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Douglas C. (Douglas Crawford) McMurtrie.

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by the Minister of the Interior in August, 1917, 5 forms the basis
for, all reeducational activities and states the limits of Government
and private responsibility. The functions of the board are stated
to be assistance to war cripples in —

1. Medical treatment (in so far as this is not covered by the military

authorities).

2. Material relief.

3. Reeducation.

4. Placement.

5. Claiming of pensions.

This does not mean that these activities are actually to be taken
over by the board. It merely supervises and assists, filling in the
gaps wherever necessary. The reeducation schools are to remain, as
before, under the management of the local committees, but the
board is to supervise and inspect, giving charters to new committees
and revoking charters of those which do not come up to the stand-
ards. It will largely replace the voluntary federation, which has
announced its intention of giving up its work as soon as the Gov-
ernment board is actually in operation. Owing to the necessary
delay in choosing the parliamentary representatives the board has
not up to December, 1917, held its first meeting. Its first provision
is, as mentioned above, a Government board, which shall be the
ofiicial body supervising and regulating all the work for the war
cripples. This board consists of 19 members. Four are elected by
Parliament — 2 senators and 2 deputies. The other 15 are appointed
by royal decree on the suggestion of the prime minister, as follows :
Five ministerial nominees, representing the departments of the
interior, war, navy, treasury, and of industry, commerce and labor;
two nominees of the surgeon general, who shall have special tech-
nical qualifications ; three nominees of the volunteer associations for
the care of war cripples, one from the actual institutions caring for
war cripples ; four elected by the National War Cripples' Association.

The board is under the minister of the interior. It must render a
report to him every year, which he in turn must present to Parlia-
ment. A yearly appropriation is set aside for it from the budget
of the department of the interior.

The board has its office in Rome, with the offices of the ministry of
the interior, its office force being furnished by the Government. It

* Bollettino della Federazione Nazionale del Comltatl dl Assistenza al Soldatl Ciechi,
Mutilati, Storpl. Rome, 1917, 11, 66.

• Bollettino della Federazlone Nazionale del Comltatl dl Assistenza ai Soldatl Ciecljl,
Mutilati, Storpl. Rome, 1917, 11, 199-213.



112 EVOLUTION OF SYSTEMS OF VOCATIONAL REEDUCATION.

is supposed to work in very close connection with the societies and
institutions all over the country, which are concerned with war
cripples, and thus to have an authorized representative in every
locality. There is criticism of the board by the existing social
agencies, to the effect that it may easily become bureaucratic and
political, and so be out of touch with the actual needs of the work.
Until the board has fairly started its activities it is not possible to
tell how real this danger is. The federation is in close touch with
the prime minister, who has the appointment of a majority of the
members, and has itself been allowed to nominate three of them, so
hopes to control this difficulty.

LEGAL MEASURES.

The law above mentioned, in addition to creating the national
board, fixes the general system for treatment of cripples all over the
country. Its regulations are as follows:

Crippled soldiers, after their first surgical treatment, are to be sent
to military centri di cure fisiche ed orthopediche (centers for physical
and orthopedic treatment). These are military reserve hospitals
under the army medical department with special facilities for ortho-
pedic treatment. There are nine of them in the country, located in
the army corps districts of Turin, Milan, Genoa, Verona, Bologna,
Florence, Eome, Naples, and Palermo. A soldier is in each case to
be sent to the center nearest his home, or if that is not possible, to
the next nearest. 6

At the centers the men are to receive functional reeducation, mas-
sage, and mecanotherapy, and to be furnished with a temporary
artificial limb at the expense of the Government. They are not kept
until the stump has assumed its permanent form. 7

When their cure has so far progressed that they will profit most
from reeducation, they are dismissed from the orthopedic hospital
on breve licenza (short leave) .and allowed to visit their homes.
After the term of leave, generally a month, has expired, those desig-
nated by the center as capable of reeducation must present them-
selves as part of their military duty at the nearest reeducation school.
The men excused from this duty are those hopelessly cnippled or
those who give proof that they do not need reeducation or #an attend
to their own. They are given licenza straordinaria (long/leave) and
may remain home until ready for their permanent prosthesis.

The compulsory stay of any man at the school is limited by the

law to 15 days. During that time he is fitted with his permanent

t

■Bollettlno della Federazlone Naziomile del Comitati di Assisten&a at Soldatl Ciecbi,
Mutilati, Storpi. Rome, 1917, 11, 8.

* Bollettlno della Federazlone Nazionale del Comitati di Asslstenssa ai Soldatl Ciecb ,
Mutilati, Storpi. Borne, 1917, ii, 203.



EVOLUTION OF SYSTEMS OF VOCATIONAL REEDUCATION. 113

prosthesis, which is selected for him by the school at the expense of
the Government. The school also has every opportunity to convince
him of the value of reeducation. If he consents to training, he
remains under military discipline. If he refuses, he receives his
discharge from the local military authority.

This combination of voluntary choice and military discipline was
already the arrangement adopted by most of the schools. It was"
admitted by all the workers in the field that the ignorant and usually
illiterate Italian peasant would be very difficult to train without the
aid of military discipline. But it was also felt that men would not
make good subjects for training unless they went into it voluntarily.
The main difficulty which the schools had experienced was that of
getting information about reeducation possibilities distributed
through the army, and compulsory stay in the schools was proposed
as the simplest way to accomplish this. It will also be an easy
method of getting statistics about the cripples as they pass through
the schools, whether they remain for reeducation or not. The fault
found with the measure is that at present the schools have not ac-
commodations to take care of every cripple dismissed from the ortho-
pedic hospital, even for 15 days. Only 20 per cent of all cripples
in the country are now being reeducated. 8 This fact was pointed out
to Parliament by members of the federation, and it was stated that
unless the Government would be willing to provide additional schools
the provision would become a dead letter. The warning was not
observed, however, so the schools will be obliged to apply their own
judgment in carrying out the law.

Regulations for Schools.

The schools, which are in this way given a semiofficial position, are
held strictly accountable to the national board. Any school, before
being recognized as fit to receive cripples, must show :

1. That it has adequate buildings and equipment.

2. That it is directed by a competent person who must be a doctor or
assisted by a doctor.

3. That it is scientifically organized and directed and that it possesses the
proper scientific apparatus for functional reeducation.

4. That it has a workshop where artificial limbs and appliances can be
properly altered and repaired.

5. There must be attached to the staff a reeducated cripple, nominated by the
local branch of the national cripple association.

The schools are responsible to the national board in all matters of
reeducation and are subject to regular inspection. In matters of

• Bollettino della Federaaione Nazlonale dei Comltatl di Assistenza al Soldatl Ciechi,
Mutilatl, Storpi. Rome, 1917, 11, 6.

57710—18 8



114 EVOLUTION OF SYSTEMS OF VOCATIONAL REEDUCATION.

hygiene, sanitation, and discipline they are responsible to the war
department, which inspects and furnishes the disciplinary officers.
The schools are expected, under the law, to receive all cripples who
apply for reeducation, but, owing to their present accommodations,
this part of the regulations can not be observed.

When a man is accepted for reeducation he remains as a regular
member of the army. He may remain at the school for a maximum
period of six months. During this time the war department pays
the school 3.50 lire a day for his maintenance, pays the man a
regular sum, according to his rank" (a private has 20 centesimi, 4
cents a day) and maintains his family at the same rate as though
he were in active service. 10 If his training is not complete at the
end of six months, the national board may retain him longer at its
own expense. If he is ready to go sooner, or if he is unruly or unfit
for training, the local military commander may discharge him at
any time. 11

Since at the time the law was passed there were a great many
cripples in Italy already discharged from the army without any op-
portunity for reeducation, the law provides that these men also may
be accepted at the schools on application. In that case they must
submit to the discipline of the school although they are discharged.
Their expenses are borne by the national board instead of the war
department.

As soon as a man has entered the school his trade is decided upon.
The decision is made by a committee consisting of the head physi-
cian and the director of the school, an inspector from the department
of industry and labor, or a person delegated by the national board,
due consideration being given to the wishes of the cripple and to
the representative of the war cripples attached to the staff. The same
committee decides on the man's dismissal from the school when his
training is complete. On his dismissal the national board and the
local military authority must be notified. 12

If a man leaves the school furnished with a certificate that he has
satisfactorily completed his reeducation, the national board may give
him a money prize. Certificates are to be given only to those men
who have done conscientious work and who have become really able
to support themselves. 18

' Bollettino della Federazlone Nazionale del Comltati di Assistenza ai Soldati Ciechl,
Mutilati, Storpi. Rome, 1917, ii, 69.

10 Bollettino della Federazlone Nazionale del Comltati di Assistenza ai Soldati Ciechl,
Mutilati, Storpi. Rome, 1917, ii, 210.

11 Bollettino della Federazlone Nazionale del Comltati di Assistenza at Soldati Ciechl,
Mutilati, Storpi. Rome, 1917, ii, 205-206.

u Bollettino della Federazlone Nazionale del Comltati di Assistenza ai Soldati Clechi,
Mutilati, Storpi. Rome, 1917, ii, 204.

11 Bollettino della Federazlone Nazionale del Comltati di Assistenza ai Soldati Ciechl,
Mutilati, Storpi. Rome, 1917, ii, 207.



EVOLUTION OF SYSTEMS OF VOCATIONAL BEEDUCATION. 115
Artificial Limbs.

The men come to the school furnished with temporary prostheses
from the orthopedic center. During their training, if the school
thinks advisable any special working prosthesis, it must supply it
at its own expense. Before the men leave they are fitted with per-
manent prostheses which are ordered by the school on models ap-
proved by the war department. No work prostheses are supplied,
but only so-called aesthetic limbs. Permanent work prostheses must
be given by the school at its own expense. The limbs may be made
either by the factory attached to the school or by firms authorized
by the war department. Such limbs must be inspected by a com-
mission appointed by the minister of war and including a representa-
tive of the national board. The limbs must be adjusted at the re-
education school, which is the only agency authorized for this pur-
pose and which must instruct the men in their use and care as part
of its duty.

All repairs to the limbs are paid for, not by the war department,
but by the national board. It is not obliged to pay for repairs
caused by a man's own carelessness, and must have inspectors to
see that the men make good use of their prostheses.

This triple division of the duty of furnishing prostheses has been
much criticized by opponents of the law. By it the government
pays for temporary and permanent limbs, but only aesthetic ones, the
schpols pay for working prostheses, and the national board for re-
pairs. It is felt that, besides the complexity of the arrangement, this
means ineificiency and injustice. The aesthetic limbs are both ex-
pensive and nearly useless, so that in giving only these the govern-
ment has not done its real duty. Members of the federation feel
that for the price the war department now pays for an aesthetic
limb it could provide a really good working prosthesis with attach-
able hand or foot, such as is used in Germany, and thus relieve the
schools of an unjust obligation. The main idea in having the
national board pay for repairs was that these will be necessary for
many years after the close of the war and will be no longer, neces-
sarily, a war department duty.

Responsibility After Discharge.

After men are discharged from the schools and from the army
the national board is expected to provide as well as possible for their
future. For those who need further medical care because of relapse
or developing illness it provides in convalescent homes at which
it pays for their treatment. For those who have no families to
return to and yet need a certain amount of care it pays for board
in private families, which must render a regular account to the



116 EVOLUTION OF SYSTEMS OP VOCATIONAL REEDUCATION.

board. 14 For all men capable of earning their own living it is sup-
posed to find positions. This last is, of course, a relative matter. The
law merely states that the board must make every effort to place
such men and that all public officials, civil service, mines, and rail-
ways must render every possible assistance. Public employment
bureaus subsidized by the State and also provincial and communal
employment bureaus are to attend to the placement of war cripples
without charge.

All employees in civil service or in charitable institutions who have
become war cripples have a right to reinstatement if pronounced
physically able to do the work. There is published also a list of
civil-service positions which will be reserved for war cripples. Men
applying for them must have a physician's word that they are able
to do the work, and among such men the most eligible will be chosen.
In competitive examinations for civil-service positions, other things
being equal, war cripples will be given precedence. 15

Private firms are obliged to reinstate their employees crippled in
the war if the employees can pass a medical examination proving
their fitness for the particular work. The medical examination and
the necessary certificate is to be furnished by the national board,
which also arbitrates between the cripple and the employer in case the
latter refuses reinstatement without reason. 16

OTHER PROVISIONS.

The national board looks after the interests of cripples in the set-
tling of pensions and in any legal difficulties in which they may be-
come involved and acts as guardian to any who are of unsound mind.

Loans for buying land or establishing themselves in business are
made to soldiers on security of pensions.

Accident insurance companies are obliged to insure war cripples
on the same terms as any other workmen. They are not allowed to
charge a higher premium to stores or factories where war cripples
are employed unless the number of these passes a certain proportion.
If there is a particularly large number of war cripples in any estab-
lishment, a slightly higher premium may be agreed upon with the
minister of industry and labor. 17

Pensions are not in any way to be affected by either reeducation or
employment of war cripples.

» Bollettlno della Peaerazlone Nazlonale del Comitatl di Assistenza al Soldatl Ciechi,
Mutilati, Storpi. Rome, 1917, ii, 206.

M Bollettino della Federazione Nazlonale del Comitatl dl Assistenza al Soldatl Ciechi,
Mutilati, Storpi. Rome, 1917, ii, 68.

"Bollettino deila Federazione Nazlonale del Comitatl di Assistenza al Soldatl Ciechi,
Mutilati, Storpi. Rome, 1917, ii, 208.

"Bollettino della Federazione Nazlonale del Comitatl di Assistenza ai Soldatl Ciechi,
Mutilati, Storpi. Rome, 1917, ii, 209.



EVOLUTION OP SYSTEMS OF VOCATIONAL REEDUCATION. 117

The Government promises, with the aid of the ministers of war
and of the navy, to provide as soon as possible for a census of all the
war cripples in the country, discharged or still in service.

This law makes the general basis for the care of war cripples fairly
definite. There is, of course, much criticism on the ground that it
was framed and passed by politicians and not by experts; that its
provisions will be immensely slow in coming into operation ; and that
it promises a number of things which can not be carried out. The
bureaucratic nature of the board, the lack of accommodation among
the schools to whom so much responsibility is given, the illogical divi-
sion of responsibility for artificial limbs, are the principal ones. In
relation to the promised census it is also stated that unless it is taken
by people with social training it will be purely medical and official
and will give little basis for planning the after life of the cripples.
The provisions of the law are still being discussed and amplifications
suggested.

MEDICAL TREATMENT AND ARTIFICIAL LIMBS.

It will be seen that the general relation of medical treatment to
trade training in Italy is that first followed in France and still in
England, where training follows treatment, rather than that of
Germany, where the two are simultaneous. Though the two proc-
esses are separate, the agencies responsible for them are not, the
national board and the war department being both concerned in both
processes. Since the successive processes of rehabilitation are the
same in all countries, we may take up the work being done in Italy
in the usual order, i. e., medical treatment and functional reeduca-
tion, provision of artificial limbs, trade training, and placement.

Italy is still incompletely equipped with orthopedic hospitals.
There are only nine military orthopedic centers in the country, the
reserve hospitals at Turin, Milan, Genoa, Verona, Bologna, Florence,
Eome, Naples, and Palermo. Most of these are excellent, particu-
larly the hospital at Milan, furnished with all modern devices, the
Istituto Eizzoli at Bologna, and the Clinica Eummo at Naples. The
Eed Cross has also equipped an excellent orthopedic hospital, the
Istituto Eomiti at Spezia, and others are being gradually supplied
by the volunteer committees.

The interest in scientific care for cripples is very keen. Though
the subject was not much studied before the war, specialists are doing
remarkable work on it now. Italy has followed France in her in-
terest in scientific apparatus for measuring muscular capacity. Most
of the hospitals are furnished with Prof. Amar's machines for this
purpose. There is also much use of mecano-therapeutic apparatus
for reeducation of the stump and much study as to its best treatment.
A great deal of this appears still to be theoretical.



118 EVOLUTION OF SYSTEMS OF VOCATIONAL REEDUCATION".

Most of the technical journals are just beginning to discuss the
value of outdoor exercise and games in functional reeducation, a
factor which plays such a large part in German therapeutics. This
is being tried at Bologna with great success. 18

The criticism made by experts in the cripple field is that so far
much too much money has been spent on elaborate mechanical aids
and the simple factors of easy work and outdoor play have been
neglected. 19 Since functional reeducation is such a new subject, it
is also stated that at the beginning of the war many men were sent
home without any attempt at it, and, therefore, suffered from un-
necessary stiffness and from ignorant use of prostheses. 20

Artificial Limbs.

The whole problem of artificial limbs, like that of functional re-
education, is only beginning to be dealt with in Italy. Before the
war such limbs were obtained from Germany and there were almost
no facilities for manufacture at home. At the beginning of the
war there was great hardship because of the difficulty of obtaining
any artificial limbs at all for many of the cripples. Such as could be
had were of an ancient type with none of the modern improvements. 21

Soon after Italy's entrance into the war there was formed at. Milan
a committee to establish a national factory for prostheses. The com-
mittee received the support of the army medical authorities and of
the minister of war and had capital contributed from all parts of
the country. A representative was sent to England and France to
study the best forms of prostheses. The factory was then started
under a committee of experts, its object being to manufacture artifi-
cial limbs and sell them to the Government at cost and to study and
perfect their manufacture. 22

Since even this national factory can not supply all the limbs for
the whole country, various other shops have sprung up. Reeduca-
tion schools are all obliged by law to have a shop for repairs and
many of them manufacture all their own prostheses. There are also
private firms which furnish limbs on specifications from the war
department. The criticism now made is that whereas at first men
had to wait unduly long for their prostheses these are now furnished
so soon that the stump has not time to heal properly.



18 Bollettino della Federazione Nazionale del Comitati di Assistenza al Soldati Ciechi,
MutilatI, Storpi. Rome, 1917, 11, 132.

"Bollettino della Federazione Nazionale del Comitati di Asslstenza ai Soldati Ciechi,
Mutilati, Storpi. Home, 1917, 11, 112.

■ Bollettino della Federazione Nazionale del Comitati dl Asslstenza ai Soldati Ciechi,
Mutilati, Storpi. Rome, 1917, ii, 36-37.

21 Comitato Lombardo per 1 Soldati Mutilati in Guerra. Milano e la Lombardia per 1
soldati mutilati in guerra. Eelazione. . . . Milan, Mar., 1917, 37-38.

"Comitato Lombardo per 1 Soldati Mutilati in Guerra. Milano e la Lombardia per I
soldati mutilati In guerra. Eelazione. . . . Milan, Mar., 1917, 40.



EVOLUTION OF SYSTEMS OF VOCATIONAL REEDUCATION. 119

No standard type of limb has yet been decided upon, but the Gov-
ernment in March, 1917, appointed a commission to study the matter
and lay down rules. 23 This commission has not yet reported.

At present the types used are various. As mentioned above, the
Government agrees only to furnish aesthetic limbs which are gener-
ally of an old fashioned and useless type. There is much propa-
ganda among doctors and school directors as to the value of the
simple and inexpensive work prosthesis which is really more durable
and useful than the aesthetic limb. The new Italian inventions
advocated are all of this type.

1. Paoletti leg. — Made and used at the Florence school. This is
a jointed steel skeleton. The upper part consists of two horizontal
steel-wire rings a foot or so apart into the upper one of which the
stump fits. There is an aluminum sphere at the knee with an axis
connecting with the lower leg which consists of a steel rod replace-
able by a wooden aesthetic leg. 24

2. Zumaglini leg. — This is a simple wooden leg with a ball-and-
socket joint, fixable in extended position. A calf and foot can be
adjusted over it for dress purposes. 25

3. Putti leg (for transition stage). — This is also an artificial peg
leg, the wooden frame into which the stump fits being triangular
rather than round and adjustable to suit the size of the changing
stump. 26

4. Zumaglini foot. — A wooden foot in two pieces with a ball-and-
socket joint, upper and lower piece joined by upright steel band.
The wooden pieces move easily on one another when walking and
the foot can be bent in any direction, even laterally. 27

5. Hoeftman arm, (for upper arm amputations). — This is a long
leather cuff fitting over the stump and attached to a canvas harness
laced around the chest. At the end of the leather cuff is a flat Dlate
into which appliances or a dress arm may be screwed. 28

6. Zumaglini arm. — This is a steel claw fitted with a spring so that
it can be fixed in any position. It is to be attached to a flat plate



Online LibraryDouglas C. (Douglas Crawford) McMurtrieThe evolution of national systems of vocational reeducation for disabled soldiers and sailors → online text (page 13 of 38)