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CHAPTER I

INTRODUCTION

ON A HOT summer afternoon in 1863, a foreign representative to the United States, several members of the Cabinet, and the President of the United States are said to have been traversing one of the broad avenues of Washington. They were discussing matters of international importance. It was, therefore, somewhat surprising to the others when Abraham Lincoln abruptly interrupted the conversation and left the group. Stooping at a nearby tree, the emancipator lifted a fallen baby bird to its nest. Returning to his associates, Lincoln remarked, "And now, gentlemen, continue."-1-

-1- The author has searched unsuccessfully for the source of this anecdote. It is a story he heard as a young child, and is one which he has never forgotten. It is very appropriately illustrative of the spirit of the movement to aid crippled children.

Although one of the greatest leaders the world has ever known found time to give his attention to an unfortunate little bird, until the past century all humanity has carelessly and consistently neglected its own unfortunate crippled children. For centuries of the Christian Era men have declared, like Mr. Scrooge in Charles Dickens' immortal Christmas Carol, "What then, if he be like to die, he had better do it, and decrease the surplus population." Hundreds of millions of those declaring themselves followers of the Master who said, "Suffer little children to come unto me, for such is the kingdom of God," -2- and again, to the hunchback woman, "Woman, thou art loosed from thine infirmity,"-3- have made crippled children public jests, exiles from society.

-2- St. Mark, Chapter X, 14.

-3- St. Luke, Chapter XIII, 12.

The world has undoubtedly suffered greatly from this carelessness. Hundreds, who might otherwise have contributed to the beauty of civilization, or have led their fellow men to new accomplishments, have been deprived of their birthright. In the past, only the wealthy cripples have had any opportunity for education. And even they have been handicapped by lack of orthopedic knowledge on the part of the medical profession. It is commonly believed that Lord Byron had a clubfoot. As a matter of fact, the great poet might have lived to an advanced age and produced volumes of additional poetry, had he not received the attention of a "quack doctor." As a young boy, Byron was afflicted with "lameness due to a contraction of the tendon Achilles which compelled him to walk on the balls and toes of his feet. The foot (later) was considerably distorted so as to turn inward, a malformation which may have been caused altogether by the violence with which it was treated."-4- "The lad at Nottingham suffered much at the hands of a bone setter, Lavenden. . . . Blind to the nature of the case, the man did precisely as any other pretender of his kind would have done. . . . He rubbed the foot with oil, twisted it about with violence screwing and torturing bone and muscle into better behavior."-1- In the opinion of medical men, had Byron been given the proper care, his deformity might have been entirely cured. As walking was always painful for him because of his obesity, he continually dieted. The dieting reduced his resistance, which, had it been stronger, might have successfully combated the fever which carried him away on the battle fields of Greece at the age of thirty-six years. Thus was the world deprived of one great man through carelessness.

-4- John Cordy Jeaffreson, The Real Lord Byron, Vol. 1, London, 1833, p. 35.

-1- John Cordy Jeaffreson, The Real Lord Byron, p. 77.

The movement to care for and educate children, maimed or deformed by disease or accident, may be considered to have two aspects, the humanitarian and the sociological. This classification is recorded not because any such distinct cleavage exists, but to satisfy those who insist upon a mechanistic interpretation of life. Unless the "science" of sociology succeeds in making life more beautiful for its students, for the immediate spiritual happiness of the largest proportion of human beings, or for generations to come, it is an inexcusable waste of time. Were life really the dismal mechanical existence that some of our sociological scholars are pleased to interpret, it would seem that this information had best be transmitted to as few humans as possible. If life, properly understood, were truly nothing but a birth-to-death struggle, devoid of joy or pleasure, it would seem that the "laissez-faire" policy of those who interpret it in this manner had best be extended to education and study of the sort they pursue. The popular proverb, "ignorance is bliss" is easily extended to this sort of knowledge, for the ignorant might then grasp their few momentary transports of ecstasy without realizing their error.

As a matter of fact, no such situation exists. The study of crippled children brings to the right-minded man an appreciation of his own happy, healthy existence, a deeper understanding of the suffering and distress of his neighbors, leading to a deeper and finer emotional experience, as well as the knowledge of how to reduce and alleviate this suffering.

Edgar F. Allen, known to the world as "Daddy," President of the International Society for Crippled Children, is a man who can testify to these facts from personal experience. He says,

"In our work for crippled children we seek the sympathetic friendship of all who agree that human sympathy for human suffering is the motive spirit of civilization. The accomplishment of this object, this hope, and this aim is our desire, and we trust that the future will make it a reality in thousands of lives and hearts."-2-

-2- From an address entitled Our Vision.

The humanitarian aspect of this movement, then, is as truly sociological as are the "scientific" facts which demonstrate conclusively the extent to which the number of social dependents is reduced. The vision of hundreds of thousands of men and women devoting their time and energy to the purpose of bringing happiness to the 350,000 or more crippled children of this continent, is indeed a hopeful sign for humanity and civilization. Progress may not be demonstrable in vital statistics, but the socializing of the most noble of human emotions, the parental instinct, and its extension to the care of infants and adolescents, utterly or partially helpless through no fault of their own, is an evidence of a forward trend of no small significance.

It cannot be denied that charities frequently fail to strike at the heart of a social evil. To a certain extent this is true of the work under discussion. If living conditions among the poor were improved, many children would have better resistance to diseases of any sort. Education might eliminate much of the carelessness that results in allowing an orthopedic disease to run too far for permanent cure. Much could be done to avoid traumatic (accidental) disabilities. A better quality of milk would reduce to a minimum the number of children afflicted with "surgical"tuberculosis. In recent years, much has been done and much has been planned to reduce these causative evils.

The fact remains, however, that we have with us, and will probably always have with us, a number of crippled children. In 1916, twenty-seven thousand persons were afflicted in an epidemic of infantile paralysis-1- (poliomyelitis). Eighty per cent of this number were under five years of age. Through the efforts of agencies to care for crippled children, a majority of these children have been saved from permanent disability. A century ago this same catastrophe would have added twenty thousand new names to the list of the nation's dependent cripples.

-1- Edna L. Foley, Home Nursing Care of Infantile Paralysis. The Nation's Health, Vol. V, No. 8, p. 503. August 15, 1923. A conservative estimate of 15,000 was suggested by Miss Helen Hare in A Study of Handicapped Children, June, 1919. Indiana University Studies, Vol. VI, No. 41.

Those who are turning their efforts toward aiding crippled children have not forgotten the wisdom of emphasizing prevention. The International Society for Crippled Children strongly advocates and subscribes to any program which will decrease the danger of bacterial infection from milk, or improve living conditions to avoid epidemics. Special orthopedic institutions and organizations are foremost in urging education to decrease those social relationships which may result in congenital deformities. All of these groups, however, recognize that for this problem, at least, the colloquialism "better late than never" is essentially true. Curative and educational measures justify themselves, if only to avoid unnecessary economic waste.

With the objections outlined above, are frequently correlated questions as to whether special care and special education for crippled children are not wrong in that they result in institutionalizing the patients. Frequently this objection is well founded. There are still homes and hospitals devoid of most of those kindly features with which modern institutions aim to cheer their patients. There are still superintendents who dress the little ones in uniform and inflict that disagreeable type of discipline which results in sullen obedience. The author has been informed that uniform dress is less expensive than variety. What false economy!

But it should be borne in mind at this point that the problem of the crippled is very different from that of the normal child. Unlike the latter, the crippled or deformed youngster is a lonely creature, unable to join in the sports of other children, and constantly reminded of his disability. This frequently develops an abnormal psychology, a moroseness, self-consciousness, so affecting his point of view as to add to an unfortunate physique a mental peculiarity. Most of us, reading Byron's poetry, will distinguish from page to page, the effects of his mother's insult, "You lame brat."-1-

-1- Byron is said to have replied: "I was born so, mother." See his drama The Deformed Transformed, Part 1, se. 1.

A modern, properly conducted orthopedic school, convalescent home, hospital, or sanatorium will never result in "institutionalizing" its patients. On the contrary, the child is furnished with companions of his own age, similarly handicapped, able to develop with him games and sports in which a crippled child can participate. Thus during those formative years of his life, rarely reminded of his disability, the child develops a healthy, normal psychology.

The greatest advantage of special care lies in the fact that trained nurses and skilled orthopedic doctors are constantly at hand to reduce the child's handicap to a minimum, and possibly, in course of time, to cure it. Braces, frames, and casts must be properly adjusted to achieve their full effect, and too often the parent at home destroys their value through lack of skill. More will be said on this subject in a later section.

This movement has a tremendous economic value. Thousands of men and women who otherwise, through no fault of their own, would become social dependents are being transformed into useful and constructive citizens of the community. As will be shown later, a majority of the institutions are teaching occupational therapy, and assisting their graduates with vocational guidance. It has been found that, except for those patients suffering from congenital disease, the intelligence of the crippled child is at least average. Some authorities maintain that it is above average, and it is certainly true that the handicapped youth, under proper guidance, will be particularly anxious to overcome his disability by greater excellence of mental accomplishment.-1-

-1- "Physical inferiority creates a mind on the defensive and desiring to attain success by other means than that which a poor physique renders impossible." Alexander Horwitz, M. D., The Cripple's Place in Society, Thru the Ages. The Nation's Health, Vol. V, No. 8, p. 511.

There are six divisions of action which complete this movement. The first is to decrease, as far as possible, those causative influences and environmental conditions which are favorable to the creation of crippled children; the second, to locate and bring to the clinic or dispensary crippled children whom neighbors and ignorant or destitute parents are neglecting; and the third, to distribute these children, making surgical operation and acute hospital care available for those who are in need of treatment, and convalescent care available for those whose general physical condition should be improved preliminary to operation, or whom proper conditions of environment and treatment during an extended period of time will improve or cure.

The fourth step in this work is to insure crippled children the general and fundamental education which physical handicaps have for so long made impossible. In addition, they should be given the benefits of occupational therapy, vocational training, and vocational guidance and assistance. Fifth, it should be ascertained definitely that children leaving special institutions do not return to the unfortunate environmental conditions in which their affliction originally developed. Last, it should be the duty of every interested individual to arouse public sentiment which will support legislation and make available funds to make possible the fulfillment of the five steps named above. Public co-operation should accompany all of this social machinery, and in addition there must be the all-important personal contact with the unfortunate little ones. The latter is a blessing to all those who participate, and is the most natural curative and cheering influence which can be afforded to the patients.

In the course of this book we shall first step back and examine those darker ages when physical imperfection was a horrible stigma. We shall examine in a cursory manner those physical conditions which cause children to be handicapped. We shall then follow the little cripple as he is carried to the modem clinic, subjected to modern miracles of surgery, brought to the cheerful convalescent home, where he perhaps stands erect for the first time in his life, and where he is brought from the darkness of ignorance and introduced to the delights of education; and we shall finally gaze upon him and his fellows as they step forth into life and find themselves fully able to cope with their problems as if they had never been prostrate.

CHAPTER II.

HISTORY

There was a great holiday in Babylon. Well might the Babylonians rejoice, for had not their valiant warriors conquered those Israelite dogs, those worshipers of the hated Jehovah! The great Nebuchadnezzar rose from his throne and, crossing the spacious imperial chamber, stepped upon the balcony, that he might gaze upon the returning hosts. From the narrow street below, shone the lately burnished spears of his victorious soldiers. Column after column marched past their royal master, driving before them their reluctant Hebrew prisoners. Men, women, and children, thousands of new slaves to build the empire to new grandeur. Then came a group which caused Nebuchadnezzar to glare with anger, and shudder with fear. These crippled children, what demons had his soldiers brought with them!

"Bring me the prisoners," he said, "that I may pick my slaves from among them. But bring me 'children in whom there is no blemish.'"-1-

-1- See Daniel I, 4.

The Babylonians were not alone in their fear of cripples. Today we know that a child is crippled because disease has checked the natural development of a part of his physical organism, or because he has been maimed by some unnatural environmental condition. But organic evolution did not enter the popular consciousness until Darwin's Origin of Species and Descent of Man had extended the theory to animal and human life. Today the sociologist defines the cripple as "a person whose (muscular) movements are so far restricted by accident or disease as to affect his capacity for self support,"-2- but for generations the cripple has suffered from popular superstition resulting in fear and contempt.

-2- Formulated by the Education Committee of Birmingham, England, whose subcommittee of inquiry took a complete census of cripples in Birmingham, 1911. Accepted by most organizations as a standard definition.

Dr. Horwitz, assistant professor in the Orthopedic Surgery Department of St. Louis University, in an article entitled The Cripple's Place in Society Through the Ages, published in The Nation's Health of August, 1923, called attention to the fact that the word "cripple" is derived from the Anglo-Saxon word "creep." The word "dwarf," he points out, is closely akin to the Sanskrit word "dhvaras" meaning "evil one incarnate." The psychology behind this evolution of diction is obvious. The doctor lists four causes for the traditional dislike of the physically handicapped:

1. A dislike of the imperfect, as among the Hebrews.

2. The knowledge that the cripple would be a burden upon the community, and be a poor soldier.

3. The thought that an imperfect body necessarily harbors an imperfect mind.

4. The fear of an evil spirit.

Convinced that the cripple embodied an evil spirit, of ill omen to the community; that he would never be an asset to their armies; and that he was apt to become a social burden, our fore-fathers ostracized him, sacrificed him to their Gods, or abandoned him in his infancy. We note the following passage among the laws governing the Levite priests, an early record of the fear and ostracism with which cripples were confronted among the Hebrews; "Whosoever he be in their generations that hath any blemish, let him not approach to offer the bread of his God. For whosoever man he be that hath a blemish, he shall not approach: a blind man, or a lame, or he that hath a flat nose, or any thing superfluous, or a man that is brokenfooted or brokenhanded or crookbackt, or a dwarf, or hath a blemish in his eye, or be scurvy, or scabbed,. . .he shall eat of the bread of his God. . .Only he shall not go in unto the vail, nor come nigh unto the altar, because he has a blemish."-1-

-1- Leviticus, XXI, 17-23.

The Spartans exposed their unfortunate children in infancy. Roman law allowed the paterfamilias to destroy his children, but did not require any uniform procedure. The Romans made the first recorded provision to care for cripples. Pope Gregory, in 590 A. D., included them in his classification of infirm and destitute to be supported by public funds.-2-

-2- H. Hare. A Study of Handicapped Children, p.5. (Ind. Univ. Studies.) Also H. K. Mann. The Lives of the Popes in the Early Middle Ages. Vol. I, (590 A. D.-657 A. D.), pp.194-195.

During the Middle Ages, two famous men who overcame their disabilities were "Hermann, the Cripple," a German who died in 1054, and a French poet, Paul Scarron, who died in 1660. The first of these was entirely paralyzed, and found it almost impossible to speak. His greatest achievement was the production of a history of the German people during the tenth and eleventh centuries, entitled A Chronicle of the Six Ages of the World.-3-

-3- Children's Hospital Journal, Huntington, W. Va., Nov., 1923, p.4.

As a rule, however, medieval cripples, and particularly crippled children, were cruelly exploited for purposes of amusement. The contemporary lack of a sense of social responsibility toward the handicapped has resulted in the survival of very little literature specifically demonstrating this situation, but much has come down to us in the fiction and drama. The courts of Europe were constantly entertained by deformed jesters and fools, and, in Italy, Roman beggars made slaves of crippled children to exhibit their deformities on the public roadways and gain the sympathies of pedestrians. Frequently these men would actually maim children, or increase their infirmity, that the appeal to sympathy might be more effective, and the profits resultantly greater.-4-

-4- H. Hare. A Study of Handicapped Children, p. 6.

Among the famous cripples of literature, the Hunchback of Notre Dame is a well known figure. According to Victor Hugo, the Hunchback was found by the Bishop of Notre Dame in the square outside of Notre Dame Cathedral in the year 1466, the child being then four years old. "Upon this bed it was customary to expose foundlings of public charity."-1- The author quotes the conversation of those who observed the deformed baby.-2-

-1- Victor Hugo. Notre Dame de Paris, 1831. Translated by A. Alger, 1888, p. 217.

-2- Victor Hugo. Ibid, pp. 213-14.

"It sees with but one eye; there is a wart over the other."

"What do you predict from this pretended foundling?"

"I think it would be better for the people of Paris if this sorcerer were laid on a fagot."

"A fine flaming fagot."

In Verdi's Rigoletto, the scene of which is Mantua, in the sixteenth century, we have a picture of the typical deformed court jester, the tool of his master, and the object of public jest. -3- Although orthopedic surgery did not always exist, in every age there have been healers who have effected cures with neurotic individuals through the exertion of psychological influence. Montaigne, in an essay entitled Cripples, mentions "a certain priest, who by words and gestures cured all sorts of diseases." He continues: "Riding the other day through a village about two leagues from my house, I found the place yet hot with the rumor of a miracle lately wrought there." -4-

-3- Richard Aldrich. Verdi: Rigoletto. Essay on the Story. New York, 1902.

-4- Michel de Montaigne. Essays, Vol. III. 1588. Translated by Cotton, London, 1811.

The essay, published in 1588, does not so much as suggest humanitarian kindness toward the deformed. In the sixteenth century, Luther advised that a rachitic baby be thrown into the river.-5-

-5- H. Hare. A Study of Handicapped Children, p.6.

After a "moral holiday" of six centuries, the initial law providing for some care of cripples was passed in England during the reign of Queen Elizabeth (1601). The first Poor Relief Act included cripples among those offered asylum care. It was not until two hundred and thirty years later that an institution exclusively for the care of crippled children was at last founded. "The Royal Bavarian School and Home for Crippled Children," a convalescent home, was opened in Munich by Johan Nepimak in 1832. This institution was taken over by the Bavarian authorities in 1844, and has since been operated by the state. From this beginning, the movement spread throughout Germany, France, England, Switzerland, and Italy, in the order named. In 1872 the first effort toward the industrial education of crippled children was instituted by Pastor Hans Knudson, who founded an industrial school in Copenhagen, Denmark.

In the United States, the Hospital for the Ruptured and Crippled was opened in New York City in 1863. Three years later the New York Orthopedic Hospital and Dispensary entered upon the same work. In Philadelphia, the Home of the Merciful Saviour, established in 1884, was the first American Home to care for crippled children. The pioneer school for crippled children was the Industrial School for Crippled and Deformed Children, established in 1893, for the purpose of making Boston cripples self-supporting.

Although the movement had made considerable progress, the infantile paralysis epidemic of 1916 demonstrated clearly that facilities were as yet entirely inadequate. During the past eight years, nation-wide efforts of various fraternal and social organizations have increased greatly the number of convalescent homes, state hospitals, clinics and sanatoria. Writing in 1912, Mr. Douglas C. McMurtrie, for many years the leader in rehabilitation of cripples, remarked: "From a national stand-point, however, the situation is most unsatisfactory, all institutions being grouped around four or five cities. The gravest defect is that immense sections, notably in the West and South, are without any provision whatever."-1-

-1- The Care of Crippled Children in the United States.

While there are still vast sections of this country in which there is little or no provision for the care and education of crippled children, twelve years have brought an extensive development in this work, and a significant improvement in the situation. In the course of this volume we shall see how the Shrine, hundreds of Rotary, Kiwanis, Elks, and other clubs became interested. In the more densely populated states adequate facilities are rapidly being developed; and the widespread interest in the movement promises well for future development in less populous areas.

CHAPTER III

HOW CHILDREN BECOME CRIPPLED

Medieval folk-lore informs us that two itinerant knights once chanced to meet at a crossroad. Suspended from a tree at the intersection, a splendid shield marked the domain of a third knight, a noble who was famous for deeds of valor. The travelers exchanged friendly greetings and introduced themselves. In the course of time the conversation turned to a discussion of the owner of the great shield above them.

"I like the effect of the white design on a black background," exclaimed the first knight.

"I beg your pardon," said his companion, "but it is black on a white background."

"Sir, you contradict me! A black background, I say."

"White!"

"Black!"

Therewith the knights drew their swords, each to punish the other for his impertinence. After a frightful duel, one was about to wound mortally his vanquished companion when a gust of wind reversed the great shield and showed it to be of opposite color combinations, one side being black on white and the other white on black.

"Truth," says William James, "is always 'in so far forth.'" It depends on the position of the observer. So, in the question of how children become crippled, we find two positions: that of the sociologist, who emphasizes fundamental environmental conditions, and that of the physician, who presents the immediate clinical diagnosis. We further ascertain that among the physicians there is a wide diversity of opinion as to what constitutes the most frequent crippling cause.

In this chapter, it is our aim to examine those immediate physical conditions which cause children to be physically handicapped. We do not pretend to interpret these phenomena from a medical point of view; but it is necessary for the sociological scholar of this philanthropic movement to have some slight acquaintance with the major types of crippling diseases and their comparative frequency. This, too, must be "in so far forth."

The primary point of controversy relative to the comparative frequency of causative diseases involves a definition of what shall be called a crippled child, as distinguished from other classes of handicapped children. Some authorities include cardiac and pulmonary tuberculous patients in this classification; others would extend it to those children deficient in sight or hearing. For our purposes, it will be best to define a crippled child as "one, who by reason of congenital or acquired defects of development, disease, or trauma, is deficient in the use of its body or limbs."-1- There are literally hundreds of other definitions which might be adopted; but this emphasis on the actual deficiency of function creates a group sufficiently limited and distinct in its needs to constitute a separate field of study.

-1- Definition by Miss Mabel Smith, of the Ohio Department of Welfare, presented at a meeting of the Ohio Society for Crippled Children, June 15, 1921.

Miss Reeves divides crippled children into two classes, "the maimed and the diseased,"-1- admittedly "the broadest" possible classification. It would seem to exclude the rachitic children who probably suffer from a deficiency of certain chemical materials, rather than from an active disease or resultant handicap and those children who become partially crippled as a result of poor posture or improper clothing. Among one hundred and ninety-seven school children recently examined in New York City, the following potential deformities were tabulated: -2-

-1- Care and Education of the Crippled Children of the United Stales, p. 20.

-2- Foot Defectiveness Among School Children, Public Health Report. Volume XXVI, No. 44 April 11, 1921.

A satisfactory classification would seem to be implied in Miss Smith's definition, quoted on the previous page. The diseased include the victims of "surgical" tuberculosis and several less frequent active conditions. There is a group of congenitally crippled children; a group of traumatically crippled children; and a group of those suffering from acquired defects of development (the post infantile paralysis cases, the rachitic cases, and those environmentally crippled children referred to above.)

Having arrived at a classification of these causative conditions, we are faced with the problem of deciding which of them is most frequent, and what are the relative frequencies of the others. Three surveys have presented widely varying conclusions: one in Birmingham, England, in 1911; one in Cleveland, Ohio, in 1916; and one in New York City, in 1920. The Bureau of Information of the International Society for Crippled Children recently conducted a survey of the percentage findings of the various institutions of the country. These, too, varied widely. "It depends on the position of the observer."

The three censuses referred to above presented the following results, respectively:

These figures suggest several possible interpretations. The efforts of anti-tuberculosis agencies have undoubtedly reduced the frequency of this disease in all forms during the past thirteen years. At the time of the Birmingham survey, the "dread plague," as it affected bones and joints, was generally considered the primary crippling cause. Another reason for the increase of infantile paralysis cases demonstrated above is the greater facility with which poliomyelitis is now diagnosed. A third cause for this discrepancy in the above statistics is the tremendous increase in the number of sanatoria and convalescent homes in which tuberculosis cases are cared for, resulting in a decrease in number of cases revealed in surveys of this type. Since 1904 the number of sanatorium beds in the United States increased from 8,000 to over 66,000 in 1923, or more than eight times the original number.-1- Another interpretation which will explain some of the variation in these censuses is the fact that Cleveland did not include rachitis, bringing the poliomyelitic and tuberculous percentages proportionately higher than New York City which did include this condition. A fifth explanation presented in the Wright Report of the New York City Survey suggests that the Birmingham survey was conducted in a manner not apt to locate readily all of the rachitic cases.-2- If these should have been higher, the tuberculosis percentage again would have been proportionately lower.

-1- Tuberculous Directory, National Tuberculosis Assoc., 1923.

-2- Henry C. Wright. Survey of Cripples in New York City, 1920.

Eighteen orthopedic hospitals reported in the International Society Survey of 1924. Nine of them replied with estimated percentages. These were applied to their total capacities, with the following results:

Nine other hospitals reported quantities in a group of 5,171 children, as follows:

Fifteen convalescent homes reported the following percentage findings on an average total capacity group of 923 children:

For the entire group of 6,507 children representing thirty-three institutions in seventeen states, the following percentages were tabulated:

One other source of information is presented in the form of an Ohio Department of Health Report on 1,125 clinical orthopedic diagnoses. The most frequent orthopedic diseases presented are the following:

The primary conclusion to be drawn from these figures is that infantile paralysis now probably causes the crippled condition of more children than does any other disease. The only group which fails to demonstrate this fact is that of the convalescent institutions, probably because the reduction of surgical interference in bone and joint tuberculosis has filled these institutions with this class of patients requiring heliotherapy treatment and general convalescent care. Although it may be safe to approximate the proportion of poliomyelitis at about one-third, the exact group division depends on the location, on the specific interest of the attending orthopedists, and on the time of investigation. Infantile paralysis is an epidemic disease, and new groups of after-care patients appear periodically.

It is probably safe to conclude that "surgical" (bone and joint) tuberculosis is second in frequency among these diseases.

Somewhat lower than infantile paralysis, the percentage of this cause is probably considerably higher than is indicated in the several reports here presented. There is always a large number of crippled tuberculous patients under care in the general and special sanatoria of the country. In thirty-one general sanatoria reporting in the International Survey, approximately 6.5 % of the entire group of adult and juvenile beds represented were then devoted to children crippled by "surgical" forms of tuberculosis.-1- There are approximately 150 special tuberculosis institutions in this country which admit this type of patient. Furthermore, with the exception of one or two small infantile paralysis homes, the sanatorium is the only special institution exclusively devoted to a specified crippling disease. A number of such institutions are reserved for crippled children. Outstanding examples are the Seaside, a state institution at Niantic, Connecticut; the North American Sanitarium at Ventnor, New Jersey; and the Neponsit Beach Hospital, at Rockaway Beach, New York.

-1- 304 in a group of 3,139 general sanatorium beds.

Judging from the entire group of statistics, congenital deformities would seem to be third in frequency, slightly over one-tenth; rachitic deformities fourth; and trauma fifth. The high percentage of rickets in New York City may be ascribed to the fact that this condition results from malnutrition, a common metropolitan phenomenon. Accepting this classification of causes, only peculiar local conditions can explain the variation in the Ohio report. It will probably be impossible ever to arrive at a permanent and specific tabulated classification of the frequency of various causative diseases among crippled children. The value of such a table would hardly justify the effort involved in acquiring the necessary statistics. But, as the needs involved in curing and preventing the several conditions vary according to the nature of the diseases, it is significant to know approximately in what order of frequency they may be found.

Social agencies and institutions should be prepared to satisfy the various needs presented by all of these causative conditions. The prevailing orthopedic sentiment against surgical interference in tuberculous cases makes necessary proper convalescent and heliotherapeutic facilities. Various types of therapy should be provided to restore the poliomyelitic patients to the use of their limbs. It is of primary importance that two groups should interest themselves in this problem: a non-professional group which will provide the resources to support these facilities, and a professional group which will operate them. In the next chapter we shall study the non-professional and professional social agencies.

CHAPTER IV.

SOCIAL AGENCIES

The glowing sun lay close to the horizon as hundreds of Memorial Day merry-makers crowded onto homeward bound trolley cars at Elyria, Ohio, May 31, 1907. Two of the latter had covered more than half of the distance from the baseball field to the central part of the town when the motorman of the second car turned his head to address a member of the throng packed into the space behind him. In a second his vehicle had crashed into the car ahead. Several hours later the Elyria Evening Telegram printed the following account of the accident:

"A disastrous collision between two sections of the regular six o'clock run on the Cleveland and Southwestern occurred tonight a few minutes before six o'clock, on Middle Avenue between Fourth and Fifth Streets. The second car was following the first section at a rapid rate of speed. With a deafening crash the cars came together, the rear one rising upon the other and forcing its way into the front one a little above the floor, catching the ill-fated passengers, crushing feet and limbs.. . .At the hospital, the scene beggared description. Crowded and poorly equipped for such an emergency, the victims were perforce strewn upon mattresses on the floor -- or anywhere they could be placed. Volunteer nurses tendered their willing, if inexpert, help. Homer Allen has a badly fractured arm and his feet are badly crushed."

On June 3d, appeared this item: "A large concourse gathered at the home of E. F. Allen on Third Street to attend the funeral services of his son, Homer, yesterday afternoon, at 3 o'clock."

Out of this tragedy, fourteen years later, was born the International Society for Crippled Children. To Edgar F. Allen, the wealthy father of the deceased young man, this horrible catastrophe seemed a divine intercession. He first saw the need of an adequate hospital in Elyria. And in 1908, The Elyria Memorial Hospital opened its doors. Slowly there came to him another vision. He began to realize that there were helpless little ones with no facilities for care or education. And so, in 1915, was erected a new building, adjacent to The Elyria Memorial Hospital. The Gates Hospital for Crippled Children had come into being. But "Daddy" Allen realized that this would not solve the problem of the crippled child. He saw that it was a responsibility of neighbors. He saw that other people must be interested. He spoke to nearby Rotary Clubs, and clinics were opened that the crippled children might be found and given the necessary attention. Each Rotarian was given the responsibility of following up two children.

The new movement spready -sic- rapidly. In 1919, interested Rotary Clubs organized the Ohio Society for Crippled Children. Two years later, New York Rotarians had followed the example of Ohio. And soon there was in existence the International Society, a group of such organizations engaged in this work.

To Mr. Allen goes the credit of finding a social vehicle for carrying the message of the crippled child. But "Daddy" had put into practice what predecessors had hoped for and attempted for years. As early as 1889 a group of Cleveland girls had organized the Sunbeam Circle, which eleven years later had established the first kindergarten for crippled children at Alta House. In 1900 was organized in New York City, the Association for the Aid of Crippled Children. In 1914, a New Haven group had organized the Crippled Children's Aid Society, Inc.

Thirteen years ago, one man assumed the task of calling the attention of his fellow citizens to the responsibility they were shirking. Mr. Douglas Crawford McMurtrie, at that time Director of the Red Cross Institute for Crippled and Disabled Men in New York City, was certainly the pioneer in the movement to awaken the American public to the problem that was facing it. In the great metropolis, the Association for the Aid of Crippled Children co-operated with the Board of Education in transporting children to and from school, and maintained eight nurses, who endeavored to improve home conditions. A limited number of convalescent homes and orthopedic hospitals was caring for a few of the handicapped, but existing agencies were isolated exceptions.

For a period of five years, Mr. McMurtrie published a prodigious amount of literature urging education and better facilities. He aroused sufficient interest so that in 1912, the Russell Sage Foundation employed Miss Edith Reeves to make a personal survey of thirty-seven existing institutions. Two years later she published the first comprehensive study of the subject ever written, the Care and Education of Crippled Children in the United States.

The infantile paralysis epidemic of 1916 lent a new impetus to the creation of organizations for the aid of cripples, and appropriation of time and money for this purpose by national fraternal and social organizations. During the years 1917-1919 all efforts turned to war work, and the post-war rehabilitation of crippled soldiers. But the great International organization was soon to take up its task.

Today six types of social agencies assume the task of aiding their unfortunate little neighbors. There is first the International Society, a group of state and provincial societies which aim to increase non-professional interest in the problem. The central office forms a clearing house for the exchange of information; and a guiding factor to direct the efforts of the state societies toward sponsoring efficient and expedient legislation and operating machinery. A second group is composed of the international social and fraternal societies whose member clubs are making themselves socially valuable by doing individual case work to aid local handicapped children or co-operating with existing agencies to locate the cases. Other such organizations have national programs for this type of work.

A third type of social agency is the national philanthropic organization, which finds the problem of the crippled child a necessary part of its charitable program. A fourth group is the official state or national governmental agencies, whose duty is to promote education throughout their territory, or increase general welfare. A fifth group, the local philanthropic organizations, undertakes to solve the problem in a particular community. In addition to all of these, there are the local groups which select the problem of the crippled child as the object of their energies for a limited period, or to dispose of certain charitably endowed funds.

The state societies of the International Society for Crippled Children are founded on the principle that there are three fundamental divisions of the work for crippled children, "the lacking of any one of which, as we see it, makes impossible the sum total. They are these:

"1. The Professional, which has to do with the hospitals, convalescent homes, orthopedists, the medical profession, the nurse, the Social Service worker and the schools.

"2. The Financial, whereby the price of the cure must be available, which, we believe, should be the duty of the state through legislation, either direct from the state treasury or from charging the cost back to the county from which the child comes. Ninety per cent of the children lack the price of cure.

"3.The Human. After the first two have been provided, there must be some organization, and we are thoroughly convinced that it should be a state organization which has a definite purpose and which has the interest of the crippled child at heart, adding the human touch in connection with the professional and financial, being an originating and policing agency, and seeing to it that the machinery set up should week by week, month by month, and year by year, function."-1-

-1- The Care, Cure and Education of the Crippled Child, a pamphlet published some years ago by the International Society for Crippled Children, p. 4.

Aiming to form the third of these elements, there are at the present time ten state societies, the Illinois, Ohio, Michigan, New York, Ontario, Pennsylvania, Kentucky, Tennessee, Virginia, and West Virginia organizations. Others are in the process of construction. Each of these groups has a president, one or more vice presidents, a secretary-treasurer, or separate officers for these positions, and in several states, "field" or executive secretaries who devote all of their time to surveying the field of action, inciting new enthusiasm, and ascertaining that the work is progressing.

The individual club members pay dues to their local organization, which are in turn sent to the state society headquarters. According to an Ohio estimate, the $4.00 per year Ohio dues are divided in the following manner:

$1.66 to office and executive secretary salaries.
.56 to office expense.
.66 to publicity.
.60 to traveling.
.50 to the International Society for Crippled Children.

The following state society program was outlined in an address by Dr. E. H. Marshall, one of the leaders in the Illinois movement:

1. Surveys of existing conditions in every county.

2. The establishment of as many orthopedic centers scattered throughout the state as may be practical.

3. The promotion of the establishment of special schools for crippled children through the aid of educational bodies.

4. The establishment of a central headquarters bureau, which should act as a clearing house for information and initiate and co-ordinate local movements.

5. To aid in the advancement of the science of orthopedics, the carrying on of necessary research, and the development of preventative measures; the improving of the science of hospital management and equipment pertaining to the care, cure and education of crippled children through affording means of exchange of information and ideas, and financial assistance wherever practical.

The central binding agency to which these state societies contribute is headed by Mr. Allen. It is "a voluntary organization, composed of State and Provincial Societies; individual, active, sustaining, associate, and life members; and public and private officials of organizations directly coming in contact with the care, cure, and education of crippled children, which was conceived in the mutual desire of its membership to promote the welfare of handicapped children. It is not a child-caring society but one which seeks to promote that public intelligence and perfected co-operation with all child-caring agencies which will insure to crippled children everywhere the best medical attention and education suited to their needs. Above all, the International Society aspires, through personal contact with the crippled children and their parents to bring into the lives of these handicapped children the sunshine of normal human relationships and a realization that physical handicaps need not bar the way to success nor prevent the enjoyment of a happy, useful life."-1-

-1- Definition, Purpose, Objective Plans of the International Society for Crippled Children, published by a Special Committee, and issued June, 1924.

In addition to the officers (president, vice-presidents, treasurer, secretary, and executive secretary), there is a Board of Directors, an Advisory Council of recognized authorities in the various phases of this work, and six committees, namely, the Education, Finance, Legislative, Professional, Publicity, and Public Relations groups. The first of these aims to sponsor and co-operate with provincial and state society educational programs, and national and international organizations which aim toward the development of adequate facilities for the education of the crippled child. The Finance Committee prepares an annual budget for presentation to the Executive Committee, ascertains that this money is thereafter available, and endeavors to raise an endowment fund to insure permanence in the work of the society. The Legislative Committee co-operates with the state societies in endeavoring to secure effective state legislation. On the Publicity Committee are the Director of the Bureau of Information, the Editor of The Crippled Child, a bi-monthly magazine published in the interests of the movement, and members in charge of Magazine, Rotary, Radio, Motion Picture, Educational, Professional, and Newspaper publicity. The Public Relations Committee achieves contact with other organizations, agencies, and institutions interested in this work.

Among international social organizations whose member clubs are doing local case work or co-operating with existing agencies, are Kiwanis Clubs, the Benevolent Protective Order of Elks, the Exchange Clubs, the King's Daughters, and the Lions Clubs. The Kiwanis Clubs, whose membership includes over 83,000 leading business and professional men in over 1,100 cities of the United States and Canada,-1- have adopted an official program to aid under-privileged children. A special committee on Service to the Under-Privileged Child submitted the following recommendations to the 1924 convention of the organization:

-1- Kiwanis Activities, Volume II, 1922-1923, p.1.

1. That a Committee on Service to the Under-privileged Child, a future citizen, be appointed annually by the District Governor of each Kiwanis District.

2. That a Committee on Service to the Under-privileged Child, a future citizen, be appointed annually by the president of each Kiwanis Club.

3. That a club should not start any line of service to the under-privileged child until thoroughly informed regarding it. It should get the necessary information by appointing a special committee to gather and present it in the form of a report. It should find out what is being done. It should get in touch with local, state, and national experts, social workers, college professors, health officers, and keep the matter before the attention of its members by special sessions and report.

At the Eighth Annual Convention of Kiwanis Clubs, held in Denver, Colorado, July 16-19, 1924, one hundred and forty-five clubs were reported interested in physically defective, or crippled, children. This work ranges from isolated case-work to the endowment of orthopedic wards, as was done at the Memorial Hospital, in Johnstown, Pa., or supporting a central orthopedic hospital, as sixty per cent of the Kiwanis Clubs in Indiana are reported to be doing.-1-

-1- 1. Annual Reports of Kiwanis Club Standing and Special Committees, Denver, June16, 1924.

Elks' work, although by no means confined to New Jersey, is outstandingly extensive and effective in that State. The New Jersey States Elks' Association appointed a Crippled Kiddies' Committee, which in turn recommended that the Exalted Ruler of every Lodge in the State appoint a similar group. Surveys were made in the various localities, and contacts were established with the various functional state departments. A medical advisory board supervised the clinical work, the State Department of Labor made available their entire medical and rehabilitation staff, equipment, facilities, and established clinics; the Department of Health offered the co-operation of Child Hygiene nurses for follow-up work; and educational facilities were provided by the Department of Education, under the state laws of 1921. In June, 1924, fifty New Jersey Elks' Crippled Kiddies Committees, aided by the Department of Health, were holding clinics, providing braces, casts, and other necessities, operating convalescent homes, sending children to hospitals for care and treatment, conducting outings, and doing similar valuable work.

Masons are another group of international scope aiding crippled children. The Nobles of the Imperial Shrine each pay an annual contribution of $2.00, which is being devoted to the erection of children's orthopedic hospitals throughout the United States. A Board of Trustees is now operating five institutions: the Shreveport, La.; Twin Cities (Minneapolis - St. Paul, Minnesota) ; San Francisco, California; Portland, Oregon; and St. Louis, Missouri, Shriners' Hospitals. In addition, there is the Mobile Unit, which holds clinics in the various Hawaiian Islands and sends the children to Honolulu hospitals, or gives them home treatment. Hospitals are under construction at Springfield, Mass., and Montreal, Canada. Sites have been chosen in Chicago, Illinois, and Philadelphia, Pennsylvania.

On May 1, 1924, in addition to 243 children which had been treated and dismissed by the Mobile Unit, 700 children had been received as patients in the various hospitals, and 500 had been dismissed, restored to normal condition or greatly improved.-2-

-2- Report of the Board of Trustees of the Shriners' Hospitals for Crippled Children, 1924.

In addition to the institutions operated by the central committee, the Nobles of the Hella Temple, Dallas, Texas, maintain an orthopedic hospital for children, the Korsair Temple, at Louisville, Kentucky, plans to open a convalescent home, the Al Chymia Temple in Memphis, Tennessee, has erected an addition to the Children's Hospital School, operated by the King's Daughters Circle; and the Scottish Rite Masons of Atlanta, Georgia, operate the Scottish Rite Hospital for Crippled Children. This was the first Masonic institution for crippled children in existence, opened in 1915, a new building having been erected two years later. The Masonic hospitals, all of which have waiting lists, are open to patients of any creed or race, and have become a very important factor in the treatment of crippled children throughout the country.

National organizations whose programs include aiding crippled children to various degrees, are the Russell Sage Foundation, the Rockefeller Foundation, the American Red Cross, local chapters of which are frequently doing active clinical work, the Salvation Army, the American Child Health Association, the American Orthopedic Association, the American Medical Association, the American Hospital Association, the National Education Association, the National Welfare Association, the Department of Health, Washington, D. C., the National Tuberculosis Association, the Boy Scouts of America, and the Rockefeller Institute of New York City.

The actual operative machinery which supports the care, cure, and education of crippled children is, in most states, in the hands of State Departments. The authority for their work will be studied in greater detail in the next chapter, but some account of their function is necessary in a discussion of social agencies.

In Ohio, the work of State Departments is probably better developed and wider in scope than anywhere else in this country. When a Rotary Club or other agency wishes to hold a clinic, a public health nurse is generally furnished by the State Department of Health to proceed with follow-up work, and sometimes to assist at the clinic. One of the interested parties submits the child to the judiciary in the person of a judge of the Juvenile Court, who in turn may commit the child into the temporary custody of the State Department of Welfare. If the latter accepts the child, arrangements are made for care and treatment, the cost of which is paid from a rotating fund, and charged back to the county from which the child was received. As soon as the child is in the convalescent stage, the State Department of Education provides instruction, either at the bedside or at home.

In other states, these departments function in this movement to varying degrees. State Boards of Control are frequently responsible for special institutions for crippled children. The judiciary is almost invariably responsible for commitment. Some states, less active in work to aid crippled children, merely make appropriations to Departments of Health, or Public Welfare, a portion of which is to be devoted to the care of indigent handicapped children of all types.

The Federal and State Rehabilitation Bureaus undertake the problem of placing cripples in suitable vocations at the end of their academic training. In Ohio, the Civilian Rehabilitation Service frequently receives direct co-operation from the teachers in the schools for crippled children, who ascertain to which vocation the pupils seem best fitted and make a report to the Director of the Service. The child is then frequently placed immediately upon graduation. -1-

-1- Under authority of an Act of Congress, H. B. 4438, and of State Legislation, April 29, 1921, in House Bill 218.

Local interested agencies vary in activity from providing complete clinical, educational, transportation, and convalescent facilities as does the Association for the Aid of Crippled Children, in New York City, to finding vocational opportunities. The Association in New York City, an organization with over three hundred members and many more contributors, on January 1, 1924, had 3,024 cases under observation. A special bus, owned by the Society, brings the children to schools, hospitals, or clinics. Sixteen home nurses, employed by the Association, during the year 1923 made 44,509 home, hospital, and dispensary visits. A number of children are sent annually to the summer convalescent home at Tarrytown, New York.

The Association for Crippled and Disabled, in Cleveland, Ohio, which in 1918 merged with the Sunbeam Association,-2- conducts an Orthopedic Center, at which is located a branch of the Civilian Rehabilitation Service, The Sunbeam Shop, a salesroom for products made by the clients of the organization, the Sunbeam Training School and Workroom, a Home Industries Department, a Physiotherapy Department, a brace shop, and the headquarters of the following committees: The Committee on the Welfare of Cripples in Institutions, the Social Service Department, the Committee on Co-operation with the Public Schools, the Cleveland Chapter of the American Physiotherapy Association, and the Orthopedic Council, which furnishes professional advice whenever needed.

-2- Formerly the Sunbeam Circle. Name changed in 1916.

An example of a local organization giving limited attention to the problem of the crippled child, is that of the Philadelphia North American. During the unusually hot summer of 1901, this paper opened a cottage on the beach at Atlantic City, New Jersey, for those children who ordinarily participated in its outings in Fairmont Park, but who were too weak to make the trip. A member of the editorial staff, feeling a keen sympathy for these little ones, held a party on his porch and charged for ice cream and lemonade. The proceeds were donated to the Outing Fund. The event was given some publicity, and soon "porch parties" became a city-wide fad. By the end of the summer, enough money had been received to open the North American Sanitarium in Ventnor, a suburb of Atlantic City. This institution eventually became an all-year-round "surgical" tuberculosis sanatorium for children, in which form it exists today.

An example of a temporarily interested organization is the James Whitcomb Riley Memorial Association. Wishing to commemorate the name of their great poet, the people of Indiana organized this corporation, which, in addition to receiving state aid, is raising funds by subscription to build a $2,000,000 children's hospital adjacent to the Robert W. Long Hospital, in Indianapolis. This institution will have a large orthopedic service.

Temporary organizations have at times been created to conduct surveys of cripples. Three of these surveys, the first held in Birmingham, England, in 1911; the second in Cleveland, Ohio, in 1916; and the third in New York City in 1919, have received international recognition. A fourth was undertaken by the Child Welfare Council of Toronto, Canada, in 1923. In addition to many lesser surveys, conducted more or less comprehensively by interested groups in smaller cities, an extensive investigation, which promises to be very significant to the entire movement, is now in progress in Chicago.

Except for a census of the maimed and crippled, completed in Massachusetts in 1905, the Birmingham survey was the first investigation of this type ever conducted. The Massachusetts census merely attempted to ascertain the number of handicapped, whereas the British investigation arrived at some definite conclusions regarding causative diseases, availability of facilities, and ratio of cripples to population. It was conducted by a special Subcommittee of Inquiry, working under the central Birmingham Education Committee, and was a model for the work conducted in Cleveland, five years later.

The Welfare Federation of Cleveland appointed a special Committee on Cripples, in 1915, to survey conditions in that city. The work was assisted financially by the Sunbeam Association, which also co-operated with active service. A house-to-house canvass, and visits to 150,000 families located 4,186 physically handicapped persons, of which 49 % had been disabled in chldhood.-1-

-1- Education and Occupations of Cripples, Juvenile and Adult. A Survey of All the Cripples of Cleveland, Ohio, in 1916, published in N.Y. City, 1918.

On April 4, 1919, as a result of the efforts of the New York Committee on After-Care of Infantile Paralysis Cases, representatives of forty-one organizations, associations, and hospitals, appointed a Special Committee on Survey of Cripples, which undertook to survey six typical districts of the city. It was found that full information could be acquired only by questioning domestic servants and janitors, in addition to the families in each home. Relatives were hesitant about disclosing the fact that one of their number was handicapped physically. This fact probably explains why so many local and less carefully conducted surveys show only a comparatively small number of cripples per thousand population.

Canvassers in this survey were instructed to make as little use of the word "cripple" as possible. They were to state the purpose of their visit in other terms, make sure that the family visited understood that they were giving no financial assistance, promise that all information was to be confidential, credit no information from children, avoid using children as interpreters if possible, make note if persons interviewed were of extremely low grade mentally, become familiar with charitable organizations in the district, in order to be able to consult these for further information, and fill out cards with the following information concerning each case: -1-

-1- Henry C. Wright, Survey of Cripples in New York City, N. Y., 1920. Printed and distributed by the New York Committee on After-Care of Infantile Paralysis Cases,

Name
Case Number
Sex
Age
Lives with
Time in U. S.
Address
Time in State.
Apartment
Birthplace of patient
Borough
Birthplace of father
Block
Birthplace of mother
Color
Married or single
Name of husband or wife
Nearest relatives (names and ages of children)
Name of last employer
Name of Physician (last date)
Name of hospital or clinic (last date)
Church (last date)
Transportation furnished by (walks, free bus, car line, etc.)
Help needed (why), or vice versa
General condition (good, fair, or infirm)
Education (common school, high school, special, school for cripple, home teaching.........private or public).
(Date began-Date ended)
Support before and after handicap.
Income per week (Family, family pension, or assistance of relatives.)
Name of relief institution, and dates.
Name of canvasser, investigator, and agency.
Date.

Because the effort to aid the 350,000 physically handicapped children of this continent is a comparatively new field of philanthropy and needs intensified activity, because cripples of any age are particularly difficult to locate, due to the traditional disgrace attached to this condition, because any worthy field of philanthropic endeavor is essentially the responsibility of neighbors, and because such service is highly valuable to the happiness of those who serve, the wide-spread participation a social agencies in the movement to aid crippled children is necessary and highly valuable to those who are aided and those who participate.

CHAPTER V.

LEGISLATION

Early in the fall of 1896, a group of staid adults, charity workers, and physicians, assembled in an open meeting of the Minnesota Conference of Charities and Corrections, were astonished to find themselves confronted by a twelve year old crippled child. The little girl, Jennie Haskins, by name, was pleading for the support of this body toward the erection of a state hospital for crippled children. The late Dr. Arthur J. Gillette, then a young and rising orthopedic surgeon, supplemented the little girl's address with a paper on the Duty of the State to the Crippled Child. Although the idea was a new one, the untiring efforts of the young orthopedist secured a hearing for it at the next session of the Minnesota Legislature.

When the politicians met in April, the little girl and her professional friend once more delivered their pleas. They told of the little cripples for whom neither care nor education was available; and, forgetting political obligations and agreements, one after another the representatives rose and signified their approval of the first legislative act in the United States to provide care, education, and treatment for crippled and deformed children. On Apri1 23d, the Governor signed his name to Chapter 289 of the Minnesota Laws of 1897, and a hospital was soon ready for occupancy.

"Laws," say Professors A. W. Small and G. E. Vincent, "are regulative principles which shall secure that co-ordination of activities which is essential to social existence and growth. They are the embodiments of psychical modifications in social knowledge, feeling and volition."-1- The enactment of laws to provide and regulate machinery for the care and education of crippled children was a natural result of increasing social interest in this problem. More than half of the states in the Union have already made some legislative provision for this purpose and agitation in others is aiming toward this end.

-1-An Introduction to the Study of Society. Ch. V, ss 194, 195, pp. 357-8.

From an economic standpoint such laws should aim first to avoid pauperization of the families of the children. It is advantageous neither to parents nor patients to make available an unlimited number of hospital beds free of charge. Even in states where provision has been made against such possibilities, parents have been known to attempt to use political influence to keep children in custody longer than is necessary. The result of this action is to deprive other and more needy little ones of remedial facilities and at the same time to pauperize the families thus aided.

Such laws should distribute the public cost of these facilities as fairly as possible, both to relieve the state of a large burden, and to apportion the charges according to the number of patients aided in the various districts. They should, at the same time have the funds necessary for cure and education constantly available, in order that local economic depression should not deprive the children of thoroughly necessary assistance.

From the standpoint of the problem itself, legislative action to aid crippled children primarily should bring the facilities to the children. A single institution, scholastic or curative, located in a central portion of a state, will distribute the benefits of appropriations only to a small proportion of the needy ones. Such legislation should further avoid discouragement of private philanthropy. Too often public institutions or public subsidies to private organizations remove the inducement for private charity. Such legislation should be enacted in a form which will guarantee continuance of efforts to aid crippled children, regardless of economic conditions and regardless of political influences. Finally, the possibility of political influence in the operation of such laws absolutely should be avoided.

The Ohio plan, embodied in Senate Bill 174 and House Bill 200, is the most successful and efficient system of legislation now in operation. It provides for the co-operation of individual philanthropists, official state departments, and professional social workers. Under Senate Bill 174, applications to the local juvenile court for the care, treatment, and education of a crippled child may be made by parents, guardians, or other interested persons. The judge shall determine the degree to which parents are unable to pay for such treatment, and then make a report of his findings to the Department of Welfare. The latter may accept the child for temporary custody, and ascertain that the child is treated at the nearest of the ten Ohio orthopedic centers. Expenses incurred at the hospital are paid by the State Department from a rotating fund and charged back to the county in which the child resides. The latter charges the parents according to the findings of the juvenile court.

Under House Bill 200, the state superintendent of public instruction may grant permission to any local board of education, which maintains special classes for cripples, to pay the board of a crippled child, who, in the judgment of the Board and the superintendent, cannot be daily transported to his home. This bill further provides that such Boards of Education shall pay for transportation of the crippled children in case they are unable to walk to the school building. Finally, House Bill 200 states that upon petition of parents or guardians of crippled children in any school district, the Board of Education shall apply to the superintendent of public instruction for permission to establish a special class for these pupils. At the close of each school year the Boards of Education are to be refunded by the state the excess operating cost for such pupils, not to exceed $300.00 for the instruction of each, and $250.00 additional for those children boarded at the expense of the local school authorities.

These laws avoid pauperization by charging parents for care and treatment to the degree in which they are able to pay. They avoid overcentralization by leaving the question of where the child should be treated to the discretion of the Department of Public Welfare and by providing for district classes. They avoid unfair apportionment of expenses by charging the cost of care and treatment back to the counties in which the children reside. By the latter plan they avoid the pressure of political influence. There is ample encouragement for private philanthropy in the need for orthopedic wards in local general hospitals. The state is not burdened with the expense of constructing large orthopedic or general institutions.

There are four types of state legislation to provide operative, remedial, and convalescent facilities. There is first the Ohio, distributed and decentralized plan, described above. This type has recently been adopted in Pennsylvania -1- and in North Dakota.-2- Closely akin to the Ohio method is that of Michigan, Oregon, Kansas, and West Virginia, where patients are committed in a like manner to one or more specified hospitals. The fault in these states lies in the attempt to include elements of the older system in the new plan. The purpose of supplying privately operated institutions with patients avoids the expense of constructing state hospitals; but, in these states, fails from insufficient decentralization to reach all of the cases. Following the original Minnesota plan of central state institutions are Wisconsin, Indiana, (original construction cost furnished by public subscription), Massachusetts, New York, Iowa, Minnesota, Nebraska, and North Carolina. Illinois, under the statutes of l917, will use the new Illinois Surgical Institute as a state center for this purpose.

-1- Commitment in Pennsylvania is direct to institutional and educational facilities. The Department of Welfare is notified in all cases that such decrees have been put into operation.

-2- Pennsylvania General Assembly Act. No. 276, approved June 7, 1923, and North Dakota Senate Bill No. 176, approved 1924.

In Michigan, crippled children, whose parents or guardians are unable to provide treatment, are submitted to the probate court for investigation, and subsequently sent to the University of Michigan Hospital. The state bears the entire expense of treatment and care. The expense of returning children to their homes is paid by the hospital and charged to the state in the event that the superintendent is satisfied that parents or guardians are unable to assume this charge.-3- A similar law provides that Oregon children should be committed for treatment to the University of Oregon Medical College.-4- In Kansas such treatment is given at the Medical Department of the University of Kansas.-5- Commitments to the latter institutions are made by the county commissions or officials, and expenses are charged back to county or city authorities.

-3- Act No. 274, P. A. 1913, (Michigan).

-4- Session Laws 1917, Oh. 145, Code (1921) as 8525-8537. (Oregon.)

-5- General Statutes, 1920. Ch. 121, ss.. 28-37. (Kansas.)

Section 5-a, Chapter 22, Acts of the Legislature of 1917, in West Virginia, provides that it shall be the duty of the State Board of Control to admit indigent crippled children to the various State Minors' Hospitals for treatment free of charge. Minnesota legislation appropriates funds for the construction of the state hospital, and provides that the State Board of Control shall decide on admittances. The hospital, however, is free of charge, and restricted to indigent patients.-1- Wisconsin provides for the treatment of crippled children at the State Public School and Massachusetts provides for the admission of crippled children to the Massachusetts Hospital School for care and cure. Both of these institutions have separate hospital buildings. Indiana authorizes the Board of Trustees of the University of Indiana to establish and maintain a hospital for the treatment of children, after a commitment by judges of circuit, criminal, or juvenile courts upon the application of a citizen of the county in which the child is a resident.-2-

-1- Minnesota Laws 1907, Ch. 81; 1909, Ch. 130; 1897, Ch. 289; and General Statute 1913, 4135-4138.

-2- Indiana, Acts, 1921, Ch. 226, p. 833.

The New York legislature has provided for the treatment of indigent crippled children at the state orthopedic hospital upon application of a county superintendent of the poor or a commissioner of charities.-3- The famous Iowa Perkins Law of 1915 provides that on complaint filed by any probation officer, school teacher, superintendent of the poor, or authorized physician, the judges of the juvenile courts shall conduct investigations of crippled or deformed children called to their attention. If the judge finds that the child can be remedied and that the parents are unable to pay expenses for such remedies, he shall enter an order sending this child to the hospital of the medical college of the University of Iowa for free medical and surgical treatment and care. This institution is now provided with distinct and extensive orthopedic facilities. Nebraska and North Carolina have state orthopedic hospitals conducted along the lines of the Minnesota institution.

-3- New York Charities Law 1909: Ch. 55; 1916, Ch. 118.

A fourth type of legislation for the care and cure of crippled children is the annual appropriation for this purpose turned over to specified agencies for disposal in this work. Appropriations of this type have generally been a compromise between the legislators and agencies urging the adoption of more extensive programs. In Florida, $10,000 a year was appropriated to State Board of Health orthopedic work after a failure to provide sufficient funds to erect a state orthopedic hospital authorized in an act of May 30, 1911.-4- In New Hampshire, after the State Board of Charities had asked every legislature since 1906 for the small amount of $1000 annually for this type of work, $2500 was finally granted in 1919-1- and increased to $3000 in 1923. The legislature of Virginia annually appropriates to the State Board of Health; $25,000 for the treatment of crippled children at the Medical College of the University of Virginia. Separate legislation for the custodial care of incurable crippled children exists in three states; Minnesota, which provides for such care at the State School for Feeble Minded; Connecticut, which appropriates funds to the Connecticut Children's Aid Society for custody of these children at the Crippled Children's Home at Newington;-2- and Kansas, which provides for such care at the State Orphan's Home at Atchison.-3- Legislation providing state aid for sanatoria in a number of states indirectly supports the treatment of children crippled by "surgical" tuberculosis. In Connecticut, funds are annually provided for the maintenance of a special sanatorium at Niantic, for non-pulmonary tuberculous children.

-4- Florida, Laws of 1911, Ch. 6133.

-1- New Hampshire, Laws of 1919, Ch. 202.

-2- Parents pay as able, not to exceed $2.00 a week.

-3- General Statutes, Kansas, 1915, ss. 9703-9706.

There are three types of legislative acts providing for the education of crippled children. The modern type is that of Ohio, described on page 30. There is also provision for bedside education, as in the Ohio bill. A third method is the establishment of a state school for crippled children, either in connection with convalescent or hospital facilities, or independently. Following the Ohio model to a greater or lesser degree are Illinois, Michigan, Minnesota, Missouri, New Jersey, New York, Oregon, and Wisconsin. Illinois House Bill No. 325 (1923) is almost a replica of the Ohio legislation, except that it does not include the blind or deaf and makes no provision for bedside instruction. Boards of education and school directors of any district may apply to the Department of Welfare for not more than $300.00 a pupil per annum as excess cost for crippled children in special classes. In addition it is stipulated that truant officers or officers in each school district within the state shall report and enroll every crippled child within the meaning of the act. The district board of education is required to make special educational provision if one or more such children are found.

Michigan legislation for district crippled children's classes stipulates a minimum of five pupils of this classification.-4- Missouri provides state aid for such classes. Section 178, Article IX, of the New Jersey school law provides in part that the Board of Education of every school district must provide specially adapted equipment and facilities for crippled children, and that if there are ten or more of such children, a special class or special classes must be organized.. It is stipulated that such classes shall not exceed eighteen children. They must be financed by local authorities, as no state aid is provided. New York State has legislation providing for special classes for crippled children. At the present time, a committee has been authorized to investigate the local situation with a view toward making further recommendations.-1-

-4- Senate Bill No. 297, Michigan Legislative Session of 1923.

-1- Educational Law. (New York) 1917, Chapter 559, Section 1020.

Minnesota, under the laws of 1921, Chapter 141, authorized school districts to establish classes for crippled children provided that there were not less than five pupils of school age in each class. Boards of Education establishing such classes are to be paid $200.00 annually per pupil to cover the excess transportation and equipment, providing that the child attends school for a full nine month period. Should circumstances make it impossible for the child to continue classwork through out the year, payments are to be made in proportion to the amount of attendance. Wisconsin school boards in large cities are authorized to provide transportation and lunches for crippled pupils.

A stipulation in Mississippi school law provides transportation for crippled children in that state.

Bedside instruction is provided in Ohio, both at hospitals and at home. House Bill No. 200 provides that three hours of home instruction shall be counted as equal to the attendance of one child for two days at school. The Act, of course, limits such instruction to those patients who cannot, even with the help of transportation, be assembled. The Pennsylvania law includes the words "and provide suitable education." This bill is the most flexible of any of those under discussion and leaves a considerable latitude for the Juvenile Courts to insist on adequate care and education for these children. Minnesota is the only other state providing for the expenditure of funds for bedside instruction. The state hospital is made available for the "treatment, care and education of crippled and deformed children."

Massachusetts, Michigan, and Wisconsin have authorize state schools specifically for the education of crippled children. The Massachusetts institution is a combined orthopedic hospital, convalescent home, and school, both academic and industrial. The Wisconsin institution is primarily a state public school for dependent children, -2- but has special facilities to care for the crippled. Juvenile courts are empowered to commit children for treatment or education, and they are to determine the degree to which parents must pay for these facilities.-3- A portion of the Michigan State Public School at Coldwater is devoted to the handicapped. An unusual law, relative to crippled children, is the Wisconsin statute of 1919 which provides that midwives, physicians, parents, or guardians must register the birth of a congenitally deformed child within twenty-four hours. There is no analogous law in other states.

-2- Located at Sparta.

-3- School Laws, 1919, s. 573a. (Wisconsin.)

Most of the legislation discussed in this chapter is too new to justify or condemn its content. The future success of those laws modeled after Ohio Bills depends largely on the degree to which the public will support their continuance. Such statutes can easily become dead letters through lack of court applications and lack of petitions for public school classes. Their possibilities for efficiency with proper social co-operation are unlimited. Witness Ohio! The older legislation providing centralized facilities is rapidly proving itself inadequate for state needs. Two of the states which led the way with central orthopedic hospitals have already adopted laws to bring educational opportunities to the child in his own district. Other modifications in their plans must necessarily follow. It will be impossible for Minnesota to have special classes for crippled children located throughout the state and the only remedial facilities at Phalen Park. Similarly it would be ridiculous for Missouri to invest hundreds of thousands of dollars in a central hospital. Legislatures everywhere may well expect to be voting for a "decentralized" plan of orthopedic centers in the near future. More of this will be discussed in the next Chapter.

CHAPTER VI.

CARING FOR AND TREATING CRIPPLED CHILDREN

Many, many years ago, our forefathers believed in miracles. They had read of how the great Red Sea had parted that the children of Israel might cross in safety, and how a rock had produced water that the Israelites might quench their thirst. Their theology was a strange mixture of belief in unseen spiritual forces with thoroughly human attributes, and very literal interpretations of Biblical mythology. Then, in the course of time, came the mechanistic scientists who scoffed and "knew better than to believe such intangible nonsense." And now curiously enough, the scientists themselves produce the miracles, and make available for us the tangible evidence.

The gateway to the wonderland of these miracles is the clinic or dispensary. The public health nurse, the social service worker, the Rotarian, Kiwanian, Elk, or other good friend, is the gentle guide. In the hospital are the magic wands and potions, and in the convalescent home or sanatorium, recoveries become accomplished facts. A few states have all of these progressive stages to care for their handicapped little ones; many have some; and a few have none of them. But the modern trend is a rapid development toward the completion of the magic pathway in every state and in every locality, for the plan has proved efficient and economical.

The Clinic

Professor A. G. Warner, in his standard work on American Charities, stated that "the dispensary or clinic is the most efficient method of hospital extension and forms a link between the sick poor and the professional staff. ....The value of the clinic lies in tying up the social service to the medical treatment."-1- The efficiency of a clinic may well be judged by the degree to which it conforms to this standard of achievement.

-1- pp. 296-297

Clinics vary from established institutional dispensaries to temporary investigating centers. Most of the large orthopedic hospitals or general hospitals with orthopedic services have out-patient departments at which are given free examinations and diagnoses. Most social organizations begin their work to aid crippled children by either one of two ways: by individual case-work, in which they bring the children to the nearby institutional clinics; or by conducting a local survey and themselves organizing a clinic, to which they bring the prospective patients.

At the clinic the child is thoroughly examined. Trained nurses record the history of his disability, all information concerning his general physical condition, and those lesser defects which proper care and treatment may cure. These records may then be classified into five groups:

A. Urgent and hopeful.

B. Hopeful but not urgent.

C. Doubtful but at the same time hopeful of at least some relief.

D. Hopelessly incurable.

E. Slight deformities which may be cared for locally. Hospital stay or operation are not necessary for these cases.-1-

-1- Prepared by The Ohio Department of Health.

The first group is immediately sent to hospitals for surgical or other necessary treatment. The second group, relatively less important, is given similar treatment upon the disposal of the first. Nurses maintain contact with the families of the third group, which receives attention after the first two. The only solution to the problem presented by the hopelessly incurable is to return them to their families or to commit them to permanent custodial institutions. The decision between these alternatives will depend on the financial situation of the families involved, and the nature of the child's illness.

The children of Group E are generally communicated with for further treatment at future clinics or at the dispensary headquarters, where braces are fitted, physiotherapy is prescribed or conducted, and general conduct is directed. The best clinics have a well balanced medical staff, a thoroughly competent orthopedist, and above all, an efficient group of social workers who follow up cases to ascertain that the treatment continues and that environmental conditions are favorable to the recovery of the child.

The value of temporary or periodical clinics, such as are organized by local social organizations, is two-fold: first, they locate the children for treatment under existing laws and by existing facilities, and second, they advertise existing conditions to communities, that public interest may be stimulated toward more stringent enforcement of already enacted legislation, and the enaction of more efficient legislation if necessary. The danger to be avoided is the possibility of unorganized and poorly conducted clinics, resulting in filling hospitals with more cases than they properly can treat, and in a large loss of time and money on children who are not followed up. The experience of most organizations is that without public health nurse co-operation, a large number of cases will be diagnosed, and about fifty per cent never will reappear for treatment. For this reason, clinics always should be held in co-operation with departments of health or agencies existing for the care and cure of crippled children.

No discussion of clinical facilities would be complete without mention of the famous clinics held under the auspices of the New York City Department of Health, in 1921 and 1922. Dr. Adolph Lorenz, an Austrian orthopedic surgeon, consented to examine a group of cripples, and on November 28th, after several days of publicity, twenty baby stations were thrown open for the examination of crippled children under sixteen years of age. Three cases were to be selected from each station for examination by Dr. Lorenz himself, and he promised to perform several of his operations, known as "bloodless surgery." On the appointed day, 2,113 children from every part of New York State and elsewhere appeared for examination. Although only sixty of this large group could be examined by the visiting surgeon, the registration proved conclusively the existence of a great need for regular clinics of this type, and Dr. Lorenz agreed to conduct three public clinics each week at the Department of Health headquarters. The staff of employees consisted of the following:-1-

-1- Jacob Sobel, M. D., Franklin B. Van Ward, M. D., and Walter I. Galland, M. D., The Lorenz Clinics at the Department of Health of New York City, Monthly Bulletin of the Department of Health of New York City, Vol. XII, No. 5, May, 1922.

1. A physician in charge.
2. A technical orthopedist.
3. An associate orthopedist.
4. A consulting neurologist.
5. Supervising inspectors and medical inspectors.
6. The secretary of the physician in charge.
7. A supervising nurse.
8. Six trained nurses.
9. Four stenographers.
10. Two trained orderlies.

Ninety preliminary clinics, twenty-nine Lorenz clinics, and six operative clinics were attended by 6,376 cripples of all ages. The most significant result of this work was the instantaneous and wide-spread enthusiasm which it produced. More than one-sixth of all of the cripples in the city had undergone examination, and newspaper publicity had brought their condition to the attention of thousands of citizens who had never given thought to this movement before. As a result, hundreds of neglected crippled children and adults received necessary attention.

Acute Hospital Care.

The child has been thoroughly examined by expert clinicians. The cause of his deformity has been diagnosed, and the time for treatment is at hand. Unfortunately, at this point our pathway divides, and two avenues arouse the perplexing question as to which is the more expedient, the general hospital or the special orthopedic institution. The number of the latter continues to grow, and every new building aggravates the controversy. The advocates of the special hospital maintain that:

(1) Orthopedic and general surgery are definitely and necessarily divided and that the general hospitals too often make them one function.

(2) Nursing and care for orthopedic cases must be specialized beyond the capabilities of the general hospital. The general nurse does not understand the uses of the Bradford frame, or other details of special care for crippled children.

(3) The management of a general hospital is not interested in orthopedic cases. They are anxious to have "blood and thunder surgery cases,"-1- and find the routine orthopedic care monotonous.

-1- Gillette, A. J., State Hospital for Deformed and Crippled Children Would Be Advantage, American Journal of Orthopedic Surgery, XIV, 259-264, May, 1916.

(4) Many of the beds in general hospitals are endowed by philanthropists who are anxious to have them annually available for as large a number of patients as possible. They complain of the long term occupancy necessary for orthopedic cases.

(5) Orthopedic cases seem to "develop" when there is a orthopedic hospital to treat them. The advertising value of such an institution is significant in locating cases for which treatment is necessary.

(6) An orthopedic hospital is better fitted financially for research and scientific advancement in this field than is the general hospital.

The International Society for Crippled Children and its affiliated organizations stand definitely against the erection of further special institutions. They point out that:

(1) The general hospital with special orthopedic services has a better balanced medical staff, which will care for all defects of the crippled child. There are generally complicating conditions correlated with the orthopedic defects, with which the general physician is best able to cope.

(2) The orthopedic hospitals with complete operative facilities are not economical. They are generally erected in direct competition with existing orthopedic services and result in several partially filled institutions attempting to do the same work. New orthopedic facilities in general hospitals can be provided less expensively than new orthopedic hospitals.

(3) The operative facilities of the orthopedic hospital are not used to their maximum possibilities. The average hospital period per patient in three Shriners' institutions up to April 1924, was ninety-five and seven-tenths (95.7) days. There were, on that date, three hundred and fifty-six children on the waiting lists at Portland, "The Twin Cities," and San Francisco. With this infinitely slow turn-over (which, by the way, is rapid compared to some institutions), operative facilities lie idle much of the time. The Minneapolis institution had performed only one hundred and seventy-five operatons -sic- since its opening (March 1923).

The International Society favors the orthopedic service in the general hospital, with affiliated convalescent homes receiving patients for the recuperative period. Approximately eight efficient convalescent buildings can be constructed for the price of one orthopedic hospital, and patients can be moved through the general hospital in as little as fourteen days.-1-

-1- Patients at the Elyria Memorial Hospital are moved to the Gates (convalescent) after an average 16-day period.

(4) General hospitals will provide efficient and competent orthopedic services in proportion to the degree to which money is made available for this purpose. In Ohio, North Dakota, and other states providing a source of funds for general hospital treatment, the difficulty of disinterested managements has been eliminated. Unfortunately, in past years, these institutions lacked appropriations to handle orthopedic cases.

(5) Perhaps the greatest argument against the orthopedic hospital lies in its inability to solve the problem of the crippled child throughout the entire state. It is financially impossible to construct special institutions in enough centers to make facilities available for a very large proportion of the children of a state. The result of this situation is that large sums of money are spent in building central orthopedic hospitals and no funds remain to provide acute or convalescent services for most of the children in isolated communities. Only a relatively small number of parents bring their families to a distant city for the extended period of time necessary to orthopedic treatment.

Generally speaking, the Ohio plan is gaining ascendancy throughout the country. The argument for orthopedic hospitals carries more weight in central large communities, such as New York City and Chicago, than in farming states where distances to central institutions are too great to make the latter very effective in solving the problem. In New York City, orthopedic hospitals are probably thoroughly justified, sharing medical staffs with the great general institutions, sending their patients to New Jersey and up-state convalescent homes for the post-operative period, and helping to solve the distinct problem of this great concentrated community. In Ohio and similar states, such institutions would only compete with the established general hospitals, and consume funds which would otherwise be used for much needed convalescent facilities. Whether by special institutions or general hospitals, acute orthopedic work generally should be done in carefully selected centers. Ohio has ten of these chosen because of the presence of competent orthopedists, because they are centrally located for a particular group of counties, and because general environmental conditions, climate, and resources, are favorable. The availability of the orthopedic surgeon is a matter of great importance. He "acts as a mechanic to the human machine; he deals with its poise and movement; it is a part of his work to keep the axis true and the movement free in each of its joints; he watches and balances the output of power from the muscle groups and its transference through the tendons, and must see to the correct initiation and control of the movements of the limbs through motor and sensory nerves."-2- The general physician is often the ogre of normal children. To crippled children, the orthopedist is a Messiah. They welcome him with delight and suffer under treatment with unbelievable fortitude. It is within his power to reconstruct them in the image of their normal playmates and they appreciate whatever he does for them.

-2- G.R. Girdlestone, The Care and Cure of Crippled Children, Part I, p. 30.

There are three types of orthopedic services: those operated by the state, as in Minnesota, Iowa, Nebraska, New York, North Carolina, Massachusetts, Wisconsin, and West Virginia; those operated privately, but supplied with patients by state agencies, as in Ohio, Indiana, North Dakota, Michigan, Pennsylvania, Virginia, and Illinois; and those operated and supplied by private agencies, such as the Shriners' Hospitals, orthopedic services in general hospitals throughout the country, and special children's or general orthopedic hospitals.

A special committee on Minimum Requirements for an Orthopedic Hospital, recently appointed by the Ohio Hospital Association, listed the following basic essentials for an orthopedic service:-1-

-1- The Crippled Child. Vol. II, No. 4, p. 4, (April, 1924), and Vol. II, No. 6, p. 10 (July-August, 1924). Committee Consisted of C. H. Pelton, M. D., Chairman, B. G. Chollett, M. D, and B. W. Stewart.

1. Separate wards for children.

2. Specially prepared orthopedic surgeon on hospital staff, or admitted to practice in the hospital.

3. Special nursing service.

4. Operating room.

5. X-Ray and other laboratory facilities.

6. Separate plaster room.

7. A minimum of equipment for both surgical and non-surgical cases.

8. Where tuberculous children are accepted, suitable provision for open-air treatment.

Several of the special orthopedic hospitals have special training schools for nurses. There is coming to be recognized a need for special orthopedic training for all who participate in the actual treatment of the little ones. The Nebraska Orthopedic Hospital has a school of this type, special nurses' quarters, a medical library for their use, and a teaching' staff of practicing specialists.

An element of greatest importance in all institutions where crippled children are cared for is the environmental atmosphere. Many of the patients have suffered much pain, and their recovery is in a considerable degree dependent upon their psychological condition. The best institutions have an atmosphere of hope, good will, cheery laughter, and essential comfort. The word "cripple" is unknown. Sunlight, fresh air, and pleasant surroundings, as well as toys, amusements, books, companionship, and bedside instruction in occupational therapy always should be made available in the greatest possible degree.

Convalescent Care.

The depths of distress have been passed in safety and our pathway now leads to the convalescent facilities. "There are many patients who flounder aimlessly about clinics for week and months endeavoring to gain health, but who more often, because of lack of convalescent care, become one of the many 'half cured'."-1- In order, therefore, to avoid relapses, and also to relieve hospitals of long term convalescents, sanatoria, convalescent hospitals, convalescent homes, "hospital-schools," and summer homes or camps have been established to care for crippled children. These are happy places, filled with new delights and characterized by hope and improvements. Pallid, frail children find themselves becoming robust and ruddy, and delight in using their new found muscular power in games and contests in which they believed they would never be able to engage. Maturing children, approaching adolescence, learn to read and write for the first time in their lives, and apply themselves to their lessons with a zeal unheard of in the public schools.

-1- Hortense Kahn, Standards of Care for Convalescent Children, p. 3.

The orthopedic convalescent hospitals differ from the convalescent homes only in having available facilities for minor operations. They generally are operated in connection with general hospitals and retain their patients for shorter period than do the homes. Most of the former are operated independently, although some of them are affiliated with general institutions. Caution as to atmosphere is essential in these institutions of longer residence. Uniform clothing is most undesirable and usually is avoided by obtaining contribution from friends or relatives of the patients. Little trinkets and new garments are greatly prized by younger children and help to avoid institutionalization.

The Crippled Child has organized a "Round Robin," to which the children at a large number of convalescent homes contribute. The letters which are published periodically through a considerable amount of light on the activities in which the patients are engaged. Marion Smith, secretary at the Hospital School in Jersey City, writes: "During last summer the Rotarians gave us a number of theater parties. At most of our entertainments they furnished professional talent, which we enjoyed very much. ....The Rotarians also have a large radio installed." In another letter we are told:-2- "We make mats aprons, towels, tatting, lace. ....We have a good time Christmas. . . . We had a Christmas tree. . .dresses, candy, dolls, games, handkerchiefs, and other things."

-2- From the Youngstown, Ohio, City Hospital.

A letter from Mary Harty, a Round Robin corresponding secretary at the Country Home for Convalescent Children, Prince Crossing, Illinois, reveals the extent to which the "ambulatory" patients enjoy themselves. "I suppose the first thing of importance was the baseball game between our boys and the West team.. . .The score was eleven to ten in our favor. One day all of us older girls and boys went to the woods in our farmer's hay rack and had a wiener roast.-1- Another time one of the nurses who used to be here took us for a picnic.. . ."

-1- This institution includes a 90-acre farm which supplies fresh vegetables daily.

For normal children these activities are a matter of course, a part of their routine experience. For crippled children they are generally a new privilege, one of many unprecedented opportunities. Some of the children at the Prince Crossing institution are Boy Scouts. Another group has organized an orchestra. An excellent library has available the best juvenile literature. The children learn to dance and weekly parties are enthusiastically anticipated.

Closely akin to the convalescent homes are the institutions limited to specified diseases. The Reconstruction Home for Infantile Paralysis, in Ithaca, New York, is one of the very few institutions which exclusively care for otherwise normal children, suffering from the effects of poliomyelitis. A similar home in Elmira, New York, limits itself largely to rachitic and poliomyelitic children. In addition to these, there are special sanatoria for bone and joint tuberculous children, and general sanatoria, admitting this class of patients.

Sanatoria are special institutions caring for patients afflicted with tuberculosis.-2- They are of three types:-3-

-2- To be distinguished from the "sanitarium," an institution for mental and nervous diseases. Originaly, these two words were interchangeable. The distinction was made through the influence of the National Tuberculosis Association.

-3- From the Tuberculosis Directory of the National Assoxiation, 1923, p.4.

"1. Public institutions -- including state, county, and municipal. These are, in most instances, for local patients only.

"2. Private institutions -- operated by a non-official board by an individual for commercial purposes and open to patients from any locality.

"3. Semi-private institutions -- operated by a non-official and supported partly by private contributions or endowments, partly by fees of patients, and in some cases, partly by public funds. In most instances, admission of patients is restricted to certain groups of localities, or is otherwise limited."

Earlier studies of efforts to aid crippled children failed to take into account the large number of these patients under care in the special tuberculosis institutions. Agencies to check this disease had aroused a national interest at least fifteen years before the movement to aid crippled children had gained an extensive following. The National Tuberculosis Association was founded in 1904, and was itself a merger of several national groups. The extensive preventative, clinical, and curative endeavors which resulted from the efforts of this group had brought under sanatorium care hundreds of children, crippled by the progress of bone or joint tuberculosis. Although the development of convalescent homes has transferred some of this responsibility to special orthopedic agencies, there are still a number of these patients in sanatoria and other tuberculosis institutions.

Efforts to check the progress of "surgical" tuberculosis have been more successful than most of the other branches of orthopedic work. The J. N. Adam Memorial Hospital at Perrysburg, New York, reports the following results in the treatment of "surgical" tuberculosis during a period of seven years:-1-

-1- 1913-1929. See Annual Reports.

Of 638 cases committed to hospitals or sanatoria by the Ohio Department of Public Welfare during a period of three years, the following results were achieved:

The lower percentage of successful cures in Ohio may be explained by a lack of special facilities and the inland situation of the state. The North American Sanitarium-2- in Ventnor, Atlantic City, New Jersey, reports an average of 86% of its patients cured or greatly improved.

-2- Named before the distinction of terminology was established.

In addition to salt water bathing facilities, the "heliotherapy,' or sun treatment, has been found to produce remarkable results. This work was begun at Dr. Rollier's sanatorium the Swiss Alps in 1903. It was introduced into this country the J. N. Adam Memorial Hospital by Dr. John Pryor. It consists of exposure of the diseased part to sunlight for periods increasing from five minutes three times a day, to five, six, or seven hour periods. The exact results which take place are not understood, but there have been observed an increase in the pigmentation of the skin, a growth of hair, a general metabolism, a decrease in the number of respirations, with the increase in the depth of the individual respiration, a fall of blood pressure, and a stimulation of the nervous system indicating an improved general condition and a stronger resistance. It is important that this treatment should be given with judgment, over-exposure or personal idiosyncrasy may result in sunstroke, rising temperature, cardiac palpitation, insomnia, or nervousness.-3-

-3- Glittings, Tuberculosis in Infancy and Childhood.

Many of the special orthopedic institutions, almost all of the "orthopedic" sanatoria, and some of the general sanatoria have "sun porches" for heliotherapeutic treatment. The patients' schedules are divided so as to bring them to the porches in rotating groups. The daily program at the North American Sanitarium, for example, is as follows:

7:00 A. M. Rising hour for out-of-bed patients.
7 :30 A. M. Breakfast. Recreation until 9:00 A. M.
9:00 A. M. School for the older children. Heliotherapy treatment for the younger children.
12:00 A. M. Dinner.
1 :30-3 :30 P. M. The older children have heliotherapy.
5:00 P. M. Supper. All children are in bed by 6:00 P. M.

In addition to an academic teacher, occupational therapy is taught semi-weekly by a visiting teacher. Religious instruction is given every Tuesday afternoon.

All tuberculosis institutions emphasize the necessity of fresh air. Dormitories are rarely heated, sleeping bags and army blankets being furnished during the winter months. A minimum of clothing, out-of-door recreation whenever possible, and a constructive diet are necessary to build up the tuberculous child and avoid pulmonary infection.

Summer Camps.

In localities lacking facilities for all-year convalescent care, summer camps frequently care for some of the children. They are inexpensively supplied and operated, and achieve surprisingly excellent results. The Crippled Child of January, 1924, describes a summer camp constructed by the Rochester, New York, Rotary Club. The club was donated an old house and lot on the shore of a nearby lake. They met and proceeded to divide responsibilities, scrubbing, painting, wiring, and renovating the building. They installed new plumbing and obtained a staff to operate the camp, including a teacher, furnished by the Rochester Board of Education. The article continues, "Forty quarts of milk a day were consumed last summer, and the children gained from three to nine pounds each, with the exception of one boy who was already much overweight. Eight little girls and nine boys learned to swim.

The average gain in weight per child during the summer of 1923 at the Lake Allyn Summer Camp for Crippled Children, near Cincinnati, Ohio, was five and three-quarters pounds and the greatest individual gain was fifteen pounds. Summer homes are sometimes operated by institutions and frequently by organizations. The New York City Association for the Aid of Crippled Children supplies Robin's Nest, a summer fresh air home at Tarrytown, New York. Rotary Clubs have made available a number of fresh air camps of the type described in this chapter. It is the custom of a number of Salvation Army branches to maintain summer camps where crippled children may be strengthened by the invigorating country environment. The Outing Association for Crippled Children, in Chicago, operates a summer camp at Brown Lake, near the city; and the South Side Crippled Children's Aid Society, in the same city, is interested in Camp Happy Haven, located in northern Indiana. The Orange Fresh Air Home, at Bradley Beach, New Jersey, is supplied with children from the New Jersey Orthopedic Hospital at Orange.

Custodial Institutions.

Except for the unfortunately incurable children, the need for "asylum" or custodial homes for juvenile cripples is rapidly being minimized. During the early stages of orthopedic work, when orthopedists had not learned modern treatment for "surgical" tuberculosis (then by far the leading causative disease), a very large proportion of crippled children were considered beyond assistance. It then seemed most expedient to place many of them in custodial institutions where they would at 1east cease to be burdens to indigent families. Today, most of these patients are considered curable, and convalescent homes or "boarding out" to families have supplanted almost entirely the necessity of asylum institutions. Most of these make efforts to furnish the children with remedial treatment. There is still a need for custodial homes for the incurable children of state which have devoted all of their attention to remedial agencies, and such institutions are now being planned.

CHAPTER VII

EDUCATING CRIPPLED CHILDREN

"A graduate of the Spalding School for Crippled Children in Chicago, Illinois, is owner of a commercial printing establishment with two large motor presses and other modern equipment, all purchased through his own efforts."-1- Joe Sullivan edited a newspaper at the age of twenty years.-2- A one-armed Ohio youth operates a typewriter at the rate of 65 words a minute. Another Ohioan, paralyzed from the hips down at the age of twelve years, has completed a course in commercial illustrating and now is prepared to provide valuable service to a local advertising agency. -3- These selected examples illustrate the goal of the magic pathway, the ultimate culmination to which the efforts of the co-ordinated machinery of this social movement are directed. The real handicap of the crippled child is not, in itself, his physical dissimilarity to other children, (for physical blemishes are soon submerged in prominence by excellences of personality) but his difficulty in rendering himself self-supporting and in obtaining contact with those intellectual pleasures which are made available through education. In the words of Edgar F. Allen, "cure them if we can, but educate them we must!"-1-

-1- E. R. Solenberger, Public School Classes for Crippled Children, p. 32.

-2- See part V. p. 154.

-3- New Opportunities for Physically Handicapped Persons in Ohio, issued by The Civilian Rehabilitation Service, 1924.

-1- Education of Crippled Children, Elyria, Ohio, 1924.

In every phase of the work, the absence of education has retarded the cripple from assuming his normal place in society. Until less than twenty years ago the public was not educated to his needs. Less than fifty years ago ignorance resulted in superstition concerning the actual nature of the physically imperfect human being. In brief, the problem of the crippled child has been solved in the degree to which education, everywhere, has supplanted ignorance. Education is both a medium and a goal, and its importance in this movement cannot be over-emphasized.

It has been suggested frequently that special educational facilities for the crippled child are unnecessary. Crippled children are somehow educated in public schools when there are no special classes. Why provide extra funds for this purpose? Educators are faced with two distinct problems, the first being the education of children who are temporarily crippled, or "who differ only to a slight extent from the normal, sound child,"-2- and the second is the problem of educating those children, incurable or severely handicapped by permanent deformities. Special facilities are necessary for both types.

-2- Reeves, Care and Education of Crippled Children, p. 49.

Almost all crippled children are frequently deterred from regular school attendance, especially in bad weather. This is so because of frequent interruptions caused by correlated physical weaknesses and necessary operations. Crippled children of both types referred to above have difficulty in reaching school buildings under any circumstances, and once arriving at the school they cannot return to their homes and back to the school in a normal luncheon recess period. This class of pupils should have one or two rest periods daily, as prescribed by physicians. They further should have opportunities for physiotherapy training and treatment. The seats provided for normal children will not fit the needs of a crippled child with one or several deformed limbs. Crippled children generally have difficulty in mounting stairways which have been erected for the use of normal children. Public school teachers, accustomed to the instruction of normal children, unwittingly make demands upon their handicapped pupils which constitute a severe physical strain. Each child of the second of the two types described above must have special pre-vocational and vocational training which will train him to the most expedient use of his deformed body in earning a livelihood.

For centuries these problems prevented maimed or deformed little ones from receiving educational advantages. During the past twenty years the public has at last begun to realize the injustice of this condition, and special classes, special schools, or home instruction are rapidly developing. These special facilities meet the difficulty of interrupted attendance by elastic curriculums, small classes, and attention to the needs of each pupil. Modern educational systems furnish taxis or busses to transport crippled children to the school buildings and hot lunches are provided to avoid the necessity of difficult homeward journeys during the noon recess. Morning and afternoon rest periods are a part of the schedule, and in some institutions open air rest pavilions are available for the tuberculous pupils. Open air school rooms have become increasingly common. Trained masseurs and physical instructors co-operate with school orthopedists in administering the various therapeutic treatments.

School-room seats and desks are specially designed adjustable to the needs of each deformed body. Elevators and inclining pathways have supplanted the difficult stairways. Railings are located conveniently to assist the little cripples in passage through the buildings, and floors are specially carpetted to prevent crutches from slipping. Several Boards of Education, providing special schools, require teachers who are to instruct these classes to spend a special eight-week period in preparation for these duties. Finally, to supply the needs of each pupil, manual training, domestic science, and pre-vocational preparation are emphasized in these schools.

Education for crippled children is provided in hospitals, in convalescent institutions, in special school buildings, in special classes, in state schools, and at home. In hospitals and convalescent institutions, bedside instruction is supplemented frequently by special school rooms or buildings for ambulatory patients.

The leading controversial question among educators, as among hospitalization authorities, involves the relative expediencies of centralized or decentralized facilities. As among the institutions caring for and curing crippled children, the weight of argument is with the decentralized plan. Parents will move their families to hospital facilities more readily than they will travel long distances for the purpose of living near central educational institutions. Moreover, it is an injustice to move the children of indigent families many miles from their parents for long periods of education. Centralized educational facilities simply do not function. Michigan, which has provided for a state public school with special provision for crippled pupils, has found it necessary to erect a number of local schools to solve the problem. The enrollment of crippled pupils at the State School, at Coldwater, has always been small.

Until recent years the notable deficiency of the special educational systems for crippled children has been the fact that these advantages ceased upon the completion of eight grammar school grades of instruction. Several cities, including Chicago, Los Angeles, and Philadelphia are now extending these facilities to junior high school and senior high school education. It is to be hoped that this program will be adopted by other Boards of Education and that the universities will co-operate with the civilian rehabilitation bureaus to provide education for crippled advanced students.

The instruction provided in the various occupational arts and sciences has physical as well as vocational value. In the convalescent and acute institutions it serves to provide an interesting and engrossing source of occupation for the children. It trains them in the use of muscles which might otherwise remain inactive. In addition, this instruction guides them to a source of permanent income. Some of the industries in which these children may be instructed are sewing, lace making, chair caning, burnt woodwork, stenography, typewriting, simple carpentry, pottery, basketry, brace making, cobbling, cooking, printing, bookkeeping, the manufacture of artificial flowers, millinery, knitting, leather work, crocheting, novelty, and favor making. Quoting from the 1922 annual report of the Massachusetts Hospital School, "When a child is admitted, doctors, nurses and teachers study his case from every point of view. If his disability is temporary, he is placed without loss of time in a class where he is enabled to keep well abreast of a child of his own age in a public school. If he is permanently crippled, he soon finds work to which he is best adapted, voluntarily working side by side with the wage earners."

Some classrooms provide long tables at which the children place themselves comfortably. Other facilities are very simple. A blackboard and a desk for the instructor complete the equipment. Periods are short, and are arranged in a rotating fashion to provide instruction for one group while a second group is given the various types of medical treatment suited to the needs of each child. Some institutions have their own libraries and furnish books for the pupils as they are needed. Many arrange with the local public libraries or book stores to supply texts and extra-class reading matter when called for by the teachers.

Grading of students receiving bedside instruction, either at home or in institutions, is generally credited in a different manner from the class room system. One hour of such instruction is credited as equal to two or sometimes three hours of normal education. This is done because the children are receiving individual and concentrated attention, and do much of the work by themselves under periodical guidance.

When the crippled child has received remedial treatment, convalescent care, and has completed a thorough educational period, society has done all that it can to help him. If, after that time, business and professional men will consider him on his own merits and give him an equal chance to obtain employment and demonstrate his fitness to cope with the problems of a normal life, the magic pathway is completed and the handicap is at an end. From that time on, the "cripple" joins with his normal companions to further the prevention of those conditions which are favorable to causing deformities in other children, and, like Michael Dowling,-1- the great Minneapolis philanthropist, is probably doubly active in aiding his less fortunate little brothers. Everyone concerned is happier. Progress has been achieved.

-1- The late Michael Dowling of Minneapolis, Minis., rendered great service by aiding crippled soldiers during the World War. He was himself a cripple, supported by two artificial legs and capable of using only one arm. Mr. Dowling passed away in 1921. Some of his great fortune was left to the Dowling School for Crippled Children. In Minneapolis, Minnesota.

CHAPTER VIII

CO-ORDINATION

Inter-dependence of units is characteristic of all society. Under normal conditions, it exists unnoticed and without special impetus. Under abnormal conditions, such as are correlated with the problem of the physically handicapped, the resulting isolation of individuals breaks otherwise normal social relationships. Thus, as we study the problem of the crippled child and learn of the various existing and potential facilities for its solution, we become more and more convinced that the keynote of all efforts in this field should be co-ordination between the various active agencies, and between their component units.

The necessity for such guided and enlightened unity is pre-eminently discernible in this work because the needs of crippled children are so varied as to place demands on many diversified fields of social activity. There is a great army of pediatricians, orthopedists, and general physicians to whom the crippled child is but one of a great mass of individuals requiring physical and constitutional remedy. There are the doctors of preventive medicine and also the associated group of social hygienists, who are interested in improving public health by preventive measures. The physically handicapped form a distinct educational problem. Similarly, those who aim to relieve destitution are constantly confronted with the necessity of aiding these cases. To those who provide vocational guidance and to those who operate industries, cripples have always been a problem.

The great danger in these activities is that the ultimate solution will become a mirage to each crippled individual. Those who would aim to provide remedy without co-operating with educators to make available school facilities, place the child in the position of the prospector who has discovered gold, but has no means of transporting it to metropolitan markets. Those who would educate without co-operating with others who would relieve hunger, are equally culpable. Educational facilities which do not co-operate with the agencies which render vocational assistance are quite ineffective.

The greatest degree of unity in this movement has been achieved within individual institutions. We find the orthopedic hospital, the special class, the social service department, the out-patient department, and the general advisory medical staff combined in the modern hospital school or orthopedic center. Here the local board of education furnishes teachers; the nurses' association provides social service workers; the local Rotary, Kiwanis, or Elks' Club discovers cases and achieves personal contact with the patients; and the convalescent, operative, and medical facilities are in co-ordinated service to the child.

No such unity has as yet been achieved between national or local social agencies. The International Society for Crippled Children has made more progress in that direction than has any other agency in this field; and still it is far from a central binding agency for all institutions and organizations. The Bureau of Information of this society was organized for the purpose of making possible those national contacts, and the Public Relations' Committee is at present endeavoring to complete them. Some organization (similar to the National Tuberculosis Association for those who are endeavoring to solve the tuberculosis problem) eventually must act as a central medium for the exchange of information and a stimulus to co-ordinated activity. It might very well be an existing group, such as the International Society, which may be supported and maintained by all interested individuals and organizations in the United States and Canada.

Hastings H. Hart, Director of the Department of Child-Helping of the Russell Sage Foundation, addressed the 1923 convention of the International Society as follows: "I want to say a word about co-operation. This is a tremendous movement. It is going to take a lot of money and interest. It ought to enlist the co-operation and good will of the entire community I think that you can afford to put in a whole lot of effort to enlist the mutual co-operation of all the different agencies of people in your community.

"Take this hospital proposition. If the Masonic organization is going to build hospitals for crippled children, and the Kiwanians and Rotarians are going to carry on clinic work, unless you are working together you are just as sure to get into an injurious competition as to go ahead. You have seen the jealousy that arises when two hospitals or two organizations have undertaken the same kind of philanthropic work. This can all be prevented by a spirit of conciliation before it be too late to accomplish that thing.

"Now gentlemen, I congratulate you in this job, but you can't make a bigger mistake than to make this an organization of bachelors. If the women are not with you, you are going to let slip by you a whole lot. I have worked along these lines about fifty years. I find the co-operation of men and women in work for little children very essential, and you can't afford to go it alone. You wouldn't think of establishing a hospital and putting in it none but men nurses. You can't do it. The same holds true with regard to the organization. I am sure you are going to want the women."-1-

-1- Hastings H. Hart, The Restoration of the Crippled Child. The Crippled Child, p. 5, Dec. 1923

Since the presentation of the speech quoted above, an agreement has been reached between the Shrine Hospital Committee and the International Society whereby several of the members of the former organization are representative on the Advisory Board of the latter. Many Rotary Clubs have arranged for the co-operation of wives in the crippled children activities. Most of the present work of this organization is directed toward more complete national co-ordination.

Intra-state, the co-ordination has been achieved to varying degrees of completion. The Illinois Society for Crippled Children, in a recently published program, planned to enlist the co-operation of all interested organizations, namely, the Illinois Department of Health, the Russell Sage Foundation, the Rockefeller Institute, the American Institute of Orthopedic Surgeons, the American Hospital Association, the National Education Association, the National Welfare Association, the American Red Cross, the American Legion, (for assistance in securing beneficial legislation), the Knights of Columbus (for the same purpose), and the Shrine. Representatives of the Shrine, the State Department of Health, and the Illinois Society met in Chicago in 1923 and planned the following program:

1. The State Department of Health will concentrate on prevention.

2. The Shrine will concentrate on providing hospital beds for the "operative" and convalescent patients.

3. The Illinois Society will turn its attention to the ambulatory patients.

4. All three will co-operate in securing expedient legislation.-1-

-1- From an address by Dr. E. H. Marshall of the Illinois Society for Crippled Children.

In contrast may be cited a conference of orthopedic surgeons held in Harrisburg, Pennsylvania, March 24, 1924, under the auspices of the State Department of Welfare. An excellent group of suggestions was proposed, but no means was provided for putting them into operation. Accordingly, a second conference was held in the Senate Caucus Room, two months later. The meeting discussed the application of the Ohio plan in Pennsylvania, the function of the various professions and active social groups in completing this movement, the need of hospital beds in that state, and the necessity of avoiding pauperization. The group appointed a committee to meet monthly and formulate a program to be adopted by another conference to be called in December, 1924. The co-ordinated activities of Pennsylvania are now rapidly reaching efficiency and bringing that state to a place of leadership in the movement to aid crippled children.

When the first burst of Rotary enthusiasm brought Ohio into crippled child activities, co-ordination was sadly lacking. Clinics were held without public health nurse assistance or direction, and children were committed in wholesale lots to hospitals which were not ready to care for them. Family physicians were deprived of one pay case after another by free clinicians who examined children, diagnosed cases, and sent them to free remedial facilities regardless of whether they were able to pay or not. Had this in-co-ordinated activity continued, something similar to state medicine would have superseded private practice in Ohio, and all impetus for medical and surgical development would have disappeared.

Through the efforts of the Ohio Society for Crippled Children and the State Department of Health this disorganized and dangerous practice was first checked and finally corrected, until, at present, Ohio state departments and local social groups are working in harmony and handling the problem effectively. The co-operation of clinical facilities with family physicians cannot be too strongly urged. In the first place, the family doctor is in the best position to aid in arriving at a correct diagnosis of the case. In the second place, inasmuch as the medical profession as a group has rendered, without charge, unlimited social service in caring for destitute cases everywhere, it is only fair that indiscriminate free facilities should not deprive physicians of patients who can pay for their services. No physician should object to a second and assisting diagnosis of either free or pay patients. From the very beginning, however, the family physician should be consulted, and given the opportunity of caring for all of those patients who can remunerate him for his services. A third reason for such co-operation is the desirability of making free services available for as many indigent patients as possible, and not depriving them of these opportunities by using funds for less needy persons.

The writer was astonished to find, in conducting the investigation preliminary to the preparation of this report, that institutions and organizations less than ten miles apart were utterly unaware of the existence of neighbor groups working to solve their problem. The desirability of interchange of information; the necessity of avoiding ineffective, and sometimes conflicting, activity; the desirability of entirely fulfilling the needs of the crippled child, rather than holding before him a mirage and then failing completely to fulfill the promise thereby presented; and finally, the necessity of a policing group which also is able to stimulate activity wherever needed: -- all these justify state and national organizations, whose object is to accomplish these purposes, specifically for the crippled child problem, and for this problem only. It is to be hoped that the International group and its member societies will accomplish that purpose.

PART II

A SURVEY OF AMERICA FACIILITIES TO CARE FOR, CURE AND EDUCATE CRIPPLED CHILDREN

CHAPTER IX.

A STATISTICAL STUDY

We are told that Rome was not built in a day. The movement to aid crippled children, however, has certainly undergone phenomenal growth. So rapidly have these efforts spread in the decade which has elapsed since Miss Reeves produced her study of existing facilities, that a thoroughly accurate survey of all existing facilities has become practically impossible. When the Bureau of Information of the International Society for Crippled Children entered upon this task, the problem seemed to be a simple one to solve. Philanthropic agencies, local social groups, and known institutions were solicited for information. It seemed only a question of time until all correlated data would be accumulated.

Experience proved that this would not, and could not, transpire New agencies seemed to be organized over night. Older organizations or associations would send partial answers to questions submitted. We would discover that institutions would expand bed capacities without informing us of the change in data. Perhaps the chief difficulty in correlating the data received was in the location of general hospitals providing orthopedic services. Notwithstanding all of these impediments to accuracy and completeness, the author has been able to provide a fairly comprehensive list of agencies and institutions. Although we present herewith a tabulated statement of our finings, readers are earnestly requested to call our attention to omissions and corrections. In turn we wish to emphasize, not the statistical details which are admittedly incomplete, but the general indications which may be interpreted.

The Directory of active agencies printed in Part IV includes the following activities in the United States of America:

40 special associations active in this work.

92 orthopedic hospitals and general hospitals with orthopedic services, providing 5,381 beds for crippled children.

6 additional orthopedic hospitals, the bed capacity of which was not ascertained.

45 additional general hospitals providing orthopedic services but reporting no limited bed capacity for juvenile cases.

41 convalescent homes, convalescent hospitals, and special sanatoria provided with 2,449 beds for crippled children.

4 additional convalescent institutions reporting no limited bed capacity for crippled children.

15 summer homes and camps. Six of these have reported a total bed capacity of 239 crippled children. No information could be obtained concerning the capacity of the others.

18 custodial institutions, fourteen of which reported a bed capacity of 656. Four reported no bed capacity.

82 special state and city public schools and private day schools are provided with facilities for the education of 6,225 children. 162 classes are enumerated in 40 of these institutions.

5 additional schools provided with special classes, data concerning which has not been obtainable.

36 general tuberculosis sanatoria and hospitals reported a total bed capacity of 4,120 with 453 beds devoted especially to the care of crippled children.

7 other general tuberculosis sanatoria with a total bed capacity of 506 reported that they were caring for crippled children, but gave no figures as to the number of these cases.

Thus, 382 special institutions and organizations were discovered in this survey. Undoubtedly there are numerous other general sanatoria and general hospitals providing for the care of crippled children in this country. Their omission is due to failure to respond to questionnaires, or to failure of neighbor agencies to report their existence and activities. We may conclude from these figures, first, that existing facilities for convalescent care of juvenile orthopedic patients are inadequate. There are over twice as many beds available for operation and acute treatment as there are for convalescent observation and care. We may interpret, second, that any survey or local statistics relative to the frequency of "surgical" tuberculosis probably will be lower than the actual percentage, inasmuch as a considerable number of special institutions are devoted partially or exclusively to caring for all forms of the disease. The figures indicate that existing special educational facilities are caring for less than two per cent of the crippled children of the United States. An examination of the tables on pages 70 and 71 will demonstrate that activities to aid crippled children are largely concentrated in the central eastern coast states. There remains a great opportunity for missionary work in the territories west of the Mississippi River.

Questions frequently are raised concerning the number of crippled children in the United States, and their frequency per thousand population. Various estimates have been made to this ratio, some of them being the following:

(1) The Birmingham (England) cripple estimate of 1911: 5.7 per thousand population.

(2) The New York City Special Committee which conducted the 1919 survey estimated the number of cripples at 6.9 per thousand population. 52% of these were under sixteen years of age.

(3) The Cleveland, Ohio, survey of 1916 estimated a ratio of 6.2 cripples per thousand. Only 22% of these were children.

(4) The Massachusetts census of 1905 recorded 5.7 cripples per thousand of population.

(5) The Toronto, Canada, survey of 1923 reported 2.16 crippled children per thousand of population.

Except in the Cleveland survey, most estimates suggest that about fifty per cent of all cripples are children under sixteen years of age. Assuming this ratio to be correct, we find the following ratios of juvenile cripples to population:

On the basis of these figures, there are approximately 4,256,300 crippled children in the world; 342,500 in North America; and 264,276 in the United States. While the ratio seems to be fairly constant, it must be borne in mind that conditions in various localities will alter the proportion according to frequency of epidemics, efficiency of public health agencies, or other similar circumstances.

CHAPTER X

A STUDY BY LOCALITIES

In endeavoring to survey efforts to aid crippled children throughout the United States and Canada, two questions must be kept in mind: first, the question of how well localities which are characterized by concentrated populations are provided with facilities to cure, care for, and educate crippled children; and second, how well crippled children of isolated communities are cared for. The fact that cities in many states are widely scattered and of small population may explain why facilities for the care and education of crippled children have developed more slowly than those in the more densely populated areas, but it does not to any degree reduce the problem. Rather this situation should be a stimulus to more concentrated activity.

No attempt is made, either in this chapter, or in the directory, to list all of the general hospital orthopedic wards or services in the United States. That would be a stupendous task, and never would be completed or up-to-date. Orthopedic services in general hospitals have been listed and referred to: first, if they demonstrate a particular arrangement of facilities provided for by legislation (as for example, in Ohio); second, if they happened to be called to our attention in the course of the survey; or third, if they are the sole agencies for the solution of the problem of a particular area.

Because these general hospital facilities are not all known, it will be impossible to state the exact relation of hospital beds to population in every locality. Were this possible, it still would be necessary to demonstrate the fact that the proportion of crippled children to the entire population in every area, at the same time, remained constant. We know that this cannot possibly be true. Epidemic and other environmental conditions will lower or raise this proportion periodically. This study therefore will be confined to a general demonstration of existing methods of solving the problem of the crippled child in the various states or groups of states, and a general estimate of the degree to which existing agencies are competent. All population figures refer to the Census of 1920.

THE UNITED STATES OF AMERICA

The Northwestern Coast Area

Two orthopedic centers, Portland, Oregon, and Seattle Washington, are provided with the only facilities for aiding crippled children of this group of states. In addition to the Portland Shriners' Hospital with fifty beds, care is provided for crippled children at the University of Oregon Medical School under a legislative act which states that juvenile courts may commit indigent children to that institution for medical or surgical treatment. Due to a lack of facilities, a lack of local interest, and the long distances which the child must travel, only a very few patients have been treated under the terms of this act. In addition, the University has had some difficulty collecting from the counties, as is prescribed by the legislation. The situation will be relieved somewhat by the erection of a seventy-bed children's hospital, provided for in a legacy left to the University by the late Mr. F. S. Doehrnbecher. The Children's Orthopedic Hospital, of Seattle, is a center for Washington. Idaho is forced to send patients to one of these two cities. There can be no question that many children in this wide area are suffering for want of readily available facilities.

The Southwestern Coast Area

The problem in the southwestern coast region is closely analogous to that in the area directly north. Provision to care for the crippled children of San Francisco and Los Angeles is most satisfactory. In San Francisco is located a fifty-bed Shriners' Hospital, and the two hundred seventy-five-bed Children's Hospital. Educational facilities are provided at both these institutions. Drexler Hall, at Redwood City, and the Stanford Convalescent Home, at Palo Alto, provide convalescent care within fifty miles of the city. In Los Angeles, The Orthopaedic Hospital School and its projected convalescent home will be fully adequate to the needs of the center and surrounding counties. At Santa Barbara, the Cottage Hospital is equipped to provide necessary care for children of the extreme southern coast region. The central inland portion of the state is provided with a hospital for joint tuberculosis at Springville and a well equipped general hospital at Fresno. In Nevada, however, an area of 110,690 square miles is without any special provision for the education or care of crippled children. For inland and northern California, special educational facilities are available no nearer than San Francisco, a maximum distance of nearly 400 miles.

The Southwestern "Desert" States

In a distance of six hundred eighty-five miles between the borders of these neighbor states, one private institution, Dr. Charles Luken's Children's Home and Hospital, is the sole agency to aid crippled children. No special educational facilities whatsoever are provided. The situation speaks for itself.

The Central Rocky Mountain States

About forty-seven per cent of the population of these two states is urban. Only two centers for the care and education of crippled children are provided: Salt Lake City, where the Children's Home acts as a convalescent hospital, and Denver, provided with the Children's Hospital. In Colorado Springs, Colorado, the Glockner Sanatorium and Hospital does some orthopedic work. Thus we may interpret that under normal conditions fully fifty per cent of the crippled children of the central Rocky Mountain States have no special care available within distances ranging from fifty to four hundred miles. No special education is provided for those indigent children who are unable to attend the public schools.

The Northern Rocky Mountain States

St. Vincent's Hospital, at Billings, and The Butte Auxiliary, at Butte, Montana, would very nearly suffice to provide care and education for the crippled children of these two states if numerous organizations such as the one at Butte were constantly vigilant to find cases where such facilities were needed. Any inadequacy which may exist is due to the isolation of these communities rather than to the lack of sufficient hospital beds. A normal ratio of crippled children to population would bring the total number of crippled children of this area to less than 300.

The Northwestern Mississippi Valley Region

-1- When states are divided into two areas, the population and area of each section is approximated at one-half the total figure.

Until 1924, the Twin Cities, (St. Paul and Minneapolis) were the only ostensible orthopedic centers for this entire region. Of course the majority of crippled children, beyond a radius of one hundred miles from St. Paul, were entirely neglected. In the past year, the North Dakota legislature has passed an act which provides for treatment of crippled children at any general hospital in the state upon commitment by district courts. Charges are to be referred to the counties in which the children reside. This legislation will function efficiently in proportion to the degree to which organized society is interested sufficiently to discover cases and bring them to the attention of judicial magistrates. Similar educational legislation should be enacted. The entire state of South Dakota still is devoid of special orthopedic facilities. In St. Paul and Minneapolis, the Shriners' Twin Cities Hospital, the Dowling School, the projected University of Minnesota Hospital and its convalescent institution, and the State Hospital will be adequate for the needs of this locality. In addition, the legislature of 1921 authorized subsidies for special schools for crippled children throughout the state. There remains only the need for social co-operation in organizing these classes and schools, and legislation which will make available the cost of remedying and caring for juvenile cripples in isolated community general hospitals.

The Central Western Mississippi Valley Region

Both Iowa and Nebraska have attempted to solve the problem of the crippled child by selecting state orthopedic centers. Southern South Dakota is dependent upon these two institutions for such services. In Iowa, children are committed by juvenile courts to the University Hospital at Iowa City. Educational facilities in both of these states are greatly needed. Interested parties in Iowa are reported to be agitating for a state school, but it is sincerely hoped that they will reconsider this intention and turn their efforts toward the enaction of legislation for a de-centralized plan. In Nebraska, the Omaha Rotary Club has expressed its intention of endeavoring to interest public sentiment in additional local facilities which will supplement the State Hospital at Lincoln.

The Western States of the South

Until recently, this tremendous area was provided with only one orthopedic center, namely Oklahoma City. Children at this city are cared for in general hospitals and educated at the only special day school for crippled children in the South (The Andrew Parsons School for Crippled Children). The Hella Temple of the Imperial Shrine opened an orthopedic hospital at Dallas in 1924, providing the first orthopedic center in Texas. The El Paso Rotary Club has become interested in the situation and will exert efforts to bring about the enaction of expedient legislation. The Homan Sanatorium, at El Paso, is constructing a new building which will provide heliotherapy for juvenile bone and joint tuberculosis. This region, representing a maximum direct traveling distance of 1310 miles, presents a tremendous and interesting problem, to which those agencies interested in the crippled children movement should give their attention.

The Southwestern Mississippi Valley Region

These two states slowly are awakening to the needs of the crippled child. Facilities in St. Louis are excellent. A Shriners' Hospital, The Children's Hospital, Washington University, Barnes Hospital, and a private sanitarium (practically all of which are provided with convalescent and educational facilities) are adequate to the needs of the city and surrounding counties. An act providing for local special classes has resulted in the establishment of these facilities in Kansas City and the formation of plans for special schools in St. Louis. Social co-operation should organize these groups elsewhere in the state. The Kansas Legislature (of 1923) defeated a similar bill-1-, but probably will be asked to reconsider this decision at a future meeting. At Topeka, the Capper Fund for Crippled Children has been active in making possible treatment for over one hundred children in various parts of the state.

-1-Recommended by the Children's Code Commission.

The Central States of the Mississippi Valley

The two states represented in this region are similar in that activities to aid crippled children in both of them are at the present time centralized, and different in that Indiana is directing its efforts toward further and more complete centralization, whereas Illinois is striving in the opposite direction. Indianapolis is the Indiana orthopedic center, and will be still more so when the new James Whitcomb Riley Hospital has been completed. Chicago has been the Illinois orthopedic center, and will continue to develop new facilities to solve its individual problem. But the efforts of the Illinois Society for Crippled Children have succeeded to the extent of recently bringing about the enaction of a de-centralized school law, and will eventually develop orthopedic services in local hospitals throughout the state. In the city of Chicago, in addition to the services provided by the various general institutions, the Home for Destitute Crippled Children is a special orthopedic hospital which employs convalescent facilities at Prince Crossing, Illinois. The Shriners are erecting a special institution at the outskirts of the city. The public school system is well equipped to provide elementary and high school education for cripple Social co-operation, rendered in Illinois by Rotarians, is provided in Indiana largely by Kiwanis Clubs.

The Northern States of the Mississippi Valley

It is interesting to note that a horizontal line drawn through the center of these two states will divide them approximately into active and inactive belts. Michigan is by far the more advanced of the two in facilities to aid crippled children. The chief orthopedic center of the state is naturally Detroit, where activities center around the Children's Hospital of Michigan. State aided special classes, are located at the Leland School for crippled Children, of Detroit, and in Saginaw and Grand Rapids schools. Convalescent homes are located at Farmington (affiliated with the Children's Hospital of Michigan) and at Port Huron. Rotarians have organized the Michigan Society for Crippled Children and clinics have been held throughout the state. Legislation provides for commitment of indigent crippled children to the University Hospital at Ann Arbor, for treatment, and to the State Public School at Coldwater, for education. The Michigan Children's Aid Society frequently renders service by "placing" handicapped juveniles in "boarding homes."

Wisconsin legislation closely resembles that of Michigan in providing for education at the State Public School at Sparta, and treatment at the State (The Bradley Memorial) Hospital at Madison. Milwaukee is the only other orthopedic center in the state. The northern and less populous areas of both states present the same problem as those of the Rocky Mountain Region, namely, the task of locating the little ones in isolated communities and making facilities available at sufficiently convenient distances to ensure effectiveness.

The Northeastern Mississippi Valley

Ohio probably cares for and educates as large a proportion of her crippled children as does any state in the country. This is due to advanced legislation and the widespread social interest of Rotary Clubs (who have organized the Ohio Society for crippled Children), and Kiwanis Clubs, which are active in co-operating with agencies throughout the state. Although there is not a single special orthopedic hospital in the state, legislation making available the price of care and cure has thrown open the doors of general hospitals everywhere. Toledo, Cleveland, Elyria, Akron, Dayton, Lima, Cincinnati, Columbus, Canton, and Youngstown all function as orthopedic centers. Local clinics are held periodically, and patients are treated at the nearest available facilities. Public school classes for crippled children have been organized in all of the cities named above, and in addition at Ashtabula, Barberton, Piqua, and Springfield. This state is still in need of further convalescent facilities and at least one custodial institution for incurable crippled children.

The Central Eastern States of the Mississippi Valley

The states of this region have several characteristics in common. They all are attempting to solve the problem of the crippled child on a partially de-centralized plan. Rotary Clubs in all three have organized State Societies. All of them are confronted with the problem of bringing patients for treament from isolated mountain communities to cities. In Kentucky, Louisville is the outstanding center, crippled children receiving treatment at the Louisville Children's Free Hospital and the J. N. Norton Memorial Infirmary. The Korsair Temple of the Imperial Shrine is building a home which will provide the needed convalescent care. In Tennessee, Memphis is the outstanding center and also serves several of the central states of the South. Nashville is provided with a convalescent home which aids in solving the problem of that city. West Virginia is the only one of these states in which legislative action has been directed toward orthopedic services. The West Virginia legislature has provided for the admission of crippled children at the several state Minors' Hospitals (Welch, McKendrie, Fairmont). In addition, excellent facilities exist at Huntington and Wheeling. The characteristic deficiency of all three states is the lack of special educational facilities. Future efforts of state societies and all interested individuals probably will be turned toward the establishment of special classes in public schools.

The Central States of the South

This entire region is served by one center, namely, the Shriners' Hospital at Shreveport, Louisiana. While the latter institution is rendering a great service, it should not be made to bear the responsibility for a territory of this size. Aside from the fact that a few patients from northern Mississippi and western Arkansas are sent to the Children's Hospital School at Memphis, Tennessee, no other special facilities are in existence in any of the central southern states. There are no special classes and no active social organizations attempting to solve the problem.

The Southeastern Coast States

Two centers, Atlanta, Georgia, and Gastonia, North Carolina, serve this group of states. In Atlanta and surrounding counties, The Scottish Rite Hospital for Crippled Children and the National Surgical Institute (Decatur) serve the community in a satisfactory manner. In North Carolina, the State Orthopedic Hospital, at Gastonia, is adequate to local needs. In southern North Carolina, the Greensboro Crippled Children's Commission is active in providing care for crippled children of the immediate locality. In South Carolina, a small state appropriation provides for the care of crippled children in several general hospitals. Absolutely no special educational faci1ities are available in this region. As in other parts of the South, distances between centers must be reduced if the problem of the crippled child is to be solved.

The South Central Eastern Coast States

Baltimore, Maryland, Washington, D. C., and Richmond and University (Charlottesville), Virginia, serve as orthopedic centers for the south central eastern coast states. Baltimore is well equipped to provide for the treatment of Maryland crippled children, but one or two special scholastic classes might well be established at several other local centers. In Virginia, the Crippled Children's Hospital, at Richmond, and the University Medical College, at Charlottesville, provide for treatment of patients in the eastern counties. The recently organized Virginia Society for Crippled Children is faced with the problem of stimulating interest in the provision of special education throughout the state, and additional orthopedic services in western cities. Both Delaware and Washington, D. C., are in need of educational facilities for crippled children.

The North Central Eastern Coast States

This densely populated area is by far the most active region of the country in efforts to aid crippled children. In New Jersey, fifty Elks' Lodges, and numerous Rotary and Kiwanis Clubs are devoting their attention to solving the problem of the crippled child. Legislation has provided for local classes for crippled children and orthopedic hospitals are located at Newark, Orange, and Trenton. A number of New York City and Philadelphia institutions have located summer homes at Atlantic City, Bradley Beach, Oakhurst, and elsewhere along the Atlantic Coast. Special convalescent homes are located at Atlantic City and Englewood. A state organization of all facilities may be expected to aid in the co-ordination of all these activities in the near future.

The State of New York must be divided into two sections, Greater New York City and vicinity, which presents a distinct and individual problem, and the remainder of the state. In New York City, every possible facility is available. Three special orthopedic hospitals, orthopedic wards in a large number of general hospitals, 101 special hospital and public school classes for crippled children, an active and efficient local Association for the Aid of Crippled Children, an interested and active Rotary Club and affiliated convalescent homes and hospitals distributed throughout Long Island, New Jersey, and Connecticut,-all combine to render aid to the juvenile handicapped of the great metropolis. New York State also is well equipped to care for its crippled children. A State Hospital at West Haverstraw cares for indigent patients. Elmira Ithaca, Utica, Buffalo, and Syracuse, all act as orthopedic centers. The legislature has provided for local special education, and has recently appointed a special committee to investigate and report on further necessary facilities. Co-ordination between active agencies is developing in a thoroughly satisfactory manner. The New York State Society for Crippled Children is an active organization which co-operates with other existing agencies everywhere and the New York State Elks' Association is endeavoring to lend assistance. At the present time, the Elks are conducting a survey with a view toward revealing opportunities for further service. No more satisfactory co-ordinated efforts to aid crippled children can be found any where in the world.

The problem of the crippled child in Pennsylvania, like New York, must be viewed both as one of several large cities, and one for the state as a whole. As in the two neighbor states, crippled child activities are developing rapidly and in a co-ordinated manner. The recent conference at Harrisburg brought all agencies, including the Pennsylvania Society for Crippled Children, the State Departments, and the various institutional organizations, into close contact. In Philadelphia and Pittsburgh, special orthopedic institutions are well equipped to handle the problem. Orthopedic services in Philadelphia are soon to be increased by another unit of the Shriners' Hospitals. As a result of a recent law providing for judicial commitment to any hospitals for treatment whenever necessary, orthopedic beds are provided in general hospitals in the less populous sections of the state. The only outstanding deficiency in Pennsylvania provision to aid crippled children is that of local special education. It is to be hoped that steps soon will be ken to establish these special classes and schools everywhere.

The New England States

Of the New England States, Massachusetts is at present the most active in this movement. Institutional care is splendidly developed in this state at the New England Peabody Home, the Massachusetts Hospital School, the Boston Children's Hospital and convalescent home), The New England Home for Little Wanderers, and Convalescent Home of the Berkshire County Society for Crippled Children, and the Sol-e-Mar Hospital. Inasmuch as the entire Massachusetts solution of this problem has been developed along institutional lines, and inasmuch as almost every one of these institutions, possesses well equipped schools, special classes are not greatly needed in that state. The Industrial School for Crippled and Deformed Children suffices to fulfill the needs of Boston.

Rhode Island, at present depending largely on Massachusetts for facilities to aid crippled children, might well support several special classes, and perhaps one or two institutions for crippled children. New Hampshire has similarly been depending upon Massachusetts institutions for these services, and should develop an expedient and de-centralized program for aiding these cases. Vermont activities have, to a large extent, been conducted by the State Board of Health, and have been directed toward the after-care of infantile paralysis. This state also is very much in need of special facilities, the only active institution in the state being a private home for after-poliomyelitic children, at Proctor. Connecticut is the only state providing special state Sanatoria for bone and joint tuberculosis in children. A state custodial institution for juvenile cripples is maintained at Newington. Connecticut social interest in the care, cure, and education of the crippled child is awakening slowly.

Maine orthopedic centers are located at Portland and Bangor. The outstandingly active institution is the Children's Hospital at Portland. In 1924, Mr. Arthur H. Taylor, of the American Child Health Association, entered upon a program to (1) secure a census of cripples in the state; (2) study available facilities; and (3) stimulate interest and enthusiasm in various localities in the problem of the crippled child. In the process of this work, Rotary Clubs, the State Department of Health, The Children's Hospital at Portland, the Boy Scouts, and the State Department of Education co-operated. An attempt was made to duplicate the Ohio program by the establishment of ten clinic centers, namely, Sanford-Springvale, Augusta, Lewiston, Waterville, Skowhegan, Bangor, Houlton, Presque-Isle, and Fairfield. At the time of writing, organization of Rotary Club Crippled Children's Committees continues, and three successful clinics already have been held. Rotarians assisted in the transportation to Portland of cases needing hospital care. It may reasonably be expected that Maine activities will develop along the lines of those in process in Ohio, Illinois, Pennsylvania and other states in which facilities are "brought to the child." In this work, provision for special classes probably will follow the completion of clinical and social organization.

CANADA

Canadian efforts to aid crippled children have developed only in the border provinces of Quebec, Ontario, and Alberta. These facilities are still in the embryonic stage, and special education is provided only in Toronto. Outstanding institutions are the Hospital for Sick Children, and The Toronto Orthopaedic Hospital at Toronto, The Home for Incurable Children at the same city, The Children's Memorial Hospital at Montreal, The Protestant Hospital at Ottawa, and The Junior Red Cross Children's Hospital at West Calgary, Alberta. The Shriners are erecting a fifty-bed Hospital for Crippled Children at Montreal.