I
At the outbreak of war the idea of the disabled in general, and particularly of those who had had a limb amputated, was often to give up any really active trade and to seek a "situation" generally as an official with no actual manual labour. It must be confessed that many people, especially the nurses, encouraged them in this, and possibly the latter would not deny having done so.
It has rapidly become evident that there are too many maimed to be supplied with situations as caretakers of public gardens or doorkeepers, and that they will not be able to gain a living by making tricoloured decanter-mats of string or raffia or artificial flowers, when bazaars organised for their benefit by tender-hearted souls have gone out of fashion.
One of us was present a short while ago at the following little scene:—
In a hospital where there were two amputation cases, one through the lower fourth of the thigh, the other through the middle of the leg, both agricultural labourers, a distinguished man of letters, actuated by the best intentions, asked them what they counted on being able to do after they had been fitted with artificial limbs. The first replied that he hoped to return to agricultural work, the second that he would never be able to do that but would look out for a "situation." Our friend was much surprised to hear us say that he would be ill employed in using his influence to obtain his desire for the second patient, because a man with only one leg could work on the land with almost no diminution of his ordinary capacity, even with the old-fashioned kneeling peg leg.
As Jean Camus has well said in a recent article in the Paris Médical, "We are beginning to pass beyond the phase when re-education of the maimed was left to chance. It is felt now that the frivolous efforts of benefactresses who, acting with the best intentions but without reflections, are delighted to be able to transform into a shorthand typist an honest farm labourer who had a strong attachment to the soil and could quite well return to it, must be avoided. Such feats are both culpable and absurd."
These fantastic ideas must be got rid of, and all our efforts must be co-ordinated, the complexity of the conditions to be dealt with being duly weighed.
Given a maimed man the first care should be to educate to the maximum all the uninjured and remaining parts. It is too often forgotten that among the parts remaining the brain plays a leading rôle, even the chief rôle, not only because it is the organ of "good will" without which all attempts at re-education are fruitless, but also because good will being given the intelligent man will succeed better and will be able to adapt himself to more delicate work. "Physiotherapy cannot be prescribed," says J. Camus, "as quinine is prescribed. The malarial patient who takes the latter medicine benefits whether he wishes to or not. The wounded man who submits each morning to his mechanotherapeutic treatment does not recover unless he wishes."
It is very difficult to make the layman understand this. He invariably takes for granted the good will of the patient, with all of whose complaints he sympathises, without for a moment realising that they sometimes degenerate into jeremiads, often with an ulterior motive. An examination by a doctor—and an experienced doctor—is therefore necessary in order to determine under what physical and mental conditions an amputation case can be re-educated; so that he may understand that it is entirely to his interest to work as quickly and as well as possible, that begging is degrading, and above all that private charity is temporary and exhaustible; and that in consequence he must as quickly as possible put himself into a condition to supplement by a salary justly earned the pension or gratuity which is certain to be insufficient for his maintenance.
It can never be sufficiently insisted upon in dealing with the maimed that by resuming work, and on account of the functional improvement resulting from doing so, they need have no anxiety that their pension will be reduced, because the amount of this is based on the extent of the injury itself and on the man's rank, and not on his profession before he became a soldier. In the same rank the pension is the same for a surgeon or a lawyer, if both have lost a hand.
It is a deep-seated notion, instilled into the minds of injured workmen by the often suspicious folk who advise them, that if they begin work before their case has been settled their pension will be less.
It must be acknowledged on the other hand that the civil expert is often faced with a difficulty. As our law stands—and it is unfair—work cannot be resumed partially with provisional half-pay followed later by whole-time work with permanent salary. This difference is important to our wounded soldiers, who have everything to gain by a rapid and complete re-education and whose duty it is to do whole or part-time work while their legal position is being arranged and before the wound, in legal phraseology, has become "consolidated," that is to say, before the completion of treatment.
It is only fair to add that the patients are not alone to blame and that the administration has for long been guilty of an error against which reaction is growing, viz. delaying re-education until the time when the local condition has become permanent and the patient has been discharged and has received his prosthetic apparatus.
This delay is deplorable, on both medical and social grounds. On medical grounds because in very many cases before treatment is quite complete the addition of carefully graduated and supervised work is an important part of the treatment. On social grounds because it is necessary to fight in every possible way against the common tendency of the patient to fall into habits of laziness and intemperance.
This is now understood, and almost everywhere to-day the wounded soldier can resume work in workshops attached to the centres of physiotherapy, and thus begin his re-education while continuing his treatment.
At a certain stage resumption of work becomes the best therapeutic agent of all.
It is obvious that this resumption of work cannot supply the place of certain special treatments such as electrical treatment during the regeneration of a nerve, balneotherapy, or graduated gymnastic exercises; but is it not true that work with its continual active movement is infinitely superior to passive mobilisation by means of apparatus however ingeniously the latter may be contrived? Morover it is surely a more efficacious course of mechanotherapy when the patient works for half or all the day than is provided by the special course occupying only an hour or two.
The tendency to-day is in this direction, as, for example, at the Grand Palais, thanks to the efforts of J. Camus, and also in the agricultural centre of the XIIIth district under the direction of Belot and Privat. At a given moment all treatment may be suspended and the patient may devote himself exclusively to work with results the excellence of which Nepper and Vallée have demonstrated.
The workmen are then eligible for work in a town in private workshops, but so far this freedom has more inconveniences than advantages. A man whose working capacity is much reduced, and more especially a man who requires re-education, has no place in an ordinary workshop where neither the proprietor nor the foreman nor his fellow-workmen are in truth much inclined to concern themselves about him. Where actual education is necessary this is best supplied in special workshops where the patient will be among comrades handicapped like himself, whose progress he will be able to watch and whose efforts he will imitate, rather than among able-bodied workmen, by comparing himself with whom he is bound to be discouraged.
The problem has been solved by the Belgians in a remarkable establishment opened at Port-Villerz, and by the Austrians at Vienna under the direction of Spitzy, as Nové-Josserand and Bouget inform us, by delaying a maimed soldier's discharge from the army until his re-education is as complete as possible. This method has proved to be to the interest both of the individual and of the State, but we do not seem to have considered this solution, and it is still to be feared that it would accord ill with the independence of our national character. The actual fact, though it has not been brought into prominence, is that our usual system of "watertight compartments" has been applied by adding to the centres of physiotherapy centres of agricultural or industrial re-education, the results obtained in which are dependent upon the efficiency of the director of physiotherapy.
This matter seems to have received very little special attention in connection with amputation cases. It is, however, of great utility to develop the strength and agility of the remaining limbs by suitable gymnastic exercises, to teach a man with only one leg, for example, to jump without an artificial limb and to climb a slippery rope or a ladder; or to train the left hand of a man who has lost his right; to develop the greatest possible strength in the stump by training it in movement combined with the exertion of force. In addition to this, early and provisional equipment with artificial limbs must become general. These temporary limbs are undoubtedly rudimentary contrivances, but they are functionally good and are useful on account of their mere weight.
In this connection the temporary arms used by Nové-Josserand and Bouget in their agricultural re-education centre are very interesting models. The great advantage of using a temporary limb is that the time required for the construction of the permanent apparatus, often a considerable period, is not lost in idleness, the mother of all the vices.