res u l t i n g f r o m , 173 (T.; loss of h e a r i n g , 189 f.; factors u n d e r l y i n g resistance to, 198 D i x , D o r o t h y , 151 Dogs, " S e e i n g - E y e , " 189, 222 Draftees, rejected: w i t h non-serviceconnected disabilities, 80 D r u g a d d i c t i o n , 167 D y n a m i c , term as a p p l i e d to defects, 13 " E c o l c Joffre," L y o n s , 225 E c o n o m y , p r o b l e m of reconversion to p e a c e t i m e p r o d u c t i o n , 73; handic a p p e d called u p o n to play i m p o r t a n t role in, 74; loss of man p o w e r to national, 233, 235 F.ctoinorph, 141 E d e m a , pressure o f the, 33 E d u c a t i o n , of an a m p u t e e , 59 ff.; military services' r e h a b i l i t a t i o n p r o g r a m , 94 ff.; G.I. Dill of R i g h t s , 223; stimulation of physical and m e n t a l activity t h r o u g h e d u c a t i o n a l training, 239; see also entries under V o c a t i o n a l E d u c a t i o n a l Officer, work w i t h a m p u t e e , r>9

E d u c a t i o n a l t h e r a p y , in V e t e r a n j A d ministration hospitals, 67 E l e c t r o c a r d i o g r a p h , 204 E l e c t r o e n c e p h a l o g r a p h , 166 Elks, services to c r i p p l e d c h i l d r e n , «7 Elliot, M a r t h a M., 217 Emergency t r e a t m e n t of injuries, 84 E m o t i o n a l i d e n t i f i c a t i o n , as basis of vocational interest, 125 E m o t i o n a l l y d i s a b l e d , see M e n t a l l y a n d e m o t i o n a l l y disabled

263

E m p l o y e r s , p r e j u d i c e o f , 19 ff.; l i a b i l i t y , 21; t i m e l i m i t a t i o n o n responsibility f o r c a r e of i n j u r e d w o r k e r , 48; reh a b i l i t a t i o n p r o g r a m s , 52, 76; consider age a n i n c r e a s i n g l i a b i l i t y , 89; a n d h a n d i c a p p e d persons, 128; acc e p t a n c e of t h e r e h a b i l i t a t e d disa b l e d , 140; r e l u c t a n t to r e e m p l o y t h e i r i n j u r e d workers, 228; u n f a i r claims a g a i n s t , 242 Employer's Mutual Insurance Comp a n y , clinic, 110 E m p l o y m e n t , of the p h y s i c a l l y h a n d i c a p p e d , 4, 19-22, 25; g o a l of f u l l , f o r veterans, 72; of w a r d i s a b l e d a nat i o n a l a n d local p r o b l e m , 73 ff.; key g r o u p s a n d agencies f o r p r o m o t i n g r e e m p l o y m e n t , 74; c o m p u l s o r y , f o r d i s a b l e d veterans, 74; assisting v e t e r a n to get o l d j o b b a c k , 76; sheltered, 107; v o c a t i o n a l g u i d a n c e (or shortages, p r e j u d i c e s u b m e r g e d because o f , 20 Labor unions, attitude toward nonindustrial d i s a b i l i t y , 22; assistance to m e m b e r s , 23; plans f o r d i s a b l e d veterans' r e e m p l o y m e n t , 78; suspension of v e t e r a n s ' d u e s in service, 78; demand for program of vocational t r a i n i n g , 226 La Follette, R o b e r t M., 228; see also Barden-La Follette Bill Leaders, y o u n g m e n as, 90 Leagues f o r the H a r d of H e a r i n g , 189 Learning capacity, full, reached at fifteen years of age, 89 L e g i s l a t i o n a n d a d m i n i s t r a t i o n , 104, 215-32; crystallized a r o u n d c e r t a i n groups, 23, 25; p r o g r a m s f o r c r i p p l e d c h i l d , 28; f o r c h r o n i c a l l y d i s a b l e d in N e w Jersey, 82; f o r t h e b l i n d , 186, 189; t w e n t i e t h c e n t u r y c o n t r i b u t i o n , 215; Federal-state c o o p e r a t i o n , 216; p r i n c i p l e of social insurance, 217; has not k e p t p a c e w i t h rising l i v i n g costs, 220; f o r t h e c h r o n i c a l l y d i s a b l e d , 224; n e w c o n c e p t o f , for r e h a b i l i t a t i o n , 225 ff.; m a t c h i n g Federal-state f u n d s , 228; state r e h a b i l i t a t i o n b u r e a u s , 232; see also E m p l o y m e n t legislation; P u b lic L a w ; W o r k m e n ' s c o m p e n s a t i o n ; and under titles, e.g., B a r d e n - L a Follette B i l l ; G . I . B i l l of R i g h t s ; etc. Liberty M u t u a l Insurance C o m p a n y , clinic, 110 L i f e e x p e c t a n c y , 88

L i f t i n g capacity, i m p a i r m e n t of, 171 Likeness, see Similarity L i m b m a n u f a c t u r e , a mechanical and a biological p r o b l e m , 178, 179 f_; see also Prosthesis L i m b s , artificial, 30, 49, 68, 70 L i t e r a t u r e for the blind, 186 L i v e r , cirrhosis of the, 211 L o a n s to veterans, provision of G . I . Bill of R i g h t s , 223 L o c o m o t o r system, d i s a b l e m e n t o f , 88 L o m b r o s o , 141 L o n g e v i t y , last b a r r i e r to: increase in, 88; e c o n o m i c and political p r o b l e m s , 89; see also A g e d M a c h i n e physical therapy, 85 M c M u r t r i e , R o b e r t , 225, 226 M a n , not c o m p a r a b l e to a m a c h i n e , 6, 143; f u n d a m e n t a l similarity, 8 ff.; n o p u r e physical types, 141 (see also Body); a total personality, 143; see also I n d i v i d u a l ; Personality M a n i c depressive, 162 M a n p o w e r , large source of, wasted, 233; how can w e i m p r o v e efficiency of? 235 M a n u a l arts therapy in V e t e r a n s A d m i n i s t r a t i o n hospitals, 67 M a r c h of Dimes, 32 M a r e Island, see U.S. N a v y : N a v a l H o s p i t a l , M a r e Island M a r y l a n d , colony of: tax levied f o r the b l i n d , m a i m e d , and lame, 183 M e a s u r e m e n t s , see T e s t s and measurements M e d i c a l care, Veterans A d m i n i s t r a t i o n p r o g r a m , 66 ff.; medical and surgical invalids, 196-211; need for a n organized h e a l t h p r o g r a m : cost, 234; establishment of c o m p u l s o r y universal health record, 237 ff.; as a c o m p l e t e and integrated service, 239; f o r disa b l e d veterans, 24-, f.; control by laym e n , 248; see also Hospitals; Physical restoration; Surgery M e d i c a l schools, affiliation of hospitals w i t h , 245 M e d i c a l societies, a t t e m p t to establish supervision of medical practice t h r o u g h , 51 M e d i c i n e , one of great miracles of w a r m e d i c i n e , 174; r e h a b i l i t a t i o n a third phase of, 243; g o v e r n m e n t - o p e r a t e d , 246 M e n t a l capacities, see A b i l i t i e s ; Intelligence tests

Index Mental conditioning, 64 Mental functions, impairment of, in cerebral palsy, 35, 37 Mental hygiene clinic, rehabilitation of the neurotic, 157 f. Mental hygiene movement, 1 5 1 ; government program, 153; in industry, 161 Mentally and emotionally disabled, 1 5 1 68; neuropsychiatrie veterans, 3, 36, 67, 77, 152, 156, 157, 164; benefited by techniques of rehabilitation, 104: social attitude toward mild emotional disorders, 1 5 1 ; optimistic f u t u r e for g r o u p with severe mental disability, 152; number of, in U.S., 152; cost of custodial care and treatment: measure of mental stability, 153; personality organization, 154 f., 164; the psychoneurotic, 155 ft., 163, 164; what happens to them? 156; organization of treatment, 157; vocational counselor, 159 ff.; placement, 161 ff., 166, 168; psychotics, 162, 163; need for adequate early treatment, 163; groups req u i r i n g special assistance: the chronic alcoholic, 163; brain injuries: head injuries, 164; epilepsy, 165 ff.; d r u g addiction: organic diseases, 167; intelligence and aptitude testing, 168; jobs suitable for: a source of untapped man-power, 168; see also Mental hygiene Mesomorphs, 141 Metabolic diseases, 2 1 1 Middle Ages, status of physically handicapped, 26 Military medicine, see Medicine Military personnel, disabled, see Veterans, disabled Military service, rejectees, 3; neuropsychiatrie cases, 3, 67, 77, 152, 156, 157; response and adjustment to, 9; rehabilitation programs, 14, 86, 93 ff., 97; disabled veterans, 56-80; amputee (q.v.), 59-64, 175-80; Air Force, 65, 94, 142; physical restoration, 93(1.; vocational training in hospitals, 132; spinal cord injuries, 174; blind, 188; aural disabilities, 191; induction in, a prima facie evidence of sound health, 219; personnel health records, 237 Milwaukee, curative workshop, 108 Mind, capacity to overcome defects of disease or injury, 32 Mind-body structure and function, 5 Miners, f u n d for rehabilitation of

267

severely disabled, 53; medical compensation and rehabilitation benefits, 242 Monstrosity, 39 Mothers' aid pensions, 224 Multiple sclerosis, 167 Municipal government, employment of disabled, 22; see also Legislation and administration Muscles, transplantation of, after poliomyelitis, 34; training in crippling diseases, 34 ff.; loss of muscle tone, 101 Muscular dystrophy, 167 Muscular strength, estimates of physical fitness based on, 142 Muscular twitching and grimacing, 36 Narcotic addiction, see D r u g addiction National Association f o r the Prevention of Blindness, 183 National E m p l o y the Physically Handicapped Week, 140 National Foundation for Infantile Paralysis, 32, 37 National Health Survey, 88, 196 National H o m e for Disabled Volunteer Soldiers, 66 National Rehabilitation Association, 250 National rehabilitation program, 2135' National Research Council, 68, 179 National Safety Council, 84 National Society for Crippled Children and Adults, 42 National suicide, profligacy in waste of man power, 233 National Tuberculosis Association, 201 Native abilities, see Abilities Nephritis, number of cases in the U.S., 203 Nervous and vasomotor system, symptoms related to, 155 Neuropsychiatrie veterans, 3, 36, 67, 156, 157; employment of, 77, 152 Neurosis and neurotics, 156, 157 Neurotics, placement, 163 New Jersey, rehabilitation center f o r injured workers, 52; legislation for totally and permanently disabled, 82; rehabilitation clinics or centers: physical therapy departments in hospitals, 86; financial assistance to the disabled, 135; cooperation between State Rehabilitation Commission and New Jersey Tuberculosis League, 202;

268

Index

N e w Jersey (Continued) r e h a b i l i t a t i o n scheme, 229; resistance to i n t r o d u c t i o n of physical restoration, 248 N e w Jersey C r i p p l e d C h i l d r e n ' s C o m mission, 82 N e w Jersey R e h a b i l i t a t i o n C l i n i c , vii, IO". '75 N e w Jersey R e h a b i l i t a t i o n C o m m i s s i o n , 35, 52, 82, 202, 226, 238 , N e w a r k C l i n i c , 107 N e w York City, Veterans Administration's e x h i b i t of prosthetic appliances, 68 N e w York University-Bellevue Medical C e n t e r , 109 N o r m a l person, n N u r s i n g h o m e , 87 O b s e s s i v e - c o m p u l s i v e type, 156 O b v i o u s , term as a p p l i e d to defects, 13 O c c u p a t i o n a l t h e r a p y , for amputees, 59; in Veterans A d m i n i s t r a t i o n hospitals, 67; in m i l i t a r y services' r e h a b i l i t a t i o n p r o g r a m , 94 ff.; use of, in convalescent t r a i n i n g p r o g r a m , 95; s t i m u l a t i o n of physical a n d m e n t a l activity t h r o u g h , 239 O c c u p a t i o n s , classification, 125 Office of V o c a t i o n a l R e h a b i l i t a t i o n , see under F e d e r a l Security A g e n c y O h i o , p r o g r a m to r e h a b i l i t a t e psychotics, 162; l a w a f f e c t i n g the c r i p p l e d c h i l d , 216 O l d age, see A g e d O l d age pensions, 224 O n e - s t o p veteran services, 76 O n t a r i o , ideal a d m i n i s t r a t i o n of comp e n s a t i o n , 49; pension system, 247 -Industrial Accident Commission, 5' O n - t h e - j o b t r a i n i n g courses, 137 f. O p e r a t i o n s , c a p s u l o p l a s t y a n d synovect o m y , 98 O r t h o p e d i c disabilities, defects, 24, 180; facilities f o r p r o p e r m a n a g e m e n t of, 29; see also A m p u t e e ; Paralysis O r t h o p e d i c p a t i e n t , r e h a b i l i t a t i o n , 16981; a r t h r i t i c , 169, 170 ff.; physical restoration, 170; surgery for, 173 f.; paralysis, 173, 174; a m p u t e e s , 175 ff.; cosmetic defects, 180 O r t h o p e d i c service of V e t e r a n s Administ r a t i o n , 67 O r t h o p e d i c surgeons, 29

O s t e o m y e l i t i s , 3g O t e e n , N . C . , Veterans A d m i n i s t r a t i o n p r o g r a m s : of r e h a b i l i t a t i o n , 68; for t h e t u b e r c u l o u s , 200 Otosclerosis, 190 O u t p a t i e n t physical restoration service, 109 P a p w o r t h , Eng., village settlement for t h e t u b e r c u l o u s , 202 Paralysis, V . A . p r o g r a m for paraplegics, 68; r e h a b i l i t a t i o n , 69, 175; need f o r braces a n d facilities for t r a i n i n g in w a l k i n g , 70; h o w d e f o r m i t i e s may be h e l p e d , 98; tendon t r a n s p l a n t a t i o n , 99; physical a d j u s t m e n t of paraplegics, 106; h o p e for them, 174; paralysis f r o m disease and i n j u r y , 173, 174 Paraplegics, see under Paralysis P a r k i n s o n i a n i s m , 167 Pastur, P a u l , 225 Pensions, system to supersede w o r k m e n ' s c o m p e n s a t i o n considered, 53; system an e c o n o m i c p r o b l e m , 72; veterans', 72; f o r invalids, 81, 224; and work restoration closely related, 111; paya b l e because of psychiatric disorders, 152; f o r u n e m p l o y a b l e tuberculous, 202; d i s a b l e d veterans: a c c o r d i n g to p e r c e n t a g e of disability, 219; for the c h r o n i c disabled, 247; f o r incapacity to w o r k , 248 P e r f o r m a n c e , differences in, 7 P e r s o n a l i t y , w e l l - a d j u s t e d , 21; traits associated w i t h physical characteristics, 141; total, 143; incredibly tough, 155; f u n c t i o n a l disturbances, 164 Personality organization, consistency a n d u n i f i c a t i o n of, 154 Personality p a t t e r n , e v a l u a t i o n of total. 115 fT.; personality tests, 117, 120; proj e c t i v e techniques, 118, 120 P e r s o n n e l , m a i n t e n a n c e of p r o p e r relations a m o n g , a neglected phase of m e n t a l h y g i e n e , 161 P e r s o n n e l w o r k , j o b analysis, 143 Petit m a l , 165 Phonograph records, literature for b l i n d r e c o r d e d on, 186 Physical activities, analysis o f , 145 Physical a n d m e n t a l capacities, interr e l a t i o n a n d interdependence, 101 Physical characteristics, 141 Physical c o n d i t i o n i n g , 51; in military services' rehabilitation program, 94 ff.; see also Physical restoration

Index Physical defects, as a s t i m u l u s to overcompensation, 4 Physical fitness, low state of n a t i o n a l , 3; concepts o f , 3 ff.; d e f i n e d , 6; c o m p l i c a tions of a t t e m p t s to e v a l u a t e , 11, 141 ff.; estimates o f , based o n muscular strength, 142; s t a n d a r d f o r m f o r d e t e r m i n a t i o n of r e q u i r e m e n t s for anv j o b , 145; r a t i n g scales, 147; estimates distorted, 233; see also Physical restoration Physically h a n d i c a p p e d , c i v i l i a n : extension of r e h a b i l i t a t i o n benefits to, vii; a n a t i o n a l and i n t e r n a t i o n a l probl e m , viii; versatility a n d a d a p t a b i l i t y , 4; p r e j u d i c e t o w a r d , 11, 57, 128, 129, 234 (see also P r e j u d i c e ) ; i n t e r p r e t a tion of term, 12; basic f e a t u r e disting u i s h i n g , 13; p r o b l e m s , 16-25; n u m ber in the U.S., 16-17; classifications, 24; chief s t u m b l i n g b l o c k s in w a y of e m p l o y i n g , 53; p e r s o n a l i t y p a t t e r n , n g f f . ; i n t e l l i g e n c e , 122; v o c a t i o n a l training, 128-39; w o r k a d j u s t m e n t , ig6; a n a t i o n a l c h a l l e n g e , 233-51; recognition of p o t e n t i a l i t i e s , 233; ina d e q u a t e t r e a t m e n t , 235; m a j o r centers and agencies, 253-58 Physical p a t t e r n , u n i t y of man's, 9 Physical restoration, 93-104; n a t u r a l disposition to, a p h e n o m e n o n of all h u m a n tissue, 33; deficiencies of law a n d practice, 46 ff.; i n a d e q u a c i e s of provisions basic to, 47 ff.; must be complete, 64; V e t e r a n s A d m i n i s t r a t i o n p r o g r a m , 66 If.; p r o g r a m of the military services, 93 ff.; not a c h i e v e d by p i e c e m c a l mpthods, 93, 102, 105; in surgical and medical cases, 104; Federal-state c o o p e r a t i o n , 228 ff.; restriction o f service t o those w i t h static defects, 249; see also M e d i c a l care; Rehabilitation Physical s t i g m a t a , association w i t h criminal b e h a v i o r , 141 Physical t h e r a p y , in t r e a t m e n t of cerebral palsy, 36; in V e t e r a n s A d m i n i s tration hospitals. 67; f o r c h r o n i c disabled, 85; in p h y s i c a l c o n d i t i o n i n g , 94, 96; n o t c o o r d i n a t e d w i t h o t h e r f o r m s of t r e a t m e n t , 105 Physical types, no p u r e , 141 Physicians, called u p o n to e s t i m a t e w o r k i n g c a p a c i t y a n d disability evaluation, 5: u n d e r v a l u e capacity of h a n d icapped to w o r k , 20; selection of, in

269

c o m p e n s a t i o n h e a r i n g s , 50; massp r o d u c t i o n t r e a t m e n t in industrialaccident practice, 110; professional o b l i g a t i o n , 239 Physico-mental d e m a n d s a n d capacities,

'45 P i l g r i m Fathers, d e c r e e re m a i m e d soldiers, 56 P l a c e m e n t , selective, 140-48; work capacity, 140 If.; selective, of d i s a b l e d must be on a businesslike basis, 140; d e v e l o p m e n t and benefits of j o b analysis, 144 ff.; selective, basis of w h o l e selective m o v e m e n t , 144; affected by personnel officer's p r e j u d i c e or conf o r m i t y to c o m p a n y policies, 146; rati n g scale, 147; of t h e m e n t a l l y a n d e m o t i o n a l l y d i s a b l e d , 161 ff., 166, 168; p s y c h o n e u r o t i c s a n d t h e psychotics, 163; of the b l i n d , 185, 186, 187 f.; t h e d e a f , 193; of t h e t u b e r c u l o u s , 200; r e d u c t i o n of capacity w i t h age, 208; see also E m p l o y m e n t Plastic surgery, 100; cosmetic defects that require, 180 P r e j u d i c e , physical fitness a p p r a i s a l s influenced by, 11 f.; psychosocial, 18 ff.; g r o u n d s for r a t i o n a l i z i n g , 20; in legislative halls, 23; t o w a r d , the c r i p p l e d child, 26; the p h y s i c a l l y h a n d i c a p p e d , 57, 128, 129, 234; a g a i n s t e m p l o y m e n t of the b l i n d , 187; greatest obstacle to r e h a b i l i t a t i o n , 233, 250; t o w a r d emp l o y m e n t of d i s a b l e d , 247 Poliomyelitis, cause of c r i p p l i n g d e f o r m ities, 31-35, 36, 39, 169; t r e a t m e n t , 32; t r a n s p l a n t i n g p e r o n e a l muscles to restore n o r m a l foot b a l a n c e , 34; education and v o c a t i o n a l t r a i n i n g : retardation, 34; paralysis of t h e t r u n k muscles, 40 Pratt-Smoot A c t , 186 P r e v e n t i o n , n a r r o w t r e a t m e n t o f , in legislative schemes, 234 P r e v e n t i v e r e h a b i l i t a t i o n , 238 P r e v o c a t i o n a l s h o p , 96 P r o b a t i o n a r y t r a i n i n g , 127 P r o d u c t i o n , record o f , a c h i e v e d by substandard g r o u p s , 3 P r o d u c t i v i t y , of the b l i n d , 188 Professional A d v i s o r y C o m m i t t e e , 230 Prosthesis, need f o r better s u p e r v i s i o n of p r o c u r e m e n t a n d f i t t i n g o f , 30; W o r k m e n ' s c o m p e n s a t i o n law provisions, 49, 243; M a r e Island p r o g r a m , 59; Veterans A d m i n i s t r a t i o n p r o v i -

270

Index

Prosthesis (Continued) sions, 67, 69; prosthetic service card, 70; physical restoration of amputee, 102 f.; prosthetics industry, 106, 180; desirability of early use of, 176, 177; preparation of stump for, 178; procurement of, 179; patient's adjustment to, 180; for hard of hearing, 191 Psychiatric disorders, pensions paid by V.A. because of, 152 Psychiatry, mentally and emotionally disabled, 157 Psychic seizures, 165 Psychological criteria, of no use in determining physical efficiency, 143 Psychological preparation, first step in rehabilitation of the amputee, 178 Psychology, questions answered by schools of, 156 Psychometric testing, 121 Psychoneurosis and psychoneurotics, 155 tf., 161, 163. 205 Psychopathic hospitals, 158 Psychophysical unity of mind and body, 5 Psychoses and psychotics, 156, 162, 163 Psychosomatic, term, 143 Psychosomatic symptoms, 156 Public, deep-seated aversion toward disabled, 250 Public assistance, pensions to replace, 248 Public assistance laws, basis for, 224 Public health, significant aspect of progress in, 88 Public Law 2, 219 Public Law 16, 71, 222 Public Law 113, 228 ff. Public Law 236, 227 Public Law 346, see G.I. Bill of Rights Public Law 359, 221 Public Law 877, 220 Public Welfare, Department of: recommended, 231 Puerto Rico, bone tuberculosis, 31 Pulmonary disorders, chronic, 202; see also Tuberculosis Putti, 239 Race, social handicaps of, 12 Racial superiority, myth of specific, 8 Randolph-Shephard Bill, 187 R a t i n g scale, 147 Reco Workshop, work capacity of the tuberculous, 199 Red Cross, American, 225

Red Cross Institute for Crippled and Disabled men, New York, 106. 225 Reemployment, see Employment Registration, compulsory, 250 Rehabilitation, extension of benefits to civilian handicapped, vii; of the physically handicapped, 13 ff.; number of disabled made employable, 14, 17; new connotations, 15; of the injured worker, 44, 46; inadequacies of provisions basic to physical restoration, 47 ff.; greatest bar to complete. 49; of disabled veterans, 56-80; principles of, 91-148; primary goal, 101; reproducing original work activity as part of. 111: vocational training, 12839; goal: controversy between two schools of educational thought, 128; a highly individualized service, 136; in practice, 149-211; of the mentally and emotionally disabled, 151-68; orthopedic patient, 169-81; vocational, of the blind, 185; national program, 215-32; nine integral factors, 229; preventive, 238; organized and integrated service, 239; core of program, 240; means team work, 244; development of full facilities in place of pensions urged, 247; see also Medical care; Physical restoration Rehabilitation Advisory Council, 230 Rehabilitation Center for the Disabled, New York City, 108 Rehabilitation centers, 51, 108; services available to union members, 23; goal, 104; community, 111, 240, 245; integrated programs, 105-13; economic advantages, 106; educational responsibility, 111; cost, 112; ideal center, 113; recommended, 231 Rehabilitation Clinic, Newark, N.J., see New Jersey Rehabilitation Clinic Rehabilitation commissions, 52; autonomous, 250 Rehabilitation counselor, service to the physically handicapped, 232 Rehabilitation legislation, see Legislation Rehabilitation of disabled veterans, see further Veterans, disabled Relief, pensions to replace, 248 Research, 111 Reserve officers, law re retirement pay, 224 Respirator, 32

Index Rest, nature's way of securing repair, 34 Retrolental fibroplasia, 182 R h e u m a t i c diseases, chronic, 88 Rheumatic fever, in schoolchildren: symptoms, 40; treatment, 41 R h factor, a cause of cerebral palsies, 36 Rickets, 31 Roosevelt, Franklin D „ 3 1 ; executive order establishing grades of disabilities, 2 1 9 Rorschach personality test, 120 Royal Air Force, master plan f o r the care of casualties, vii; philosophy behind rehabilitation program, 94; physical restoration progTam, 103 Rusk, Howard A., 89, 109 Russell Sage Foundation, 182

Safety factor, h u m a n , 4, 6, 18, 46, 99, 1 1 4 , 143, 196, 209 Safety movement, 45 St. Dunstans. Eng., rehabilitation of the war-blinded, 188 St. Vitus dance, 36 Sanatorium, rehabilitation programs, '97 San Francisco mechanical trade unions, guarded work opportunities for veteran members, 78 Schizophrenic, 162 Scoliosis, 40 Second-injury funds, 2 1 , 53 "Seeing-Eye" dogs, 189, 222 Selective placement, see Placement, selective Selective Service, disqualification because of psychiatric illness, 3, 152; rejectees, physical defects, 1 1 Selective Service Act, section re reinstatement of veterans, 76, 78 Selective Service Board, local: services for returning veteran, 76 Senility, two types, 88; see also Aged Service hospitals, rehabilitation program, see under Military service Servicemen, see Veterans Shaw, George Bernard, 88 Sheltered work, 202 Sheltered workshops, 109, 189, 199, 247; recommended, 231 Shepard-Towner bill, formulated principle of grants-in-aid, 216 Shriners, services to crippled children, 27 Sight-conservation classes, 183

271

Similarity of human capacities, 7 ff., 10, 114 Skin and cartilage, transplantation of, 100 Smith-Hughes L a w , 226, 227 Smith-Sears Vocational Rehabilitation Act, 226, 227 Social attitudes, toward the physically handicapped, 1 1 ff.; adjustment to hostile, 18; crystallized around certain groups, 25; see also Prejudice Social insurance, 45, 8 1 , 242; acceptance of principle, 2 1 7 ; pensions for the chronic disabled, 247 Social legislation, see Legislation Social Security Act, provision for blind, 186; for crippled children, 216 f. Social training, value of work training as, to disabled serviceman, 64 Solomon Islands campaign, rehabilitation services available to casualties of, viii Spastic paralysis, see Cerebral palsy Specialization of professional services, 29 Speech correction and training, 192, 193 Spinal cord, destruction of cells in, 33; injuries, 174 Spine, curvature, 40 Splints, 34 "Sports," genetic, 83 Sports, participation of amputees in, 59 State agency for the blind, see under Agencies State Boards of Health, empowered to enforce reporting of congenital defects as part of birth certificate, 39 State hospitals, 158 State rehabilitation programs, medical aspects submerged, 248 State programs, employment of disabled, 22; early reporting of congenital deformities, 38; care of crippled children, 39, 42, 216, 2 4 1 ; provisions for industrially disabled, 49; rehabilitation activities programs, 79, 248; vocational training of handicapped, 130; apprentice training, 138; care of blind, 183; Federal-state cooperation, 183, 216 f., 227, 228 ff.; rehabilitation bureaus, 232; U.S. Employment Service transferred back to, 249 Static, term as applied to defects, 13, 14 Static disability, 81 Stroke, 173, 208 Stutterer, 193

272

Index

Subcommittee on A i d to the Physically Handicapped, 231 Substandard groups, record of production, 3 Superstition, effect o f , 82 Surgeons, see Orthopedic surgeons Surgery, certification of specialists, 29; use of, in poliomyelitis, 34; physical restoration, 97-104; plastic, 100, 180; causes of incapacity after treatment, 104; medical and surgical invalids, 1 9 6 - 2 1 1 ; early a m b u l a t i o n , 209 Sweetser, 1 5 1 Synovectomy operation, 98 T a l k i n g Book, 186 T e a m w o r k , contagious spirit o f , 105 T e n d o n transplantation, 99 Tennessee, f a i l u r e to provide rights and benefits for miners, 242 Tennessee Eastman Corporation, 62 Tests and measurements, personality, 1 1 7 ff., 120, 126 T h e m a t i c Apperception T e s t , 120 T h e r a p y , see Manual arts therapy; Occupational therapy; Physical T h e r a p y T h o r a c i c surgery, 198 T h o r n d i k e , Augustus, 67 T i m k e n R o l l e r Bearer C o m p a n y , employment of blind workers, 187 T r a d e unions, see L a b o r unions T r a n s p l a n t a t i o n of skin and cartilage, 100 T r a u m a t i c surgery, 85 Tuberculosis, of bones and joints, 3 1 , 39; Veterans Administration's rehabilitation program f o r servicemen, 68; rehabilitation program, 197; arrest and recurrence, 198; physical strain and work tolerance, 199; placement of arrested cases, 200 ff.; what happens a f t e r discharge from sanatoria? 201; Federal-state action slow to develop, 202; partially productive g r o u p , 2 0 1 ; unemployables, 202; of the kidney, 209 Ulcers, gastric, 209 Unemployability, 17, 25; no adequate investigation made, 18 Unemployment, 17; irreducible minimum, 18; tragedy behind degradation associated with, 1 0 1 ; the crippled and disabled, 128 Unemployment Compensation provision of G.I. Bill of Rights, 223

Unions, see Labor unions United Cerebral Palsy Associations, 37 United Mine Workers of America, health and welfare fund established, 53; compensation and rehabilitation benefits, 242 United Mine Workers Welfare and Retirement Fund, 23, 132 United States, low state of national fitness, 3; traditional attitude toward the disabled, 23; workmen's compensation administration, 4g; preference to veterans in Federal employment, 79 A i r Corps: screening of applicants, 142 A r m y : physical therapy and convalescent programs, 85; philosoph\ behind rehabilitation program, 94; use of tests and measurements, 126; rehabilitation of blind veterans, 188; of aural casualties, 191; law re retirement pay for reserve officers, 224; health records, 238 A i r Force: rehabilitation program. vii. 65, 94 Women's Army Corps: benefits granted to, by Voorhis Act, 222 Bureau of Pensions, 66 Bureau of War Risk Insurance, 65 Civil Service Commission, see Civil Service Coast Guard: rehabilitation of blind veterans, 188 Women's Reserve: benefits granted to, by Voorhis Act, 222 Defense, Department of: function to recruit marginal workers, 74 Employment Service: employment of disabled, 25, 249; effect of transfer back to states, 49; service to disabled veterans, 74, 75, 79; placement of psychotics and neurotics, 163 Labor, Department of: unemployment data, 17 • Marine Corps: rehabilitation of blind veterans, 188 Women's Reserve: benefits granted to, by Voorhis Act, 222 Navy: program of rehabilitation, vii; slogan, 14; physical therapy and convalescent programs, 85; philosophy behind rehabilitation program, 94; educational services, 97; use of tests and measurements, 126; rehabilitation of blind veterans, 188: of aural casualties, 191; health records, 238

Index N a v a l Base Hospital s , E f a t e , N e w H e b r i d e s , viii N a v a l H o s p i t a l , Phila.: r e h a b i l i tation of blind, 188 N a v a l H o s p i t a l , M a r e Island, Calif.: r e h a b i l i t a t i o n of casualties f r o m Pacific, viii, 58 ff.; ideal s e t t i n g for case studies, 61: v o c a t i o n a l g u i d ance, 62 Women's Reserve: benefits granted to, by V o o r h i s A c t , 222 P u b l i c H e a l t h Service, 65 U n i t e d States C h a m b e r of C o m m e r c e , 17 University of C a l i f o r n i a , Radiation L a l j o r a t o r y , 63 V a l l e y Forge G e n e r a l H o s p i t a l , Pa., reh a b i l i t a t i o n of b l i n d veterans, 68, 188 V a n Nuys, Calif., center for r e h a b i l i t a tion, 69 Vascular disease, 207 V a s o m o t o r and n e r v o u s system, symptoms related to, 155 V e t e r a n coordinator, 77 Veterans, e m p l o y m e n t of, 22; c o u n t r y u n p r e p a r e d to reabsorb, 57; p e n s i o n p r o b l e m , 72 ff.; u n f a v o r a b l e reaction to labor, 78; role of organizations, 7g, 246; special a d v a n t a g e F e d e r a l gove r n m e n t offers to, 79; jobs e x c l u s i v e l y a v a i l a b l e to, 79; resiliency o f m e n t a l a n d social a d j u s t m e n t , 120; educational p r o g r a m , 221; facilities veterans of all wars are e n t i t l e d to, 222; provisions for, u n d e r G.I. B i l l of Rights, 223; o n - t h e - j o b t r a i n i n g , 246; e x p l o i t i n g of, for political ends, 246 disabled: r e h a b i l i t a t i o n , 56-80; attitude of p u b l i c t o w a r d : e u l o g i z e d and f o r g o t t e n , 57; cynicism, d o u b t s , a n d fears: w h e n r e h a b i l i t a t i o n must begin, 58; the a m p u t e e , 59-64, 175 ff. (see also A m p u t e e ) ; personality adjustments: physical and m e n t a l cond i t i o n i n g , 64; r e h a b i l i t a t i o n of paraplegics, 69; v o c a t i o n a l g u i d a n c e a n d training, 7 1 ; e m p l o y m e n t , 72 ff.; work of W a r M a n p o w e r C o m m i s s i o n , 75; r e e m p l o y m e n t , 76 ff.; special a d v a n tage Federal g o v e r n m e n t offers to, 79; blind, 188, 189; F e d e r a l and state grants, 189; " S e e i n g - E y e " dogs for, 189, 222; legislation for care o f , 219 ff.; pensions a c c o r d i n g to p e r c e n t a g e of disability, 219; grants insufficient: additional a l l o w a n c e for d e p e n d e n t s ,

273

220; most i m p o r t a n t laws of past d e c a d e , 221; m e d i c a l care of o w n choice, 245 f. V e t e r a n s A d m i n i s t r a t i o n , 56; responsibility f o r v e t e r a n a f t e r d e m o b i l i z a t i o n , 65; r e o r g a n i z a t i o n : m e d i c a l p r o g r a m , 66; a u d i o l o g y u n i t , 68; e x h i b i t of p r o s t h e t i c a p p l i a n c e s , 68; a m p u t a t i o n center, 69; p r o g r a m of v o c a t i o n a l g u i d a n c e a n d t r a i n i n g , 7 1 ; educat i o n a l service, 97; m a i n t e n a n c e f o r disabled veteran d u r i n g period of t r a i n i n g , 135; p e n s i o n s p a y a b l e because of p s y c h i a t r i c disorders, 152; m e n t a l h y g i e n e clinics f o r o u t - p a t i e n t n e u r o p s y c h i a t r i c t r e a t m e n t , 158; s h o p f o r m a n u f a c t u r e of artificial limbs, 179; p r o g r a m s f o r t h e d e a f , 192; prog r a m in r e h a b i l i t a t i o n of t u b e r c u l o u s at O t e e n , 200; l e g i s l a t i o n basic f o r p o l i c y a n d p r o c e d u r e s , 219; C o n gressional a p p r o p r i a t i o n for h e a l t h , w e l f a r e a n d e d u c a t i o n p r o g r a m s , 220; scope of activities, 221; p r o c e d u r e p r e s c r i b e d by V o o r h i s A c t , 222; facilities a v a i l a b l e to veterans of a l l wars, 222; l a w s a d m i n i s t e r e d by, 222, 223; m a c h i n e r y f o r d e v e l o p m e n t of reh a b i l i t a t i o n centers, 245 D e p a r t m e n t of M e d i c i n e a n d Surg e r y , h o s p i t a l r e h a b i l i t a t i o n activities to be c o o r d i n a t e d u n d e r , 67 D i v i s i o n of Physical M e d i c i n e a n d R e h a b i l i t a t i o n , 66, 67 Prosthetic a n d Sensory A i d s service, p r o g r a m , 67 V e t e r a n s B u r e a u , 65, 66, 227 V e t e r a n s P r e f e r e n c e A c t , 223 V i l l a g e settlements f o r the t u b e r c u l o u s , 202 V i t a l c a p a c i t y , test o f , 143 V o c a t i o n , a d j u s t m e n t of h a n d i c a p p e d , 23; c h a n g e of, a strain o n m o r a l e , 101; chances of c h o o s i n g a successful, 114 V o c a t i o n a l counselor, q u a l i f i c a t i o n s a n d r e q u i r e m e n t s , 131; f o r the n e u r o t i c , 159 ff.; p a r t of team in w h i c h psychiatrist is d o m i n a n t , 163 V o c a t i o n a l e d u c a t i o n , state b o a r d of, 232 V o c a t i o n a l E d u c a t i o n A c t , 226 Vocational guidance and counseling, 114-27, 246; n e e d of i n j u r e d w o r k e r f o r t r a i n i n g a n d , 55; a d a p t a t i o n to i n d i v i d u a l needs, 62 ff.; V . A . p r o g r a m of t r a i n i n g a n d , 71; total p e r s o n a l i t y

274

Index

Vocational guidance (Continued) pattern, 1 1 5 ; projective techniques, 1 1 8 , 120; aptitude tests, 122 ff.; vocational interest tests, 124(1.; choice of employment, 124; importance of emotional identification and j o b preference, 125; vocational information, 127; needed for the blind, 187; for the deaf, 193; cardiacs, 206 Vocational rehabilitation, see Rehabilitation Vocational training, 128-39, 2 1 1 ; need of injured worker for counseling and, 55; for amputees, 62 ff.; V.A. program of guidance and, 7 1 ; modern concept, 1 3 1 ; counseling service, 1 3 1 ; bedside training, 132; for long-term cases, 133; within the trade or industry: for a production emergency, 137; of handicapped and nonhandicapped should be same, 137; orthopedic patient, 170; the blind, 188 f ; time and cost limits of courses, 222; on-the-job training, 137 ff., 223, 246 Voorhis Act of 1941, 22*

W a r , toll of young adults, 89 W a r industries, programs of apprentice training, 138 W a r Manpower Commission, 75, 249 W a r medicine, see Medicine War-production effort, response of individuals to, 9 War training, 137 f. Washington Society for the B l i n d , 185 Watson-Jones, Sir, vii West Virginia, failure to provide rights and benefits f o r miners, 242 White House Conference on child health and protection, 2 1 6 Wildcat strikes, 78 Willow R u n plant, employment of women, 9; of deaf-blind, 193 Women, in w a r occupations, 9 Women's Army Corps, benefits granted to by Voorhis Act, 222 Women's Reserve of the Coast Guard, benefits granted to by Voorhis Act, 222 Women's Reserve of the N a v y and Marine Corps, benefits granted to by Voorhis Act, 222 Woodrow Wilson Rehabilitation Center, Fishersville, Va., 109 Work, an emotional release and stabiliz-

ing force, 1 0 1 ; restoration and pensions closely related, 1 1 1 ; the best therapy, 163; work tolerance of the tuberculous, 199; see also Employment; Jobs Work adjustment, 196 Worker, physical defects detectable by preemployment examinations, 11; superannuated: older war workers, 89; matching physical characteristics of, and the job, 144; identifying, with a specific job category, 146 injured, 43-55; types of disabilities, 43 f.; industrial accidents, 44; rehabilitation, 44, 46; psychological and social reaction in wake of injury, 48; states' provision for industrially disabled, 49; rehabilitation centers for, 5 1 ; second injury: compensation for the permanently disabled, 53; need for vocational counseling and training, 55; legislation for care of, 217 f.. 242; responsibility for, 243; see also Accidents Worker-job relationship, 145 Working capacity, 140 fr.; estimates of, 5 f.; undervaluation of disabled individual's, 20; 110 way to determine, 1 4 1 ; meaning coupled with physical demands of job, 145; matching demands of, to capacities of individual, 145; pensions for incapacity to, 247 f. Working conditions, analysis of, 145 Workmen's compensation, 44, 1 1 1 ; compensation costs from second injuries, 2 1 ; present system of administration a bar to rehabilitation, 49; second injury funds: payment of awards, 53; failure to discharge obligations and legal functions, 53; commutation of payments, 54; restoration of injured workers, 228; services denied to miners, 242; goal lost sight of by administration, 243 legislation, 45 ft., 52, 217; inadequacies, 46 ff.; need for provision for artificial limbs, 49; necessity of bringing up to a modern standard, 218; benefits available under, 243; rehabilitation as goal of, 244 Workmen's Compensation Bureau, 52; Newark Clinic and curative workshop, 107 Workmen's Compensation Clinic, T o ronto, 1 1 0 Workshop, in occupational therapy de-

Index partment of hospital, 96; curative, 107 ff.; sheltered, 109, 189, 199, 231, »47 Work therapy, 108 Work training, for amputees, 6 i ff. World W a r I, center for training casualties of, 106; rehabilitation of blind at St. Dunstans, 188; legislation enacted to care for needs of veterans of future wars, 219; legislation re disabled veterans of, 222, 227; veterans rehabilitation program, 245 World W a r II, low state of national

275

physical fitness, 3; an episode in a long and indefinite conflict, 56; work of the W a r Manpower Commission, 75, 249; programs of apprentice training, 138; amputees, 175; blind casualties, 182; created field for placement of blind, 185; pensions for disabled veterans of, 219; veterans no longer eligible for l>enefits under G.I. Bill of Rights, 221; law extending benefits to disabled in, 222; veterans rehabilitation program, 245 W o r l d W a r Veterans Act, 65