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thirty-five doctors is rendered freely to the children and the state. At present there is an orthopedic nurses' training school in connection with the state hospital, an elementary and advanced course of study in the hospital school, and provisions for vocational training.

Within the state there are about fourteen private institutions which have some cases of children with surgical tuberculosis, a unit of the Shriners' chain of orthopedic hospitals, and an endowed school and convalescent hospital in connection with the state university.

In 1921 the state enacted a law which established classes for crippled children in the public schools. Boards of education which organize such classes are paid from a state subsidy, not to exceed $250 per pupil for a full school year's attendance.

Ohio.-The Ohio plan has three distinct periods of development covering a period of about twenty years. The first consisted in the enlargement of the administrative, co-operative and supervisory powers of the state departments of welfare, health and education. This development made it certain that the state institution was not needed in Ohio, and it never will be built.

The second period was from 1911 to 1921, when laws which took root from the principles laid down by the White House Conference called by President Roosevelt in 1909 were passed, providing that the state should plan to care for dependent children without additional institutions.

During the past four years the third period has brought forth additional laws and private organizations inspired by Edgar F. Allen, president of the Ohio and International societies for crippled children, which ordained a remarkable cooperative movement that is bringing to the crippled child his birthright of opportunity.

It finds crippled children unofficially through surveys and officially by school enumerators who are required by law to give special information to county auditors and to the state department of education regarding crippled children from one to twenty-one years of age. Expert diagnoses are made by approved and selected orthopedic surgeons in all parts of the state, especially in rural sections, in diagnostic conferences or clinics organized and supervised by the state department of health.

Parents, guardians, local nurses, Rotarians, teachers, health commissioners, welfare workers, and state nurses follow up the clinics and see that the existing facilities are brought to the children or the children to the facilities, as the cases respectively require. Many children are taken care of privately and the rest are taken to the juvenile court for commitment to the division of charities in the state department of public welfare, or to special schools for education, or given the benefit of trained field service or home care and instruction, depending upon their several circumstances and conditions.

The state division of charities is responsible by law, through its orthopedic nurses, for the care, relief, and education of committed crippled children. It

contracts with individuals, approves institutions and hospitals, pays the bills, which are then charged back to the counties from which the children are committed, and supervises the children, in their own homes or wherever they may be, as long as the commitments last. This division has a rotating fund of about $53,000, which is protected by the attorney-general of the state, whose duty it is to collect from counties which allow their bills to become delinquent. The juvenile court collects partial payments from parents and guardians.

Education is, in a way, the most important part of the program, because it applies to all crippled children who are not feebleminded, while the surgical operation applies to only about 20 per cent of them. Therefore it is arranged so that crippled children come within the provisions of the compulsory school law.

Local school boards, with the permission of the state director of education, may provide home teaching, special classes, special schools, or pay for the board, tuition, or transportation of crippled children when necessary. The state department of education, besides furnishing a state subsidy for the education of crippled children not to exceed $300 per pupil per year, maintains a bureau to supervise special education, and a division of civilian rehabilitation for cripples over fifteen years of age.

Last available statistics show that 91 clinics have attracted 4,300 cases. Up to April 1, 1925, the state department of public welfare accepted 1,092 commitments. There are now 50 special classes and schools in 17 different cities, 7 of which are located in hospitals or convalescent institutions, and 95 home teaching cases in 35 different communities. The enrolment for special education varies, but is about 850 pupils. The annual per capita cost in the welfare department is approximately $300, and in the educational department, for excess costs, about $250. Including duplicates, the three state departments are in touch with more than 6,000 crippled children.

Iowa. One of the states following the general principle found in the Minnesota plan, that deserves special attention because of the amount of work which has been accomplished in medical care for crippled children, is Iowa. The chief difference from the Minnesota program is that the care and relief is given at the orthopedic division of the general hospital at the state university.

As in Ohio, juvenile courts may commit "any legal resident of Iowa, residing in the county where the complaint is filed" to the university hospital. While any adult may file a complaint, a specific duty to do so is placed by law upon "physicians, public health nurses, members of boards of supervisors and township trustees, overseers of the poor, sheriffs, policemen, and public school teachers." Patients may be treated who are not committed, and the hospital authorities "shall collect from the person or persons liable." Patients may be treated also outside of the hospital.

There is no direct information at hand to tell how much money is spent on children with orthopedic difficulties, except that statistics show there were 1,576

such cases out of a total of 3,425 treated during the last fiscal year. The appropriation for all was about $900,000, so that an estimate of $415,000 may be made for crippled children. This is exclusive of capital invested. As stated before, this number of crippled children treated is relatively very high and indicates the law must be very vigorously enforced.

It seems to a limited degree that the Iowa plan represents a combination of the principles found in Minnesota and Ohio. It differs from Ohio chiefly in being a centralized plan, so far as treatment is concerned, and in that it greatly neglects the education of crippled children except during the period of their hospitalization. Great success in finding crippled children seems evident.

Massachusetts followed the lead of Minnesota and established a state orthopedic hospital, convalescent home, and special school. Hospital facilities for one-hundred patients provide medical, surgical, and nursing care. In addition to the standard public school curriculum, music, domestic science, cobbling, sewing, and other various industrial and vocational preparatory subjects are taught. Indigent children are admitted directly on a voluntary basis upon application of parents and guardians. A number of the admittances are private, or "pay" patients. When parents are unable to pay, the charges are referred to the county or city in which the child previously resided. The hospital and school have an average attendance of three hundred. The cost is approximately $175,000 for 360 patients, as estimated by the state department of public welfare. We have no figures on the capital invested.

Probably the first state census of cripples was made in Massachusetts. She has a well-distributed number of private institutions and agencies caring for crippled children. These represent a unit of the Shriners' chain of hospitals, orthopedic departments in general hospitals, institutions for incurables and custodial cases, as well as for convalescents, agencies for after-care, and also research, and finally for various types of education. Some of these are related to the state government. "Institutional care is splendidly developed in this Inasmuch as the entire . . . . 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. . . . .”

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New York. It is thought by some that New York State now represents a development which is most typical of the best sentiment of the country on the subject of state programs for crippled children. While she has had a state institution since 1900, a recent survey made by a special state commission has led to new legislation establishing a program largely independent of the institution, although including it in the major purpose to coordinate all efforts, public and private.

This act provides a statutory definition of a physically handicapped child, and an advisory commission for physically handicapped persons which, in addition to rehabilitating handicapped persons over fourteen years of age, is "to

stimulate all private and public efforts designed to relieve, care for, cure, or educate physically handicapped children, and to coordinate such efforts with the work and functions of governmental agencies." This commission is also "to maintain a register of physically handicapped children [and] to use all means and measures necessary to meet adequately the physical and educational needs of such children, as provided by law."

The state will seek out all crippled children, from birth to eighteen years of age, insist on their being adequately cared for, and furnish the costs of care, relief, and education when parents, guardians, and local communities fail to do so as required by law. Many leaders in the work in New York State believe this will, in a reasonable length of time, practically revolutionize the work of the state relating to cripples.

HEALTH ACTIVITIES OF CHILD CARING AGENCIES EXAMINATIONS ON ADMISSION

Arlene Bauer, D.A. Blodgett Home for Children, Grand Rapids

The entrance examination is an old but still ever new subject as the advance of medical science and mental hygiene steadily renders it more complete. The opportunity it gives the child for far-reaching physical betterment often overbalances the seriousness of his removal from home.

Statistics show that a child is actually a liability until twenty years of age, rendering the establishment of a firm foundation of health through a preventive program of real social and economic value.

An entrance examination properly begins in the securing of a complete history of the family in so far as it affects the physical and mental health of the child, also the family's health habits, as a measure of its effect on his present condition as well as upon the cooperation one can expect upon his return.

Efficiency and cooperation through interest of the physician is most important in his selection, also the addition of ear, eye, nose, and throat specialist, if possible, to examine expertly the eyes and ears that, unknowingly defective, have so often wronged a child through a false terminology of dulness and even mental deficiency.

The routine given every child should consist of Wasserman, smear, urinalysis, nose and throat cultured VonPirquet, vaccination, and toxin anti-toxin, the latter harmless in their reaction after the sixth month.

Points of physical history including birth, feeding, development, previous illness, operations, immunization, hygiene, and habits, as well as physical examination consisting of general nutrition, heart, chest, abdomen, genitals, muscles, bones, joints, glands, skin, and nervous system were discussed with especial emphasis on tonsils and their far-reaching causes for ill health; also

teeth, and the fallacy of lack of care under the assurance that they will soon fall out, while in the meantime the child may be gathering infection or because of tenderness improperly masticating, resulting in lowered resistance or the beginning of a serious underweight condition; thyroid and its important relation to the building of bone and fat; and last, malnutrition with its varied serious effects and treatment. Dr. Emerson, of Columbia University, states that 90 per cent of children are underweight from physical defects, especially naso-pharyngeal obstructions, lack of home and personal control, overfatigue, faulty food habits and improper food, and poor hygiene.

In conclusion, I emphatically state that this valuable information is worthless unless used, not only until the child is as physically and mentally perfect as it is possible to make him, as thoroughly educated in health habits as his mentality permits him to become, but until this knowledge is so thoroughly disseminated in his home as to establish proper health habits and bring about a recognition of the need of periodic health examinations for the entire family. Only thus have we actually insured his health and given our organization the right to carry on child welfare work.

CONTINUOUS HEALTH SUPERVISION

Mary E. Murphy, Director, Elizabeth McCormick
Memorial Fund, Chicago

The title of this discussion indicates a different point of view on the care of children from that familiar to most of us a few years ago. It is distinct from the attitude with which a child caring agency brings to the attention of the hospital or dispensary the physical needs of children when symptoms of abnormality have already appeared. Continuous health supervision means a program of regular checking on the condition of children so that a healthful condition may be maintained or deviations from normal may be noted and corrected.

It is presupposed that the point of departure is the normal child, and that the program of health supervision is organized with a view to arriving at this goal of normal childhood.

Of course, a fundamental in this continuous health supervision is the physical examination, and with this distinct health point of view health supervision should provide a type of physical examination which not only notes real defects, but notes also such deviations from the normal as may have a direct influence upon the child's health. Such an examination can be made only by a physician who is familiar with the characteristics and the standards of development of normal children, and who also regards as important the whole program of the child in its relation to this physical development.

As an example of this type of thing, let me quote from the findings and recommendations made by the physician in connection with the examinations of

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