Refitting Disabled Soldiers
I
THERE are some tasks which appeal so directly and with such force to sentiment, that they stand in considerable danger of being ill performed for lack of prudent sense. There are few sights more pathetic than that of strong men who have lost their strength, and who stand helplessly before us, lacking sight or lacking limbs, or, perhaps worse than all, lacking ‘nerve,’ with all mind and will-power in abeyance, dependent upon others for every want in life. We are filled with feelings of pity, admiration, and gratitude which almost preclude the exercise of judgment. And yet there is nothing more certain than that, if the best is to be done for disabled soldiers the task of ‘refitting’ and otherwise helping them to reënter civil life as useful citizens must be undertaken with the utmost care, caution, and forethought.
The experience of previous wars helps us very little; not only because there has never been a war upon so great a scale, but because for the first time the whole resources of modern science have been ruthlessly employed in the destruction of life, — resulting in a variety of casualties which has never before been known,—and because the ranks of our great armies have been filled by men of every degree of education and every variety of occupation, the great majority of them unseasoned and unfamiliar with the sights and sounds of war. At the same time economic conditions have been so strangely disturbed that, instead of a partly disabled man finding it necessary to take every opportunity of increasing his earning capacity, he finds a temporarily depleted labor market and the lure of high wages for very little skill. He does not realize that this condition will pass, and he is naturally enough inclined to take the short view, to neglect opportunities of training, and to take employment which will very likely cease and leave him stranded, at a time when the country has begun to believe the debt to its soldiers liquidated, and to be unwilling to repeat the efforts that it now so willingly makes for their satisfactory resettlement in civil life.
Considering that Great Britain was wholly unprepared for a great war on land, it follows that there was no organization for dealing with any large numbers of disabled men. Very prompt measures were, however, taken to provide for general distress occasioned by the war.1 But there was a strong feeling against any suggestion of ‘charity’ — understood in its least noble sense — in the relief of men who had fought for the country, and in some quarters there was an almost fierce objection to voluntary bodies, such as the Soldiers’ and Sailors’ Help Society, having anything to do with the administration of public money or even of the National Relief Fund. Illogical as this objection was, it had to be considered, and it was the cause of some bitterness and friction. On the other hand, voluntary bodies, with their armies of skilled and mostly unpaid social workers, were ready when no one else was ready and possessed experience which no one else possessed. The attempt to steer between these cross-currents has on the whole been successful, and we have in the end a degree of coöperation between the official and voluntary elements which is creditable to them both. But confusion has not altogether been avoided, and there has been at least the appearance of vacillation and unnecessary delay in announcing exactly what provision would be made for the disabled. This has created a sense of insecurity and has complicated the whole problem.
For some time also there was considerable uncertainty with regard to pensions. The scale of pensions which existed prior to the present war was soon seen to be inadequate. It has been twice revised, and is now considerably more liberal than that obtaining in any other European country. For some time the principle on which pensions were granted was that of lessened earning capacity, and if earning capacity increased, the pension was liable to reduction. There is, of course, something to be said for this principle, but it had the not unnatural result of leading many men to refuse training; ‘for,’ they argued, ‘why should we exchange part of a certain pension for earnings which must be uncertain?’ This has now been altered, and pensions are granted in accordance with the nature of the disability and continue so long as the disability lasts, irrespective of the man’s earnings. Thus the insecurity and uncertainty have now to a great extent been removed.2 They are referred to here because it is in the highest degree important that men should know what treatment they have to expect and should have as much inducement as possible to make the best of their disabilities and to reënter civil life with the determination that their future existence shall be as nearly normal as may be.
It is possible that we have not considered psychology as closely as we might have done. We have been moved by that overwhelming sentiment to which I have referred above. Our legitimate admiration has led us to acclaim an army of heroes; but in sober sense no nation ever had an army of five million heroes. We have been so lavish with this great word that we have depreciated our literary currency, and we may even have led some to suspect that we meant to pay our debt with words. But the task of helping men to restart their lives — often with a serious handicap — is a hard and practical one, and its success depends both upon our own common sense and upon the character of the men we are trying to help. Without their own willing effort we can do very little. Unless we discipline our own emotion, we shall probably prove false friends and do a considerable amount of harm. We have to recognize that most of the men we deal with are average human beings, just as liable to get their heads turned as we ourselves, and with far better excuse. We are not fair to them if we fail to consider this.
The experience of the past three years indicates the principles upon which we should go to work. In the first place, the duty of caring for the disabled should be undertaken by a special department of the state, which should take into its service such voluntary bodies as are able and willing to act with it; this duty should include, —
(a) The provision of medical and surgical treatment and appliances.
(b) The assessment of pensions.
(c) The provision of industrial and professional training.
(d) The finding of suitable employment.
The second principle is that of continuity of treatment and control. There should be no break, for instance, between the military hospital where a man’s leg is amputated and the convalescent home, and again between the convalescent home and the hospital at which he is to be fitted with the new limb and trained in its use; and industrial training, or some form of preparation for it, should begin in the military hospital and proceed side by side with the medical treatment. Periods of waiting during which a man returns to his own home are unsettling and have a bad effect, besides prolonging the treatment. Long periods in hospital and home, with nothing useful to do, have also a demoralizing effect, and a patient’s recovery is likely to be more rapid if his mind is healthily occupied and he can be made interested in some light manual task.
The question of control is more difficult. In some cases, probably in the majority, it is clearly desirable that a man should not receive his discharge from the service until his treatment, including industrial training, is completed. In the Belgian army this is the case, but there the conditions are different inasmuch as the Belgian soldier has unhappily no home to go to. There industrial training is compulsory; it is also much easier, because a higher proportion of the men are skilled tradesmen. In France ‘reëducation’ is continued under military discipline, with a view to the soldier’s retention in the army as an effective military unit; but industrial training is voluntary, and a large proportion of the men refuse it. In the British army men receive their discharge, in general, much too soon, and too great liberty is left them to break off their treatment when it bores them.
The third principle is that of recognition of individuality. There should be a careful consideration of a man’s past industrial history, his aptitudes, and his ambitions. The selection of the trade that he is to be taught should depend upon a consideration of his own chances of success in it. It is useless, for instance, to set a man up as a bootmaker on his own account unless he possesses stability of character and some business aptitude, as well as the skill to make boots. Again, a man may have been a jobbing gardener in a town and express a wish to go on the land. But if either he or his wife has been bred in a city, they must be exceptional people to succeed on the land. Most city-bred folk are unhappy out of a crowd. They love the life of the streets — they cannot stand monotony, or silence, or space, or the dark. On the other hand, it should be recognized that the incidents of war and a bad wound have perhaps given us the opportunity of helping a man to realize some long-cherished plan or ambition. His confidence should be invited and every effort should be made to meet his special desires and requirements.
These principles can be carried out effectively only where there is close coöperation between the doctor and the industrial expert or technical instructor at an early stage in the man’s treatment, and where there is intelligent coöperation between official bodies and voluntary organizations, so that the utmost use may be made of the services of unofficial visitors who can take a more personal interest in a man’s future career than is possible to a hard-driven official working in an official atmosphere. The French method of ‘reëducation’ is based on this early adaptation of medical treatment to industrial needs, and the results are said to be remarkably good.
In England we have been somewhat slow in attempting to link up treatment and training. A good deal however has been done in the past year, and a vigorous propaganda has been carried on, with a view to the installation of special apparatus for mechanotherapy and the establishment of training centres in connection with the larger military hospitals.
II
Meanwhile, certain institutions have been doing special work which calls for description in detail. The first of these are Queen Mary’s Convalescent Auxiliary Hospitals at Brighton and Roehampton. Here is centralized (for England) the provision of all artificial limbs for men who have suffered amputation. After leaving the hospital where the amputation has been performed, the men are sent to Brighton for a period of convalescence. And here is offered the first opportunity of industrial training. The Brighton workshops were the gift of Queen Mary and are under the direction of Major Robert Mitchell, an expert in technical education.
Every man on his arrival at the Convalescent Hospital is given a leaflet describing the courses of instruction offered and urging him to take advantage of them. The subjects taught are, motor mechanics, with instruction which should qualify the man to take a post as chauffeur; carpentry, with training in all forms of woodwork; electric fitting — lights, telephones, bells, and so forth; bookkeeping, shorthand, and typewriting. The workshops are thoroughly well equipped, and everything is done to make the most of the short time the men remain at Brighton. As serious training, it can be no more than a beginning; but probably its greatest value lies in the fact that the men’s thoughts are taken off their injuries and a new atmosphere is created in which the predominant idea is that of usefulness. Attendance at the classes is entirely voluntary and many men do not avail themselves of the opportunity offered.
Brighton is a preparation for Roehampton. As soon as a man is ready for refitting with an artificial limb, he is transferred to Roehampton House.
It may perhaps be explained here that the Roehampton Auxiliary Hospital was started by private effort, in order that limbless men should not be discharged to their own homes too soon after amputation. The workshops and the whole scheme of training were added later, and the Brighton branch with its preparatory workshops still later.
The whole forms what may justly be regarded as a model scheme for the refitting, reëducation, and return to civil occupation of men who have lost limbs in the war.
On arrival from Brighton each man is given a leaflet, calling his attention to the facilities offered for acquiring instruction in electric lighting and motors, telephones and electric bells, motor-car mechanism and driving, engineering, woodworking and turning in workshops provided with qualified instructors; in fancy-leather work and light basket-making; in bookkeeping, typewriting, and shorthand, and other useful commercial subjects. The men are urged to make full use of these opportunities and to consult with the superintendent. Certificates are awarded to regular attendants at the workshops, and arrangements are made for discharged men to continue their training if they wish. In addition lectures in poultry culture are given, and a poultry farm has been established.
An employment bureau at the hospital helps the men to embark on their future careers, and deals with all pension and pay difficulties and other personal matters in regard to which they may need help or advice.
In addition to the teaching actually provided at Roehampton, arrangements are made with other recognized institutions for instruction in architecture, art and design, baking, brushmaking, bootmaking, chemistry, confectionery, draughtsmanship, cinema work, hairdressing, photography, silver and metal mounting, tailoring, telegraphy, and toy-making. Beyond this, many employers are willing to take men and pay them a wage while they are learning to do a particular job.
Men who have lost one arm have been placed in the following types of employment: clerk, commissionaire, gateman, gymnastic instructor, labormaster in workhouse, liftman, lodgekeeper, schoolmaster, porter, railway worker, messenger, telephone attendant, timekeeper, traveler, ward-master, watchman, weighman. Men who have lost a leg in the following: bootmaker, caretaker, chauffeur, domestic servant, electrical worker, gateman, groom, hall porter, liftman, lodge-keeper, milker, munition-maker, packer, painter, postal employee, printer, roadmaker, tailor, telegraphist, timekeeper, telephone attendant, vanman, and watchman. At the present time metal turning and fitting is the most popular form of training, and that which leads to the highest remuneration. This is due to the demands for labor from the munition factories, and is a temporary condition only.
It has been calculated that 40 per cent of the men return to their former employers and that 35 per cent will consider only employment near their homes. The bulk of these, therefore, do not avail themselves of the training at Roehampton. Of the remaining 25 per cent — most of whom are ready to accept work anywhere — 81 per cent take some form of training.
It is permissible to expect that the proportion of men willing to be trained will increase as the facilities for training are extended and become better known, and as other uncertainties are removed. For instance, a good deal of anxiety has been felt by the men and by prospective employers on the question of the insurance of partly disabled men against ‘ compensation ’ risks. The insurance companies have now, however, intimated that they will insure wounded service men reëntering civil employment, at ordinary rates.
Roehampton is the pioneer refitting dépôt for limbless men, and its work has been in a high degree successful. But, owing to inevitably limited accommodation, there is a considerable wait before men can be admitted, and once admitted, the period of training is too short to be complete. Institutions on similar lines are therefore being planned in many centres in England.
III
Arrangements for the care of blinded soldiers and sailors are very complete and are mainly the outcome of the devotion and enthusiasm of Sir Arthur Pearson, who, himself blind, has found a way of rendering service to his country which is as effective as it is unique.
St. Dunstan’s is a private mansion in Regent’s Park, London, which, with its extensive grounds, has been generously given up by Mr. Otto Kahn of New York. To this have since been added several annexes in London, in Brighton, and in Torquay. There is an affiliated hostel in Edinburgh. By arrangement with the military hospitals, all blinded service men are sent, on arrival in England, to a general military hospital in London. Here they are at once visited by a representative from St. Dunstan’s, who with sympathy and sense begins to show them the paths and tracks in the dark world which they have entered. These visits are continued daily, and easy manual tasks, such as net-bag making, are at once begun, as well as preliminary teaching in Braille. As soon as the man is fit, he is admitted to St. Dunstan’s, and here his new life really begins. The house and grounds are fitted up with such ingenuity and care that the sightless men can soon move about freely and without danger. The days are fully occupied with varied recreation and equally varied work. Practically all men learn the Braille system of reading and the typewriter; the latter not as an industrial occupation but as a means of correspondence with friends. The typewriter becomes his own property which he takes away with him when he leaves, together with a stock of Braille literature.
The working day consists of four and a half hours — two and a half in the morning and two in the afternoon. It is found unwise to expect mental concentration for longer than this. Also, the day is divided between mental work in the classrooms and manual work in the shops. Netting is taught to most men mainly as a pleasant occupation. Those who care to do so can easily earn a few shillings a week by it in their spare time. The serious industrial occupations taught are cobbling, basket-making, joinery, and poultryfarming. Men who learn boot-repairing are also taught mat-making as a second string. At both occupations good earnings are possible. The prentice at basket-making learns to make several kinds of baskets, with special reference to the demand there may be in the locality in which he is going to live. The blind man who chooses to be a joiner can be taught to make such salable articles as picture-frames, teatrays, corner-cupboards, and small tables, as well and as quickly as the man with sight.
Poultry-farming is a new industry for the blind. Men learn to distinguish birds of different breeds by touch, to manage incubators, to prepare and truss birds for table, and the like. The department is directed by poultry experts, and the men are graded in classes according to proficiency. The teaching is begun at St. Dunstan’s and continued at a poultry farm in the country. An important point in this connection is that six weeks’ training on a poultry farm is also offered free to the wives or other relatives of men intending to set up as poultry-farmers.
An occupation which is specially suitable for such blinded men as have had sufficient education is that of masseur. Massage training is begun at St. Dunstan’s, where the men acquire a knowledge of anatomy, physiology, and pathology. They then pass on to the massage school of the National Institute for the Blind, and finally sit for the examinations of the Incorporated Society of Trained Masseurs. After passing these examinations, and so far no St. Dunstan’s man has failed, they are employed at military hospitals and command dépôts.
Men who occupied secretarial positions before joining the army are taught Braille shorthand with typewriting, and a special typewriter has been built which can be operated by men who not only are blind, but have lost one hand.
Telephone operating is also successfully taught, and men can be employed in exchanges where the dropshutter system is installed. It is said that in a few weeks a blind operator can tell by sound which of the shutters has fallen, and proves himself just as competent as a sighted employee.
Apart from professional and industrial training, men gradually learn to take part in various forms of recreation which might be supposed impossible to the sightless. There are rowing, swimming, walking, and running races, physical drill, and push-ball. Every week there are dances to which women may be invited. Dominoes, draughts, chess, and cards are played in the evenings. There is a popular debating society, and most of the men play some sort of musical instrument.
Under certain circumstances, patients’ relatives are brought from all parts of the country free of cost, and are accommodated while in London at special homes arranged for their reception.
An exceedingly important part of the work is a system of after care of the men when they have left St. Dunstan’s. The aim is to see every man comfortably resettled in civil life and to make sure that he does not deteriorate in capacity or otherwise. Arrangements are made, therefore, for keeping in touch by personal visitation with each man in his own home, supervising his work, encouraging his efforts, maintaining the comradeship begun at St. Dunstan’s, and giving practical assistance when necessary by the supply of raw material, by arranging for the marketing of goods, and in various other ways.
IV
An attempt to provide training and employment for partly disabled men after their discharge from the army or navy is being made on a somewhat extensive scale by the Lord Roberts Memorial Workshops. The first workshop of the kind was opened by the Soldiers’ and Sailors’ Help Society in London during the South African War. After the death of Earl Roberts the society inaugurated a memorial fund, to be devoted to the extension of this workshop and the establishment of others in the large towns in the United Kingdom. There are now six or seven, and others are in contemplation. The shops are really industrial ventures with philanthropic backing. The principal manufactures are wooden toys and dolls, furniture, basket-work, and household articles. These are sold at market prices to the wholesale trade. On entering the workshop each man at once receives a wage of twenty shillings a week as a learner. The wages increase as he becomes more proficient. Women and girls are also employed — so far as possible, relatives of the soldiers. The idea here is, not to train men for the open labor market, but to give them permanent employment under conditions which could be modified to suit each man’s physical capacity more readily than could well be the case in any undertaking subject to ordinary commercial competition. It is probable, therefore, that, as time goes on, the men least able to stand the strain of regular work will gravitate to the workshops.
The possibility of assisting ex-service men to settle on the land has been very carefully considered by the government. The course of the war has demonstrated sufficiently plainly that it is to the interest of the nation to increase the supply of home-grown food by bringing more land under cultivation. A double end would thus be served if assistance to ex-service men took the form of turning them into food-producers. A departmental committee was appointed to consider and report upon the subject, and has advocated the state purchase of land for the establishment of state colonies of settlers, and the provision of small holdings by county councils for ex-service men who do not care to go to the state colonies. With regard to the partly disabled, the committee thought that many forms of agricultural work would be within their powers, and they advocated their settlement or employment along with the able-bodied. They were not in favor of what they termed ‘colonies of cripples.’
Action on the lines of these recommendations has already been taken. By act of Parliament the Board of Agriculture was empowered to acquire eight thousand acres, and most of this has been secured. Houses have been erected, and some men have been selected for settlement and are in training. Over a year ago some fifty men were sent to two agricultural colleges for courses of six months’ training or longer, with satisfactory results.
The question of land settlement in the United Kingdom on any extensive scale presents peculiar difficulties. Further legislation, giving powers of compulsory purchase of land, will probably be sought. But even if small holdings can be made available for every suitable man who is prepared to live on the land, it requires much faith to believe that anything considerable can be done to create an agricultural population out of our demobilized armies.
I have endeavored in a brief space to show what is being done in certain main directions for the ‘refitting’ of our maimed soldiers. But this is not, of course, the whole story. There are innumerable smaller efforts by private people, by philanthropic committees, and by municipalities and educational bodies. In connection with most, if not all, of the larger military hospitals there is an organization of voluntary workers, who undertake to teach various light handicrafts to men whose stay is prolonged. Many employers offer to train limited numbers of discharged men in various special industries. When the present writer was acting as honorary secretary to a branch of the Soldiers’ and Sailors’ Help Society such offers considerably exceeded the supply of men. It was not found possible, for instance, to find enough men to satisfy one firm which offered training and an immediate wage of thirty shillings a week for football sewing. Technical institutes all over the country are throwing open their classes to ex-soldiers, and the universities are also offering special facilities. It is, indeed, urged that, in view of the varied standards of education of the men of the new armies, the entire educational resources of the country should be made freely available to them. Commercial men, for instance, who have hitherto been content with one language, might now be persuaded to learn French or Russian or Italian. There must, however, be some element of persuasion in the matter. We are a conservative people, slow to change our habits, not greatly in love with learning. Some profess to think that this war, with all its sorrow and horror and loss, with all its glory and sacrifice and enthusiasm, with all the will to set right a great wrong which has been aroused, will change the thoughts and habits of our men and make us all a new people. But it will not. Many things in our world, we hope, will be a little better than they were before — some bad things perhaps will disappear altogether and some new things be born. But we shall be essentially the same. And we shall still need to be persuaded a little for our own good.
I have said nothing about the saddest task that is laid upon us —the provision for those men who have given more than life — whose injuries to nerve-centres have rendered them physically or mentally helpless. Special institutions are being provided for their permanent care; they are beyond ‘refitting,’ and science and humanity can only see to it that they have every comfort and attention that ingenuity and love can provide.
In May, 1917, an inter-allied conference on the subject of the treatment of the disabled men was held in Paris. Representatives were present from France, Belgium, Russia, Portugal, Italy, Serbia, Great Britain, and Canada. A large number of resolutions was passed, and stress was laid on the necessity of propaganda in order to make
known to the disabled themselves the advantages accruing from the opportunities of reëducation which are offered, and to arouse in the public a just sense of the great social problem which is involved. It was recommended that a periodical review for the Allies should be published, dealing with prothesis, orthopœdics, and all subjects relating to functional and technical reëducation. The conference was organized by a Franco-Belgian committee and will probably be called together again.