CRIPPLES. Cripples may be divided into four main cate gories: (1) Those suffering from congenital defects; (2) Those who have become deformed after birth from lack of light, air, exercise and proper diet ; (3) Those who have become deformed as a result of a crippling disease, of which the chief are infantile paralysis and tuber culosis; (4) Those who have become deformed as the result of injury.
The first category is relatively small, but important, for, as a rule the congenital defect, if skilfully dealt with at once, can be easily rectified, but if not so dealt with grows progressively worse. The second owes its origin to causes which are essentially, if not easily, preventable. The third category is on a somewhat different footing; here the cripple owes his deformity to a specific disease and the deformity can only be removed with the pre vention or prompt cure of that disease. The fourth category in cludes a large and important group, namely, the cripples who are the victims of injuries to spine and limbs. Most deformities are due not to a predisposing cause but to neglect of proper measures of prevention and cure. The potential cripple only becomes as a rule, a cripple in fact, if the necessary treatment is not given in time. Modern methods aim primarily not at housing or train ing existing cripples, but at preventing or eliminating their dis abilities. Experience has shown that 90% or even 95% of potential cripples would never become deformed if they received the right treatment at the right time. It is the object of all concerned with cripples to devise a successful technique, legal, medical and administrative, for securing the early discovery and prompt treat ment of every potential cripple who needs it.
A successful national scheme for dealing with cripples re quires (a) Adequate bodies of persons to work it, with the necessary legal and financial sanctions behind them, and (b) Efficient methods for the discovery, treatment, cure and training of cripples.
The varying measures and methods adopted in some of the lead ing European countries may be briefly indicated.
The Local Education Authorities work under the general direc tion of the Board of Education, and the Maternity and Child Welfare Committees and Public Health Authorities under the Ministry of Health. In each case the actual work is organized and carried out by the Local Authorities who receive from the Government Departments concerned a grant which amounts, as a rule, to 5o% of expenditure incurred with their approval. Broadly, the above named acts provide for the care and cure of all cripples other than non-tuberculous cripples over school age for whom at present no public body is responsible.
Preventive and Remedial Measures.—The second requisite for a successful national scheme for dealing with cripples is an efficient organization for the early discovery, treatment, cure and training of cripples. The organization which has now been de veloped in England and Wales is based upon the fundamental idea of an orthopaedi unit, i.e., an area which contains within itself the personnel, buildings, apparatus, etc., for dealing with all the cripples and potential cripples in that area. The ortho paedic requirements of such an area are :- (a) A skilled orthopaedic surgeon and a body of trained ortho paedic nurses; (b) A central orthopaedic hospital, including a hospital school and workshops; (c) Clinics in convenient parts of the area, served by the surgeon and nurses from the central hospital, with local help.
A case found early may be treated quickly and cheaply in its own home and at the neighbouring orthopaedic clinic. The more serious case will go to the orthopaedic hospital where education will be provided for the child and vocational training in work shops for the older patient. When hospital treatment is over, the patient will be returned to his own home, but will be kept under observation until all fear of a relapse is passed.
Efficient orthopaedic schemes are not yet to be found in every area, but the parts of the country where little or no provision is made for cripples are rapidly growing fewer. The provision made for the training and employment of the formed cripple lags be hind. This is due largely to the fear that has existed that advocacy of schemes for training cripples might obscure the greater issue and divert to training, energy and funds more profitably spent in prevention.
The first efforts at hospital organization for cripples date from the foundation of the Birmingham Orthopaedic Hospital in 1817, and the Royal National Orthopaedic Hospital in London in 1838, the Alexandra Hospital, the Sevenoaks Hospital, and the Cheyne Hospital, all founded soon after the middle of the last century, and the special orthopaedic department in general hospitals, starting with that at St. Bartholomew's in 1867. Of open-air hospitals the first founded was that at Heswall in 1899, and this has been f ol lowed by the establishment of a large number of country hospitals designed to give their patients the utmost benefit from open-air and sunlight.
The first efforts at the education of cripples consisted in the foundation of vocational schools. One for girls, now situated at Winchmore Hill, was founded in 1851, and two others for boys soon afterwards. The best known vocational school, the Heritage School at Chailey, was only founded in 1903. Special elementary education for invalid and crippled children owes its origin to the late Mrs. Humphrey Ward, who started a day school in London in 1898. This was followed by the passing of an Act of Parliament authorizing Education Authorities to maintain such schools, and a rapid extension of special elementary education of cripples able to get to school has taken place, first in London and afterwards in certain other large cities.
In Scotland the general principles for dealing with cripples follow in the main those of England. The same is true of Ireland where the efforts, though sporadic, are becoming co-ordinated. France.--In France, tuberculosis of bones and joints is the dominating crippling disease in children and for such patients special hospitals have been available for many years.
In 1919 the segregation and treatment of necessitous individuals suffering from tuberculosis became compulsory. Treatment in French special hospitals is financed from local taxation with additional contributions from the state taxes on racing and gambling. About 8,000 beds are available, either on the sea coast or in high altitudes. Of the marine centres Berck-sur-Mer, on the English Channel, is the most important; here, some 6,000 patients are usually under treatment in various hospitals, clinics or hotels. The large Maritime Hospital at Berck, controlled by the city of Paris and the Department of the Seine, is world famous. Similar centres with less accommodation exist on the Mediter ranean coast near Toulon and on the North Sea at Zuydcoote. The mountain hospitals are smaller and are situated in the Pyr enees and Maritime Alps.
In the treatment of non-tuberculous cripples voluntary organ izations are still called upon to bear the chief responsibility, but they tend to work more and more under a certain amount of State control, and thus a nucleus of a complete national scheme is foreshadowed. The colony of St. Fargeau in the suburbs of Paris, founded in 1919, deals entirely with children suffering from infantile paralysis. There is adequate provision for the purely surgical treatment of the cripple in the hospitals of the University centres and larger towns.
The most recent addition (1923) to the special hospital group is the Codivilla Institute for surgical tuberculosis at Cortina, in the Dolomites, which is affiliated to the Rizzoli Instituto at Bologna.
Since 1920, according to the law for the protection of physical defectives, a proportion of physically handicapped workers, at least 5o% disabled, has to be employed in certain trades and professions.
The city of Vienna has an orthopaedic hospital and an Insti tute for Cripple Welfare and in the province of Steiermark there is an Institution for Cripples where training is given and employ ment provided. In 1927 a progressive step was taken by the opening of a School for physically defective children which is run much on the same lines as the schools for physically defective children in England. There is no facility for transport from homes to school although free tickets on trams are provided for each child and attendant.
In 1927 a Society ("First Austrian Society for Work for Crip ples") was founded by Herr Braun who is himself a cripple, in Vienna. The aims of the Society are : (a) To foster in cripples themselves the desire to escape from pauperism and become self-supporting and useful members of society; (b) To bring before the country the present position and need of its cripples.
With a view to furthering this work, a census was taken of all cripples in the country and the Austrian Government approached with the idea that : (1) Education be made obligatory for crippled children.
(2) In each province of Austria a Committee be appointed consisting of a special medical authority for health for cripples, an education authority and a member of Herr Braun's Associa tion.
(3) Adequate national cripple schools, homes and training homes be erected to provide for the care, training and employ ment of cripples.
(4) Orthopaedic surgery be included in the ordinary medical examinations.
The society has, since its inauguration, opened workshops for training in various crafts and trades from its headquarters in Vienna and has opened several independent branches.
The city of Vienna, in recognition of the service done for its crippled citizens, gave both the accommodation for the workshops in Vienna and a small subsidy. Other support is raised from subscribers and to a large extent from members of the Association.
A convalescent home at Boinely, on the coast, is annexed to the central institute, and accepts patients for the completion of their treatment after leaving hospital and also students from the industrial school who are in need of rest. In most cases the cost of maintenance is borne by the State.
The administrative committee gives its services entirely volun tarily and the institute itself, although partly supported by Gov ernment grants, is dependent on the payment of patients, and voluntary donations.
The headquarters of orthopaedic work in Norway is the Central Institute for Cripples in Oslo, itself the outcome of the Handi craft School for Cripples, started in 1892. The institute is de signed for 30o cripples and is to include every provision that a first-rate orthopaedic unit involves—hospital, workshops, clinic, show-rooms for work made at the Institute, accommodation for men, women, boys and girls respectively.
An interesting feature is the establishment of more than 1,5oo Cripples Unions by the cripples themselves. The originator of the movement was a cripple who now edits a paper "Solglimt" (Sunbeam) devoted to the cause of cripples, which has over 4,00o subscribers. All the work now being done in Norway is volun tary. A "Cripples Law" which would give statutory sanction to a comprehensive national scheme, is under consideration.
Sweden.—There are no laws in Sweden regulating the ortho paedic treatment, industrial training, and social care of cripples. But there are four voluntary associations devoted to their assis tance, of which those at Stockholm, Gothenburg and Helsingburg, have established recognized institutions aided by the State. These associations are connected by means of the Central Committee for the care of cripples, which aims at the organization of cripple treatment all over the country. The three institutions have clinics, dispensaries, industrial schools, homes for pupils, evening schools, and in addition a residential school and educational home for badly crippled children. They depend in part, on patients' pay ments. Those who cannot pay for treatment are helped by the Poor Law. In the io years 1915-1925, over 23,00o patients passed through the dispensary and clinic departments, while in 1923 the number of operations was over 4,000. In addition orthopaedic clinics and departments are attached to some of the general hospitals, as for instance, those at Malmo and Lund. The St. Gorens Hospital, Stockholm, has a department for tuberculosis of the bones and joints. There are also certain seaside hospitals for children suffering from non-pulmonary tuberculosis. In 1920 a Royal Commission issued a report urging considerable extension of the present activities, but the necessary financial aid has not yet been granted by the Swedish Government.
The public concern which has developed since 1919, aroused by the number of cripples in the United States, and the interest displayed in their welfare are evidences of that broader humani tarianism that characterizes the modern attitude to all defectives. From 1863, when the hospital for the ruptured and crippled was opened in New York city during the Civil War, until 1914, inter est in cripples was confined to limited circles, and their care was largely institutional. The White House social workers' conference on dependent children, summoned by President Roosevelt in 1909, first awakened the interest of the public in these unfortunates. This interest became intensified by the sufferings of the crippled victims of the infantile paralysis epidemics in Vermont and New York during the period 1914 to 1916, when in New York city alone 6,574 surviving children required clinical treatment. After the care lavished on disabled soldiers during the World War, the conviction became general that these other cripples should be aided and encouraged also.
Causes and Prevention.—Two of the main causes of crippling are diseases affecting children and industrial accidents. Accidents on streets and highways and in the home also cause much dis ablement. In 1916 a survey of cripples in New York city disclosed 35,928, 63% becoming crippled before the age of 16. About 8,000 were under 5 and approximately io,000 between 5 and 15. Of these, 7,000 cases were remediable or correctible and 6,30o cases of rickets might have been benefited by medical and surgical attention. A survey in New York State, 1924-25, showed 30,000 crippled children. In North America, according to an estimate made in 1927, there are soo,000 cripples under 21. Of crippling conditions among children infantile paralysis accounts for 27.26%; bone and joint tuberculosis, 23.65%; congenital deformities, 13.15%;: rachitic deformities, 8.05%; traumatic conditions, 4.20% ; osteomyelitis, 3.67%; and other conditions, 20.20%. Add to the 58.96% of cripples whose condition is caused by infantile paralysis, bone tuberculosis and rickets the 13.15% of those con genitally deformed, and it is apparent that 72.11% are young chil dren, fully 50% being of pre-school age who, treated soon enough, might be cured or relieved (see BLOODLESS SURGERY). Between 12,000 and 15,000 are crippled by infantile paralysis in non epidemic and probably 40,000 in epidemic years. Legislation indi cates the preventive trend. Massachusetts as early as 1905 made a State survey. California, Illinois, Michigan, Ohio, West Virginia and Wisconsin require the enumeration of cripples. Minnesota (1897), New York (1899), Pennsylvania, Nebraska (19o5), Mass achusetts (1907), New Jersey, Michigan, Montana and Vermont (1913), Iowa (1915), Oregon and Virginia (1917), Kansas and Texas (1920), Indiana (1921), North Carolina (1922), North Dakota and Oklahoma (1923) and California and Missouri (1927) provide orthopaedic treatment in State institutions or elsewhere at public expense.
The hearings before the Congress committee concerned with the bill to promote rehabilitation of persons disabled while following their vocations, in Dec. 1918, brought out the fact that at least 800,000 men in general employment are incapacitated each year for a period of more than four weeks and require physical res toration. The average age of disability is 33. An estimate made in 1927 and based on accident statistics and rehabilitation pro grammes asserts that 50,000 persons each year are in need of vocational rehabilitation.
Education.—Among the earliest private schools for cripples founded in any country, and the first in the United States, was that conceived in 1861 and established in 1863 in New York city by Miss Cornelia and Dr. James Knight. In 1890 the New York city Children's Aid Society opened the Rhinelander Indus trial school for crippled children. Boston followed in 1893 with the well-known Industrial school for crippled and deformed children based on the Milan (Italy) plan; Chicago came next, in 1897, the city assuming the responsibility within two years; and Cleveland in 1900, when the first kindergarten was opened. Excluding the work done at the Minnesota State hospital and home for crippled children, established in 1897, the first institution started entirely by public initiative, the first public school was that planned in 1899 in Chicago and opened in 1900. The board of education little thought that it was taking an advanced step and setting an exam ple. New York city in 1906 took over under its public school "system the payment of the teachers and furnished schoolroom equipment for two of the private schools. It also started classes for crippled children, the first at Public school 104, after investi gating classwork under the Association for the Aid of Crippled Children, the latter maintaining the buses for transportation up to 1913, when the board of education undertook this responsibility. Among private schools for cripples the Widener Memorial school, built at a cost of $1,132,000 and opened in 1906, for children between 9 and I o years who remain until between 18 and 20, is noteworthy. It is lavishly and beautifully planned on the cottage system, with a summer home facing the sea at Longport, New Jersey. It is maintained with the income from a $4,000,000 trust fund created by P. A. B. Widener and the expenditure per head is $I,I15.
In 1914 there were 2,862 crippled pupils in public and private schools, 988 of whom attended the 51 public school classes in Chicago, New York, Cleveland and Detroit. Fifteen States have now passed laws making the education of crippled children in spe cial schools or classes, or by home teaching for those confined to the home, a public responsibility. According to the survey of the In ternational Society for Crippled Children made in 1923-24 there were 6,225 crippled pupils in 82 special schools. Bus transporta tion at public expense is in general practice, the boards of educa tion maintaining vehicle, attendant and chauffeur to convey the children to school, to clinic, to hospital or to places of special information or recreation, as required. Crippled children in most rural areas, however, lack facilities afforded those in urban dis tricts unless they leave home for a State institution. Forty out of 88 counties in Ohio do provide home teaching for cripples. Kentucky has a permanent commission which insures education and physical correction in rural territories as well as in large cities. With the State superintendent of public instruction it is responsi ble for the registration of crippled children; the conduct of pub lic diagnostic clinics; in co-operation with the school authorities and probate courts, for treatment in properly equipped hospitals of the State; education of crippled children during convalescence; payment of costs of care and education of poor patients and pupils ; and the proper "follow-up" supervision of cases after dis charge. Provision was made for education at about 150 private hospitals, convalescent institutions and homes for crippled children in 1924, which school work is supervised and supported by the educational authorities.
The education of cripples is threefold : the usual curriculum general in most schools; physical exercises and corrective and curative treatment including heliotherapy, special diets and rest cures; and prevocational and vocational training suited to the par ticular handicap, teaching loom-work, garme1zt, fancy flower and favour making, sheet-metal work and decorative designing. Its "excess cost" averages about $200 per year where the pupil is not boarded. Properly equipped and trained teachers are some what lacking. It was advocated in 1928 that training centres for teachers and nurses for crippled children as well as for field workers of both young and adult be established in the various States. The Michigan State Normal college at Ypsilanti, the Uni versity of Michigan at Ann Arbor, and Hunter college, New York city, alone make provision, though similar courses were contem plated (1928) at the Ohio State university and in Marion, Ill., in co-operation with the Southern Illinois State teachers college.
Training and Welfare.—Cripples are treated at special hos pitals owned and maintained at public expense in connection with State university hospitals; public institutions entirely owned and operated by the State; private institutions receiving various types of State aid; and private institutions for which fraternal or social organizations are responsible. Shriners, Rotarians, Kiwanians, Lions, Elks, the Women's Federation of Clubs, the Parent-Teach ers' Association and others all make provision for surgical treat ment, hospital care and braces and appliances for cripples. The Ancient and Accepted Order of the Mystic Shrine, for example, has ten hospitals costing from $304,000 to $661,000, and five "mobile units" which reach many crippled children in California, Illinois, Kentucky, South Carolina, Louisiana, Massachusetts, Min nesota, Missouri, Oregon, Pennsylvania, Hawaii, Utah and adja cent territory; the Scottish Rite maintains a hospital in Georgia; and there are Masonic hospitals in Texas, Kentucky and Penn sylvania.
Following the establishment of the Hospital for the ruptured and crippled in New York city referred to, the New York Ortho pedic hospital was founded in 1866. Both provided medical atten tion only. The first home for cripples was the Home of the Merci ful Saviour (1884) and the House of St. Michael and All Angels for young coloured cripples (1887) both in Philadelphia, with a summer home at Avon, New Jersey. Two were started next in New Jersey in 1892 and 1893, ten others established before 190o, and 20 between 1902 and 1912. Twenty-seven additional ones cared for a few crippled persons as subsidiary to their main work. Apart from support and training in institutions and a private school for adult men between 16 and 35 opened in New York city in 1912 by Dr. Charles Jaeger in which is taught the mak ing of reed articles, metal work, mechanical drawing, engraving and woodwork, little had been done before 1917 for the rehabili tation of adult cripples. In that year Minnesota began a study into their condition and Wisconsin in 1918 started some placement work. It was the interest of Jeremiah Millbank in them that led to the establishment in January 1918, of what is now the Insti tute for the Crippled and Disabled, New York city, the work of which indirectly laid the foundation for the vocational rehabilita tion of the disabled in the United States.
At first, the institute confined its attention to men but now also includes women. Its experience shows that complete rehabilitation means physical restoration, training for a suitable job, mainte nance during training, assistance in obtaining proper artificial aids and appliances and placement through a bureau skilled in find ing work for disabled persons. The first is outside its province; in all else its record has won national commendation. Cripples are taught printing, mechanical and architectural drawing, motion picture projection, typewriter repair and jewellery making, optical mechanical work, surface grinding and edge grinding of lenses and oxy-acetylene welding. Artificial appliances are made on the premises with special devices to enable the person to do a particu lar line of work, as, for instance, a kind of hook by which a one handed man can drive a five-ton truck and a typing finger for a girl born without fingers. For its placement bureau, a survey was made of 2,000 businesses in New York city. Its "sheltered work room" gives employment to otherwise unemployable cripples pre viously considered home-bound and another service takes work on a piece-basis to those confined to their homes. Cleveland and Chicago also have such institutions.
The Federal Government's programme for the vocational re habilitation of disabled persons was inaugurated on June 2, 192o, following the principle that workmen's compensation alone is in adequate. The original bills introduced in September 1918, by Senator Smith and Representative Bankhead failed to pass the 65th Congress but became law the following session when re introduced by Senator Kenyon and Representative Fess. Six States had established such a rehabilitation service before the passage of the national act—Massachusetts 1918; New Jersey, Minnesota, Pennsylvania and California, 1919; and New York, 192o. Provisions of the Kenyon-Fess bill were made operative for four years but a 1924 amendment extended the period to June 3o, 193o.
In 1928, 41 States had enacted laws accepting the provisions of this Federal act and providing for the promotion under State and Federal auspices of programmes of vocational rehabilitation. Federal aid offered to each State accepting the act is on the basis of dollar for dollar annually in the amount of $1,000,000 for all of the States, each receiving a share on the basis of the propor tion of its population to that of the entire country, with the pro vision that no State shall receive less than $5,00o annually. But in practice the States have expended more money; $3,335,713 for the period 1921-26 as against $2,586,918 from federal funds; 24,034 persons were rehabilitated. The number of women is gen erally small. In 1926, it was 13% but four times as many men as women become disabled. The cost of rehabilitation per case has decreased from $393 in 1922 to $233 (the cost of maintaining a person unable to work for a living in a poor house or institution is from $30o to $Soo) .
As implied by the title of the act rehabilitation is vocational not physical. Case work methods are used. Maintenance during training is a difficulty when compensation money is lacking or in adequate. Therapeutic treatment, too, must come through other agencies, for this rehabilitation service is held to be "primarily economic and only secondarily social and humanitarian." Another problem in rural areas is lack of employment for the crippled. To achieve complete rehabilitation the State service maintains co-operative relations with all agencies in a position to meet phases of the problem other than the vocational.